All Articles

Roisin Taplin, Gavin David O’Connor^*

Department of Anaesthesiology and Intensive Care, University Hospital Limerick, Ireland

Introduction: The enhanced recovery after surgery (ERAS) protocol is a set of international guidelines developed with the purpose of decreasing the hospital stay of a patient undergoing elective colorectal surgery. The ERAS protocol outlines a variety of measures that should be taken throughout a patients’ surgical stay, including at the first meeting in the preoperative phase, perioperatively and postoperatively.

Methods: PubMed database was accessed with the aim of finding relevant material on the subject of the ERAS protocol and colorectal surgery, and the outcomes for patients pre and post implementation of the ERAS protocol. The keywords chosen included ERAS protocol, implementation and colorectal surgery. Filters included access to full free text, available in English, published in the last 5 years and included clinical trials, meta-analysis, randomised controlled trials and systematic reviews. This returned 32 results of which 9 articles were included. These nine articles were reviewed and the outcomes pre and post implementation of the ERAS protocol were examined.

Results: The opinion of all the articles reviewed recommend implementation of the ERAS protocol. Each site reported improvements in various factors from length of stay, to post op complications and patient satisfaction. Implementation of ERAS protocols in elective colorectal surgery is associated with improved outcomes.

Conclusion: The ERAS protocol is a highly effective protocol for patients undergoing elective colorectal surgery. It has proven benefit in terms of decreased postoperative complications, and reduced length of hospital stay. The ERAS protocol has been successfully implemented in a variety of hospitals around the world with great effect. Future research should focus on the implementation of the protocol on other patient demographics, such as patients undergoing emergency colorectal surgery to explore its benefits in such situations.

Shinju Obara^*, Yuki Watanabe Hoshino, Satoki Inoue

Department of Anesthesiology, Fukushima Medical University School of Medicine, Hikarigaoka, Fukushima, Japan

Remimazolam is a newly introduced benzodiazepine anesthetic. Despite being classified as ultrashort-acting, it may cause delayed emergence owing to its not-so-short 80% context-sensitive decrement time. This study retrospectively analyzed 21 patients (12 men and 9 women; median age, 65 years; range, 17–82 years) classified as ASA I or II who underwent general anesthesia with a combination of remimazolam and propofol for anesthesia maintenance during the study period (May 2022 to May 2023). It aimed to determine the optimal effect-site concentrations of remimazolam, propofol, and remifentanil during surgery and recovery times. The population median values of individual median effect-site concentrations for remimazolam, propofol, and remifentanil during adequate sedation (patient state index 25–50) were 0.34 µg/mL, 1.00 µg/mL, and 5.00 ng/mL, respectively. At the recovery of responsiveness, the median values of individual median effect-site concentrations for remimazolam, propofol, and remifentanil were 0.17 µg/mL, 0.53 µg/mL, and 0.88 ng/mL, respectively. There was a significant negative correlation between the individual median propofol effect-site concentrations and age during patient state index range of 25–50. However, no correlation was observed between age and the other effect-site concentrations mentioned above. The patients regained responsiveness at a median of 13 min after termination of anesthetics, except for 2 who required flumazenil before tracheal extubation. Flumazenil was administered to facilitate emergence from sedation in two patients before extubation and in another two after extubation. No adverse events occurred, including resedation or intraoperative awareness. This study demonstrates the potential of combining remimazolam and propofol for effective anesthesia and rapid recovery. To optimize dosing strategies for the combination of remimazolam and propofol, larger prospective pharmacokinetic and pharmacodynamic studies are warranted.

Joseph C. Resch^1*, David W. Polly, Jr.²

¹Department of Pediatrics, Division of Critical Care, University of Minnesota, Minneapolis, MN, USA

²Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA

Mehdi Oudrhiri Safiani^*, Nora Fernaoui, Ahlam Chaieri, El Mehdi El Awab, Rachid Moussaoui, Ahmed El Hijri, Abderrahim Azzouzzi

Surgical Resuscitation, Mohammed V University, Rabat, Morocco

Wolff-Parkinson-White Syndrome (WPW) is a congenital cardiac anomaly characterized by the presence of an accessory atrioventricular cardiac bundle called the Kent Bundle. Discovered by Wolf, Parkinson, and White, this condition can result in recurrent, sometimes fatal tachyarrhythmias. WPW is relatively rare, affecting approximately 0.1% to 0.3% of the general population. Its diagnosis relies on electrocardiography. Its management depends on the clinical presentation of each patient, varying in accordance with the severity of symptoms. It can range from vagal maneuvers and first-line anti-arrhythmic drugs to radiofrequency ablation in refractory cases. In this report, we present the case of a 40-year-old man undergoing surgery to remove a urachal cyst. During the intraoperative period, supra-ventricular tachycardia emerged, revealing a previously undiagnosed intermittent WPW syndrome.

Daniel Odhiambo Otieno^1*, Stanley O. Khainga², Joseph Kimani Wanjeri¹, Timothy Murithi Mwiti³, Demet S. Sulemanji⁴

¹Department of Plastic, Reconstructive and Aesthetic Surgery, University of Nairobi School of Medicine, Nairobi, Kenya

²Department of Plastic, Reconstructive and Aesthetic Surgery, Moi Teaching and Referral Hospital, Kenya

³Department of the Anesthesia, University of Nairobi School of Medicine, Nairobi, Kenya

⁴Department of Medicine, The Aga Khan University Hospital, Nairobi, Kenya

Background: There is limited literature on using low-dose intravenous ketamine as a single agent for procedural burn pain management during adult dressing changes.

Aims & Objectives: To determine the effectiveness of low-dose ketamine compared to morphine as a single analgesic agent in procedural burn pain management during dressing changes.

Materials & Methods: We performed an institutional review board-approved, randomized, prospective, double-blinded, controlled, non-inferiority trial. All adult patients 18 years and above scheduled for dressing change were screened. Patients who consented were randomized to receive low-dose ketamine infusion at 0.2mg/kg/hr. In the treatment group, morphine infusion at 0.1mg/kg/hr. In the control group. The primary endpoint was pain intensity, measured using a visual analog scale. Data were analyzed on an intention-to-treat (ITT) approach. Secondary endpoints included rescue analgesia requirements and the occurrence of adverse effects in both groups.

Results: 82 patients were enrolled (ketamine 41 vs. morphine 41). We compared VAS scores at

5-minute intervals during the dressing changes. Overall, pain scores are similar in both groups (p-value=0.595). The pain control was homogenous. However, the morphine group required more rescue analgesia throughout the dressing changes than the low-dose ketamine group (p=0.013 at T15, p<0.001 at T20, and p<0.001 at T30). The occurrence of side effects was similar in both groups.

Conclusion: This study suggests that low-dose ketamine provides as effective and more predictable procedural analgesia as morphine during dressing procedures for adult burn patients.

Najah Arafat Albayedh^1*, Muzan Abdelbagi¹, Yasser Samir Elmehellawy², Ragai Abdelbasset Gemi³, Omar Majed Abdul Baki²

¹Department of Anesthesia and Critical Care medicine, Al-Qassimi hospital, Emirates Health Services (EHS), Sharjah, United Arab Emirates

²Department of Anesthesia, Al-Qassimi hospital, Emirates Health Services (EHS), Sharjah, United Arab Emirates

³Department of Ear, Nose, and Throat (ENT), Al-Qassimi hospital, Emirates Health Services (EHS), Sharjah, United Arab Emirates. Professor of ENT, Cairo University, Cairo, Egypt

Introduction: Managing patients undergoing head and neck surgeries necessitates meticulous evaluation, strategic planning, and collaborative efforts with surgical teams. This approach is crucial to mitigate perioperative complications and optimize patient safety.

Rationale: Expert navigation of the challenging airway in these patients, particularly in the perioperative period, is essential to significantly reduce the risks of morbidity and mortality associated with such complex conditions.

Patient Concerns and Diagnosis: The patient presented with a supraglottic mass extending into the epiglottis space, posing significant anesthetic challenges to airway management.

Outcomes: A surgical airway was established via tracheostomy. Postoperatively, the patient was monitored in the intensive care unit for further management and was subsequently discharged to commence chemoradiotherapy. The tracheostomy tube remained in place at the time of discharge.

Lessons: This case underscored our commitment to enhancing expertise in airway management for patients with oral cancer. Our experience contributes valuable insights to the evolving field of airway management in complex head and neck surgeries.

Ambika Prasad Patra

Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India;

Benjamin R. Lewis^*, Kevin Byrne, Anna Beck

University of Utah, Salt Lake City, Utah, USA

Kevin A. S. Carroll^*, Jonathan Henglein, Paul Boland, Paul Gallagher, Kermaan Mehta, Sabatino A. Leffe, Oktay Shuminov, Alejandro Betancourt-Ramirez, Shannon F. R. Small

Department of Surgery, South Shore University Hospital, Northwell Health, Long Island, New York, USA

Introduction: The diagnosis and management of systemic toxicity in patients following regional infiltration analgesia is of paramount importance. While the mechanism and risk factors have been elucidated in previous studies, we believe that due to the potentially life-threatening nature of this rare occurrence, a greater focus on diagnostic precision and management enhancements is warranted.

Cases: Here, we describe three cases of LAST, the first in a 59 year old female following elective L4-L5 laminectomy and L5-S1 fusion, who suffered a cardiac arrest after receiving local Exparel and Marcaine at the time of closure; the second in a 69 year old woman following a rib block using local Exparel and Marcaine for the management of multiple rib fractures, who had a witnessed tonic-clonic seizure requiring intubation. The third patient is an 80-year-old male, who after an elective L4-L5 laminectomy and fusion, suffered a cardiac arrest after receiving local anesthetic (Exparel and Marcaine) at the time of closure. All patients were treated with intralipids and eventually recovered with no lasting deficits.

Conclusion: LAST events most commonly occur in the first minutes after injection, and are characterized by CNS and cardiovascular toxicities, as seen in these patients. Delayed presentations up to several days post exposure have been described. These cases exposed the opportunity for education in early recognition and most important, the need to improve the availability of intralipids. Prompt recognition and access to intralipid is critical to the treatment of LAST, and education regarding this rare but life-threatening condition is needed in surgical and trauma centers.

Roy G. Beran^1,2,3,4,5*

¹South Western Clinical School, University of New South Wales, Sydney, NSW, Australia

²Ingham Institute, The Liverpool Hospital, Sydney, Australia

³School of Medicine, Griffith University, South Port, Queensland, Australia

⁴School of Medicine, University of Western Sydney, Sydney, NSW, Australia

⁵Sechenov Moscow First State University, Moscow, Russia

Introduction: Pain is a common neurological complaint with many patients already taking narcotic analgesics at presentation to the neurologist. This paper examines an approach to pain management aimed to avoid narcotic analgesics.

Clinical Practice: Pain is subjective and may be considered as either acute or chronic pain, differentiated between pain provoking avoidance or pain without benefit. Pain management is determined by the underlying diagnosis and clinical status.

Use of Narcotic Analgesics: Narcotic analgesics have the potential for abuse and pose public health risks. Abuse has increased among street and recreational drug users. The Australian Government restricted access to combination codeine containing medications, requiring a prescription and medical supervision.

Discussion: While there exist specific pain syndromes, the use of narcotic analgesics should be judicious. Their use should be restricted to refractory pain but should not exclude their legitimate use, once alternative remediation has been exhausted and entails medical supervision.

Conclusion: Narcotic analgesics should not be the first line treatment for pain, with initial approach directed towards diagnosis and treating the underlying cause. Once refractory chronic pain has been established, narcotic analgesics should be available under medical supervision, acknowledging the risk of overuse and addiction.

Daniela Bravo¹, Rousmery Atton^2,3, Diego Mora¹, Julián Aliste^1,3*

¹Department of Anesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, University of Chile, Santiago, Chile

²Department of Anesthesiology, Pontificia Universidad Católica de Chile, Santiago, Chile

³Department of Anesthesiology, Clínica Las Condes, Santiago, Chile

Study Objective: This narrative review discusses the anatomy, mechanism of action, techniques, indications and complications of the pericapsular nerve group block in a hip surgery setting.

Interventions: The MEDLINE, EMBASE and Google Scholar databases (inception to the first week of March 2023) were searched. For anatomy, mechanism of action, techniques, and complications, cadaveric research, randomized trials, retrospective studies and case series were considered. Nonetheless, for surgery indications, to highlight the best evidence available, only randomized trials without major discrepancies with their prospective registration, blinded assessment and sample size justification were retained for analysis.

Main Results: The anatomical studies suggest that pericapsular nerve group block may work through a combination of different mechanisms (i.e., blocking lateral capsule nerves, local anesthetic spread to the femoral nerve, spread towards medial capsule nerves). Compared to alternatives, except for the periarticular local anesthetic infiltration, pericapsular nerves group block results in similar or improved postoperative analgesia in total hip arthroplasty. It should be noted that the motor blockade has not been completely circumvented and the scarcity of adequate studies on other surgical procedures prevents from obtaining further conclusions about its indications.

Conclusions: The pericapsular nerve group block has become very popular after its first description as an analgesic motor-sparing technique for hip fractures. However, without an absolute motor-sparing effect, its current indication is better supported in postoperative analgesia for total hip arthroplasty. Therefore, further investigation is required to find the optimal motor-sparing analgesic block for hip surgery.

Mustafa Karaoğlan

Department of Algology, Ordu State Hospital, Ordu, Turkey

Van N. Trinh^*, Joseph E. Villaluz

Department of Anesthesiology, Kaweah Health Medical Center, Visalia, CA, USA

Postoperative muscle spasm is a common complaint in the post-anesthesia care unit. Management of postoperative muscle spasm remains a major challenge as first-line anti-spasmodic agents are not without risk. Due to the adverse effects of sedation and risk for respiratory depression and pulmonary aspiration, conventional anti-spasmodic agents may not be an ideal choice for patients who are recovering from anesthesia. In this case series, we present three patients who underwent nonemergent surgeries with subsequent postoperative cervical muscle spasm that went unresolved with conventional PACU pain medications. Below, we demonstrate the potential utility of dexmedetomidine for management of postoperative muscle spasm. This is most notable when oral anti-spasmodic formulations are contraindicated in sedated patients and intravenous skeletal muscle relaxants are inaccessible in the PACU. After receiving incremental boluses of dexmedetomidine, the patients demonstrated immediate improvement in their cervical range of motion and their cervical muscle spasms were markedly reduced. Dexmedetomidine’s unique qualities, such as its quick onset, intravenous route of administration, and minimal effect on respiratory physiology, make it an ideal choice for management of postoperative muscle spasm.

Rachael W. Starcher¹, Craig R. Weinert¹, Kiersten Henry², Jeffery R. Dichter^1*

¹Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA

²MedStar Montgomery Medical Center, Olney, MD, USA

Intensive care units (ICU’s) are particularly susceptible to resource and personnel strain given the complexity and unpredictability of care. This featured prominently in the early course of the SARS-CoV-2 (COVID-19) pandemic, where poor patient outcomes were clearly linked to the increasing severity of ICU strain associated with decreased ICU capacity. Despite attempts at measuring ICU strain, there exists no operational model that ICU directors can implement to monitor strain or researchers can use to examine its effects.

This article reviews ICU strain indicators including census load (census, acuity, and admissions), ICU flow characteristics (admission/discharge criteria, sufficient staffing levels, and ICU performance), and consequence mediators (ICU queuing time and high-risk discharges) with attention to common themes and measures. Census load data suggests mortality risk is greater when ICU census starts higher, has high overall acuity, and with greater numbers of admissions especially when they arrive close together. Optimal ICU flow depends on maintaining a “strain mindset” when prioritizing patients, optimal ICU professional staffing, and maintaining high level ICU performance processes. Finally, delaying ICU admissions beyond six hours, or “after hours” or rushed ICU discharges result in increased mortality risk. Incorporating these ICU strain factors into an outcomes-focused model is proposed based on a conceptual framework with future research objectives recommended.

Swati Patel, Ashwini Reddy, Amiya Kumar Barik^*, Shiv Lal Soni, Narender Kaloria

Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Mandibulectomy most commonly performed as surgical management of oropharyngeal carcinoma leads to a wide array of anatomical and physiological changes which result in an anticipated difficult airway. There may be posterosuperior displacement of hyoid bone and tongue leading to reduction of retropalatal space along with loss of structural support to the tongue predisposing it to prolapse and development of obstructive sleep apnoea. Bulky flap reconstruction, limited mouth opening, and radiotherapy limiting neck mobility further compound the difficulty in airway management. This leads to a wide spectrum of issues ranging from difficulty in face mask ventilation to laryngoscopy and intubation. It is essential to individualize each case with a preformulated strategy outlining the primary and alternative approaches. A literature search was carried out using search engines like PubMed, Embase, Medline, and Google scholar using the terms “Difficult airway”, “Post-mandibulectomy”, “Difficult laryngoscopy, and Intubation”. The available literature was thoroughly reviewed by the authors before the final drafting of this article. A multidisciplinary team approach, thorough assessment, meticulous preparation, and critical decision-making are essential for successfully managing a difficult airway post-mandibulectomy.

Adrian G. Yabut, Joseph Evan Villaluz

Department of Anesthesiology, Kaweah Health Medical Center, Visalia, California, USA

Toshiyuki Kakinuma

Center for Human Reproduction, Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Japan

The World Health Organization (WHO) recommends using vacuum aspiration as a surgical treatment for spontaneous and surgical abortion in early pregnancy. They also state that dilatation and curettage (D & C) should be avoided from the perspective of safety and effectiveness and to prevent the risk of endometrial injury as it can cause thinning of the endometrium and Asherman syndrome. Maintaining a good endometrial environment is important for improving the chance of pregnancy. Manual vacuum aspiration (MVA) was developed in the 1970s. For spontaneous abortion in the first trimester, MVA reduces the risk of endometrial injury, leading to less intra- and postoperative pain and simplification of anesthesia during surgical treatment for spontaneous abortion. The WHO recommends administering standard pain relief during surgical treatment for medication-induced and spontaneous abortion but does not recommend using routine general anesthesia during MVA and D & C procedures. At our hospital, we perform MVA alone under local anesthesia using a paracervical block for the surgical treatment for spontaneous abortion in early pregnancy, and the safety and effectiveness of this has been previously reported. Here, we will describe the pain management strategy used at our hospital for spontaneous abortion in early pregnancy using MVA.

Alfredo Chiurazzi, Andrea Francioni, Neri Demarcus, Carlo V. Bellieni^*

Department of Pediatrics, University of Siena, Siena, Italy

Introduction: Pain is a major problem in clinical management of children. Pharmacological analgesia is the most commonly used analgesic treatment, but in some cases the use of non-pharmacological analgesic treatments (N-PAT) has been proposed.

Purpose: Our aims were to review the effectiveness and safety of N-PAT for pain relief in children, and to point out which are the most effective.

Material and Methods: We retrieved the clinical trials published in the years 2017-2022 in two databases: PubMed and Index Medicus, analyzing them with the PRISMA method. We used the following key-words: distraction, pain, child. Then we refined our search using in the same databases the key-words “pain” and “child”, matched with the terms that describe the N-PAT: “Virtual reality”, “Robot”, “Audiovisual distraction”, “Audio Distraction”, “Buzzy”, “Videogames”, “Parents verbal interactions”, “Distraction cards”, “Magic glove”, “Ipad”, “Picture book”, “Kaleidoscope”, “Soap bubbles” and “Hand massage”. Exclusion criteria were: reviews, case reports, papers in a language other than English, including patients other than children older than one month of age.

Results: We have screened 126 articles and 66 were excluded from the final pool. The most studied painful stimulation was needle procedures, where the most effective N-PAT was virtual reality, followed by the buzzy system. In the case of other painful procedures, few studies were available; however, in any of these painful stimulations effective analgesia was obtained with the use of virtual reality. Several studies eventually show that the combination of N-PAT with analgesic topic drugs provides more effective analgesia.

Conclusion: Some non-pharmacological treatments appear actually effective. The research in this field should be implemented to get more conclusive data, but our results are in favor of more extended use of N-PAT during potentially painful procedures.

Allan A. Abbass^1*, Joel M. Town¹, Steve Kisely²

¹Centre for Emotions and Health, Dalhousie University, Halifax, Canada

²Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia

Intensive short-term dynamic psychotherapy (ISTDP) has been studied for a broad range of somatic symptom presentations including chronic pain. Drawn from two recent meta-analyses, data using ISTDP treatment for pain conditions was extracted and meta-analyzed. Ten studies, including 6 randomized controlled trials, were examined. Short- and medium-term results were available and ISTDP yielded large and persistent treatment effects for both pain and depression within group. In the short-term follow-up, large within group effects were seen for measures of anxiety, and medium within group effects were seen on measures of interpersonal problems. When ISTDP was compared to cognitive behavioral therapy methods (CBT) in randomized controlled trials, it yielded superior effects to CBT on pain and depression measures in both short- and medium-term follow-up. There was evidence of heterogeneity which was reduced by removing 2 outlying studies, yet the results remained significant and of moderate to large effects. Two studies suggested the method was cost effective by reducing healthcare costs, medication and disability costs. Based on these findings ISTDP should be considered for chronic pain treatment guidelines. Future research directions are discussed.

Joana A. Almeida*, Andreia F. Sá, Ana M. Remelhe, Humberto S. Machado

Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Portugal

Background: Topical vasoconstrictors are commonly used to minimize bleeding during Ear, Nose and Throat surgeries. Phenylephrine is one of the most commonly used and could be an underrecognized source of intra-operative events. Total dose of administered drugs is often unmeasured.

Cases of acute pulmonary edema, cardiac arrest and death after topical vasoconstrictors (TV) have been reported. Maintenance of cardiac output is of paramount importance to avoid cardiovascular collapse. β1 receptor blockage reduces cardiac output, it is contraindicated in these situations.

Case: This case describes an intra-operative critical event after an unknown amount of phenylephrine administration.

Conclusion: Lack of awareness about phenylephrine maximum recommended dose may induce complications leading to haemodynamic instability. The authors aim to raise awareness about the use of TV, including dose, administration site and also clinical signs and symptoms that may appear after its use.  Special attention must be addressed to the drug choice for the support treatment of eventual cardiovascular symptoms.

Hilde M. Buiting^1,2,3,4*, Lisan Ravensbergen^4,5, Christa van Schaik⁶, Vincent K.Y. Ho⁷

¹Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands

²University Medical Center, Utrecht, the Netherlands

³University of Amsterdam, Amsterdam, the Netherlands

⁴O2PZ, Platform of Palliative Care, Amsterdam, the Netherlands

⁵Red Cross Hospital, Department of Anesthesiology, Beverwijk, the Netherlands

⁶Meander Medisch Centrum, Department of Medical Oncology, Amersfoort, the Netherlands

⁷Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands

Van N. Trinh, Joseph E. Villaluz

Department of Anesthesiology, Kaweah Health Medical Center, Visalia, California, USA

Filipe Antunes

Physical and Rehabilitation Medicine department & Chronic Pain Unit, Hospital de Braga, Sete fontes-São Victor, Braga, Portugal

Robert S Katz¹*, Frank Leavitt², Ben J Small³

¹Section of Rheumatology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA

²Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA

³Department of Rheumatology, Northwestern Memorial Hospital, Chicago, IL, USA

Jay Suggs*, Garrett G. Perry

Crestwood Medical Center, One Hospital Drive, Huntsville, AL, USA