Resumo em Inglês:

Abstract Background Geriatric patients undergoing major open abdominal surgery are at high risk for postoperative pulmonary complications and hypoxemia. Continuous Positive Airway Pressure (CPAP) after surgery may improve postoperative lung function. This randomized controlled trial compared two CPAP techniques ‒ automatic via nasal mask and constant via facial mask ‒ regarding pulmonary function and patient tolerance. Methods Sixty patients (≥ 60 years) were randomized (1:1) to receive either automatic CPAP (2-10 cm H2O) via a nasal mask (Group A) or constant CPAP (7.5 cm H2O) via a facial mask (Group C) upon arrival in the post-anesthesia care unit. Oxygenation (PaO2, PaO₂/FiO₂, SpO2) and spirometry (FVC, FEV1, PEF) were assessed preoperatively, postoperatively, and one hour after treatment. Comfort scores (0-10, with 0 indicating the best comfort) and complications were recorded. Results PaO₂/FiO2 improvement was lower in Group A (32.6 ± 26.3 mmHg) than in Group C (52.9 ± 40.1 mmHg; p = 0.023). FVC improvement was also lower in Group A (3.7% ± 4.0%) than in Group C (6.7% ± 4.9%; p = 0.012). However, Group A had better tolerance, with lower comfort scores (2 [2-3] vs. 3 [2-4], p = 0.002). Pulmonary function benefits were more pronounced in patients over 70 and those undergoing upper abdominal surgery. Conclusion Both CPAP techniques prevent pulmonary decline in geriatric patients post-surgery. While automatic CPAP provides better comfort, constant CPAP improves oxygenation. Although our findings are short-term, they suggest that CPAP mode selection should be tailored based on patient-specific needs.

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Abstract Objective This study compared the Pericapsular Nerve Group (PENG) block combined with the Lateral Femoral Cutaneous Nerve (LFCN) block to the anterior Quadratus Lumborum Block (QLB) in patients undergoing Total Hip Arthroplasty (THA). Methods In this prospective, double-blind trial, 80 adults scheduled for THA under spinal anesthesia were randomized to receive either an anterior QLB (n = 40) with 30 mL of 0.25% bupivacaine or a combined PENG + LFCN block (n = 40) using 25 mL of 0.25% bupivacaine for PENG and 5 mL for LFCN. The primary outcome was cumulative 24 hour postoperative intravenous morphine consumption. Secondary outcomes included pain scores, quadriceps strength, patient satisfaction and side effects. Results No significant differences were observed between the groups in morphine consumption or pain scores during the first 12 hours (p > 0.05). At 24 hours, the PENG + LFCN group demonstrated significantly lower morphine consumption (p = 0.027) and resting VAS scores (p < 0.001). Quadriceps weakness occurred in 15% (6/40) of anterior QLB patients at 6 hours (p = 0.026), whereas no weakness was observed in the PENG + LFCN group within 24 hours. Patient satisfaction and the incidence of complications were comparable between the groups. Conclusion Both anterior QLB and PENG + LFCN blocks provide effective analgesia for up to 12 hours post-THA. However, the PENG + LFCN combination offers prolonged analgesia, reduced opioid requirements and better preservation of quadriceps strength.

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Abstract Background To facilitate the surgical view, laparoscopic and robotic pelvic surgeries require a pneumoperitoneum with the Trendelenburg position, which may result in elevated Intracranial Pressure (ICP). The choice of anesthetic agents may also influence ICP. Ultrasonographic evaluation of the Optic Nerve Sheath Diameter (ONSD) is a promising way to evaluate ICP. In this systematic review, we aimed to evaluate the ONSD, as an indirect estimation of ICP, in patients undergoing laparoscopic/robotic surgeries under pneumoperitoneum and Trendelenburg position. Methods A literature search was performed to identify prospective randomized clinical trials in which the primary endpoint was the evaluation of the ONSD using sevoflurane or propofol anesthesia after the onset of pneumoperitoneum and Trendelenburg position. The mean and the standard deviation of the ONSD in each intervention group were extracted from the included trials for analysis. Mean difference with 95% Confidence Interval (95% CI) was calculated. Results Five randomized controlled trials, with 277 subjects, were allocated to this study. Compared with the baseline, there was an increase in ONSD from 0.5h to 3 hours (p < 0.05) in both propofol and sevoflurane groups. Furthermore, propofol reduced the ONSD compared to sevoflurane (mean difference: -0.23 mm, 95% CI: -0.37 to -0.10; studies = 5; I2 = 23%). Conclusion There is evidence indicating, through ultrasonographic analysis of the ONSD, that propofol probably reduces ICP compared to sevoflurane in robotic and laparoscopic pelvic surgeries.

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Abstract Background Video-Assisted Thoracoscopic Surgery (VATS) is a minimally invasive procedure associated with faster recovery and fewer complications compared to open thoracotomy. Effective postoperative pain management is important for optimizing recovery. This study compares the analgesic efficacy of the Serratus Posterior Superior Intercostal Plane Block (SPSIPB) and Thoracic Paravertebral Block (TPVB) for postoperative pain following VATS. Methods In this randomized, prospective, double-blind study, 70 patients aged 18-65 years (ASA I-III) undergoing VATS were randomly assigned to Group TPVB (n = 35) or Group SPSIPB (n = 35). The primary outcome was the 24-hour postoperative Visual Analog Scale (VAS) pain score at rest. Secondary outcomes included VAS pain scores during coughing, time to first opioid request, total opioid consumption within 24 hours, patient satisfaction, and Quality of Recovery-15 (QoR-15) scores. Opioid consumption was assessed using intravenous tramadol through Patient-Controlled Analgesia (PCA), with additional morphine, if required. Results The mean age of the patients was 52 ± 11 years, and 64.2% were male. VAS pain scores were evaluated at 24 hours and at seven time points. There was no significant difference between groups (p > 0.05) except at 1 hour postoperatively, where the TPVB group had a significantly lower resting VAS score (19 [8-28] vs. 26 [18.5-33], p = 0.031). The total 24 hour tramadol consumption was 220 mg (135-260) in the TPVB group versus 150 mg (110-230) in the SPSIPB group (p = 0.129). The proportion of patients requiring additional analgesia was 25.7% in the TPVB group versus 28.5% in the SPSIPB group (p = 0.788). Preoperative and postoperative QoR-15 scores were similar between the groups (preoperative: 137 vs. 136, p = 0.878; postoperative: 133 vs. 132, p = 0.814). Patient satisfaction scores were also comparable (8 [7-10] vs. 9 [7-10], p = 0.789). Conclusion SPSIPB provides analgesic efficacy similar to TPVB for VATS, with comparable pain scores, opioid consumption, and recovery outcomes. Given its ease of use and safety profile, SPSIPB represents a promising alternative to TPVB in multimodal analgesia for minimally invasive thoracic surgery.

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Abstract Background Post Spinal Anesthesia Shivering (PSAS) is common and linked to increased morbidity. While various methods exist to prevent it, no study has compared Nefopam and Ondansetron. This study aims to compare Ondansetron and Nefopam in preventing PSAS. Methods A prospective, randomized, controlled, and double-blind trial was conducted in the operating room of a tertiary university hospital from April 5, 2021 to April 30, 2022. It included patients aged between 18 and 65 years scheduled for surgery under spinal anesthesia. Patients received either 8 mg of Ondansetron or 20 mg of Nefopam administered intravenously over 30 min before spinal anesthesia. Main outcome measures included the number and grades of shivering episodes post spinal anesthesia at 15-minute intervals until post-anesthesia care unit discharge. Secondary outcomes included number of episodes of hypotension, bradycardia, nausea and/or vomiting. Tympanic temperature and pain at the injection site were also recorded. Results The study included 150 patients, evenly divided between the two groups. The Ondansetron group had a higher incidence of shivering compared to the Nefopam group (23.9 % vs. 16 %; p = 0.038), as well as higher incidences of hypotension (16 % vs. 5.3 %; p = 0.035) and bradycardia (13.3 % vs. 2.7 %; p = 0.016). The Ondansetron group had a significantly lower incidence of nausea and vomiting (12 % vs. 1.3 %; p = 0.010). More patients in the Nefopam group (45.3 %) reported pain during drug infusion. Conclusions Nefopam seems to be more effective than Ondansetron in preventing PSAS with fewer cardiovascular side effects. However, Ondansetron reduces the incidence of nausea and vomiting and causes no pain during administration.

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Abstract Background Postoperative Sore Throat (POST) may result in patient dissatisfaction and distress, which could possibly delay discharge. Various pharmacological and non-pharmacological approaches have been explored, yet effective techniques remain elusive. This research evaluates the impact of intra-cuff Dexamethasone, Ketamine, and normal saline on alleviating POST symptoms. Methods In this randomized controlled trial, 405 adult patients aged 18‒60 years undergoing short pelvic laparoscopic surgeries under general anesthesia for 1‒3 h requiring endotracheal intubation were enrolled. Patients were randomized into Group N (intra-cuff normal saline), Group D (intra-cuff Dexamethasone), and Group K (intra-cuff Ketamine). The primary outcome of this study was the incidence and severity of POST at 2, 6, 12, and 24 hours after extubation. Secondary outcomes were the incidence and severity of postoperative hoarseness of voice and postoperative cough at various time intervals. Results There were more patients in Group D without symptoms of POST (92.59 %) than in Group K (74.07 %) and Group N (67.41 %) (p < 0.0001) at 2 h. Similarly, more patients had no symptoms of postoperative hoarseness of voice (93.33 %) and postoperative cough (93.33 %) in Group D at 2 h. Furthermore, Group D consistently exhibited the lowest incidence of POST, postoperative hoarseness of voice, and postoperative cough at various time intervals. Conclusions Intra-cuff Dexamethasone appears to be a favourable intervention for symptom alleviation of POST, postoperative hoarseness of voice, and postoperative cough during the early postoperative period. Clinical Trial Registry Number CTRI/2022/08/044,664.

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Abstract Background and objective Videolaryngoscopy have transformed airway management by improving intubation success rates compared to direct laryngoscopy. However, its widespread adoption has been hindered by the lack of standardized classification tools for documentation and communication. This manuscript outlines the rationale and study design of the VCISpain project, which aims to evaluate the interobserver reproducibility of the Video Classification of Intubation (VCI) scale in the context of airway management using videolaryngoscopy in Spain. Methods This manuscript presents the planned methodology of the VCISpain study, a prospective, observational, multicenter, open-label study. The study will collect data on tracheal intubations performed in operating rooms, intensive care units, and emergency departments. In each case, two anesthesiologists will independently apply the VCI scale to assess blade type, Percentage of Glottic Opening (POGO), and ease of intubation. Ethics and registration The study was approved by the University of Navarra Ethics Committee (2022.079 mod1) and registered on ClinicalTrials.gov (NCT06537531). It is endorsed by the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR) and the European Airway Management Society (EAMS). Conclusions VCISpain seeks to establish a standardized classification tool for documenting and communicating findings related to videolaryngoscopy in airway management. By presenting the study rationale and design, this protocol aims to promote transparency, ensure methodological rigor, and encourage broader discussion to refine the study prior to implementation.

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Abstract Background The older population is growing, and it is estimated that, by 2050, people aged 60-years or more will have reached two billion. The increased life expectancy has led to a higher incidence of chronic degenerative diseases, contributing to increased pain complaints. This study aims to compare the pain threshold after mechanical stimulation in older adults according to gender and presence or absence of chronic pain and find the prevalence and intensity of chronic pain in this population. Methods This was a cross-sectional observational study with a convenience sample in the outpatient clinic at two research centers. All participants answered sociodemographic and clinical questionnaires, and the Pressure Pain Threshold (PPT) was assessed with an algometer. Patients reporting chronic pain answered the Geriatric Pain Measure (GPM) questionnaire. Results The sample consisted of 230 individuals, aged 60 to 96 years, 67.8% women and 32.2% men. Chronic pain prevalence was 47.8%, 29.7% in men and 56.4% in women. PPT was significantly lower in women (4.49 ± 1.78 kg) than in men (6.41 ± 1.92 kg). PPT in older individuals presenting chronic pain (4.58 ± 1.93 kg) was lower than in older individuals without chronic pain (5.58 ± 2.01 kg). There was no significant difference between genders in pain assessment by GPM. Conclusions Pressure pain threshold was lower in older women and in patients with chronic pain, the association between gender and lower pain threshold was stronger than observed with chronic pain.

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Abstract Background The efficacy of the Hypotension Prediction Index (HPI) for reducing Intraoperative Hypotension (IOH) among patients undergoing non-cardiac surgeries remains unclear. We aimed to perform a systematic review, meta-analysis, and trial sequential analysis to determine whether the HPI is effective for adult patients undergoing non-cardiac surgeries. This study was prospectively registered in the PROSPERO database (CRD42024571931). Methods PubMed, Embase, and Cochrane were systematically searched for Randomized Controlled Trials (RCTs) comparing HPI-guided therapy with standard care in non-cardiac surgeries. We computed Mean Difference (MD) and Risk Ratios (RR) for continuous and binary outcomes, respectively, with 95 % Confidence Intervals (95 % CI). Statistical analyses were performed using R Software, version 4.2.3. Results We included 11 RCTs, comprising a total of 789 patients, of whom 395 (50.1 %) received HPI-guided management. HPI significantly reduced the Time-Weighted Average (TWA) of Mean Arterial Pressure (MAP) < 65 mmHg (MD = -0.23 mmHg.min-1; 95 % CI -0.35 to -0.10; p < 0.01) and the Area Under the Curve (AUC) of MAP < 65 mmHg (MD = -97.2 mmHg.min-1; 95 % CI -143.4 to -50.98; p < 0.01). HPI also decreased the duration of MAP < 65 mmHg (MD = -16.22 min; 95 % CI -25.87 to -6.57; p < 0.01) and the number of hypotensive episodes per patient (MD = -3.38; 95 % CI -5.38 to -1.37; p < 0.01). No significant differences were observed in the number of hypotensive events, phenylephrine use, or AKI incidence (p > 0.05). Conclusion In adult patients undergoing non-cardiac surgeries, HPI use was associated with a reduction in the duration and severity of IOH, with no significant difference for adverse events. Limitations include significant heterogeneity across studies, differences in HPI implementation, and lack of long-term outcome data.

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Abstract Background Effective pain management and expedited recovery are critical in pediatric cardiac surgery. While regional anesthesia techniques provide targeted pain control and may reduce opioid use and related complications, comparative evidence among regional nerve blocks in this population is limited. This study aimed to conduct a systematic review and network meta-analysis to support clinical decision-making for optimal analgesia. Methods We conducted a Bayesian Network Meta-Analysis (NMA) including Randomized Controlled Trials (RCTs) of pediatric patients (0-12 years) undergoing cardiac surgery by sternotomy and receiving preemptive regional nerve blocks. Primary outcomes included pain scores, opioid consumption and extubation time. Both direct and indirect evidence were synthesized to rank interventions probabilistically. This study was registered on PROSPERO (CRD42024585785) and followed PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions. Results The NMA incorporated 12 RCTs, comprising 969 participants, and evaluated seven regional nerve blocks. Among the techniques studied, transversus Thoracis Muscle Plane Block (TTPB) consistently ranked among the most effective for pain relief and recovery. Other blocks, including thoracic retrolaminar block and thoracic paravertebral block, also demonstrated notable performances. Adverse events were infrequent but inconsistently reported, preventing an adequate analysis. Conclusion This NMA identified TTPB as a consistently top-performing technique across outcomes. These findings provide promising support for its inclusion in ERAS protocols, although further high-quality trials are needed. Registration PROSPERO ID: CRD42024585785.