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Challenges and Opportunities in Anesthesiology

Challenges and Opportunities in Anesthesiology

Aliaga, J., Ojeda, A., Comino-Trinidad, O., Cuñat, T., Arias, M., & Calvo, A. (2023). 

Abstract

Introduction: The COVID-19 pandemic has resulted in a significant number of cases worldwide, leading to a substantial increase in Intensive care unit (ICU) admissions. Survivors of critical illness are known to experience long-term physical, cognitive, and psychological impairments. Chronic pain is also a prevalent complication, and specifically, neuropathic pain (NP) is strongly linked to a diminished quality of life. This narrative review aims to investigate the incidence, causes and manifestations of NP in critical illness COVID survivors.

Methods: A comprehensive search of the Pubmed database was conducted on May 31, 2023, using the keywords “Covid-19” OR “Sars-cov-2” combined with “neuropathic pain” and “critical care” OR “intensive care unit” to identify relevant publications in English or Spanish pertaining to adult human subjects. The search process adhered to the recommended flowchart format outlined in the PRISMA 2020 statement.

Results:  The primary search yielded 26 results. Eight results were excluded as they did not pertain to COVID-19 pain.

Discussion: Intensive care survivors can develop new onset pain and chronic pain though various mechanisms. In the case of critical illness COVID-19 survivors, pain may arise due to viral neurotropic potential, immune-mediated reactions, and microvascular complications. Studies have reported new-onset upper extremity NP, with ulnar neuropathy being the most prevalent, followed by brachial plexus, axillary, and median neuropathies. Lower limb NP particularly sciatic neuropathy has also been documented, along with peroneal nerve, meralgia paresthetica, and femoral neuropathy. Cranial neuropathies, such as facial palsy and trigeminal neuralgia, have been observed in case series. Additionally, widespread pain frequently associated with critical illness neuromyopathy may be present. Notably, COVID-19 survivors with critical illness may experience nociplastic pain and conditions related to central sensitization, posing challenges in distinguishing them from those with Long-COVID syndrome.

Conclusion: Further research is crucial to gain a comprehensive understanding of the neurological consequences arising from critical COVID-19 illness. Healthcare professionals should maintain a high suspicion index for NP in this population. Advancing our knowledge of NP in COVID-19 survivors can help develop effective strategies to enhance overall patient outcomes.

De Mendonça, M. C. (2023).

Abstract

Anesthesiology is nowadays an independent and multidisciplinary speciality of great demand and responsibility and plays a preponderant role in the human life, from the moment of birth.

Anesthesiology has evolved since the earliest times to the present, along with the advances of science, intercepting most medical and surgical specialties, to the extent of being essential to us nowadays.

From the days of magic to the present time, the history of the speciality deserves to be visited.

This article of historical research provides a timeline review of the main themes and milestones of the specialty all over the world and particularly in Portugal, from ancient control of pain, the evolution of ressuscitation and critical care until the new technics and holistic care provided by modern Anesthesiology.

Zhang, J., Raines, D. E., Cogswell, L. P., & Strichartz, G. R. (2022).

Abstract

Binding of local anesthetics to plasma proteins has been presented as an important determinant of their bioavailability. Local anesthetics with a high potential for systemic toxicity, e.g. bupivacaine (BUP), are bound strongly by alpha1-acid glycoprotein (AAG), more weakly by serum albumin, but drug dissociation may be rapid, thus limiting the importance of protein binding. The purpose of this study was to determine the binding kinetics of BUP to AAG. Bupivacaine binding to AAG was monitored by its displacement of the fluorescent probe 1-anilinonaphthalene-8-sulfonic acid (ANS). The increased fluorescence of ANS (λ excit/em = 380/480 nm) upon binding to AAG was used to determine the equilibrium and kinetic characteristics of this reaction. By studying how BUP altered the binding kinetics of ANS to AAG it was possible to calculate the BUPs equilibrium and kinetic rate constants for AAG binding. ANS fluorescence increased ca. 50-fold when bound to AAG.  Increasing [BUP] with a constant [AAG] + [ANS] returned ANS fluorescence to its unbound status, due to complete displacement of ANS from AAG; bupivacaine’s competitive equilibrium constant, Ki , equals 1-2 μM (pH 7.4, 23oC). Pre-equilibrating AAG with BUP before the rapid (0.008s) addition of excess ANS slowed the binding of ANS to a rate limited by BUP’s dissociation: koff = 12.0 ± 0.5 s-1, corresponding to a half-time ~0.06 seconds. Therefore, although much of the total serum BUP at toxic levels (2-4 µg/mL) will be bound by plasma proteins, dissociation from the tightest binding protein shows that drug is rapidly freed during organ perfusion, allowing newly unbound drug to permeate into the perfused tissues. The very rapid dissociation of BUP from AAG means that equilibrium binding is a very poor index of bio-availability and systemic toxicity of that local anesthetic.

Krishnamurti, C., Mehdi, Z., & Chandrasekhar, V. (2023). 

Abstract

Over the past decade, the practice of anesthesiology had become inextricably dependent upon technology. Anesthetics were first discovered, then made increasingly safe, and now, more precise and efficient, all due to tremendous advances in monitoring and delivery technology. Telemedicine has revolutionized medicine and preoperative evaluations and teaching are being done via teleconference and zoom meetings. Patient monitoring has become noninvasive, and closed-loop anesthesia delivery systems are making anesthetic administration very precise and safe. Next-generation technology and innovations will eliminate human errors entirely.

Guevara-López, U., Luna, M. S., & Ramírez, E. H. (2023). 

Abstract

Background: The teaching-learning process is a fundamental competence in high-risk environments such as the operating room. Although conventional approaches are based on learning from negative performance, it is convenient to visualize the virtuous behavior of actors in specialties where security events are latent.

Objective: to explore through a survey the perception of crisis in the teaching of anesthesia in Mexico, and to identify the possible causes and precipitating factors.

Methods: A prospective observational design was used, prior approval from the research ethics committee. It was studied by means of a survey with 40 items to people who carry out their professional practice in the Mexican Republic. The positive and/or negative characteristics of specialists, student teachers, the educational program and work environment were explored.

Results: 1,125 participants responded. The highest percentage believed that there is a severe deficit in the teaching of the specialty, indicating in descending order the students, the work environment, and in similar proportions, the structure of the program and the characteristics of the teachers as the causes. Significant statistical differences were found in the attitude and values of the residents, in lack of adherence to educational programs, in the lack of stimuli, motivation and lack of recognition and encouragement to teachers, p < 0.000.

Conclusions: Our findings indicate that anesthesiologists are doing many things “right”, but the existing educational deficit can be corrected to avoid an eventual crisis, suggesting a clinical practice based on evidence and values in a better environment.

Blum, K., Gold, M. S., Cadet, J. L., Lewis, M., McLaughlin, T. J., Braverman, E. R., Elman, I., Carney, B., Cortese, R., Abijo, T., Bagchi, D., Giordano, J., Dennen, C. A., Baron, D., Thanos, P. K., Soni, D., Makale, M., Makale, M., Murphy, K. L., . . . Badgaiyan, R. D. (2023b). 

Abstract

Addiction, albeit some disbelievers like Mark Lewis [1], is a chronic, relapsing brain disease, resulting in unwanted loss of control over both substance and non- substance behavioral addictions leading to serious adverse consequences [2]. Addiction scientists and clinicians face an incredible challenge in combatting the current opioid and alcohol use disorder (AUD) pandemic throughout the world. Provisional data from the Centers for Disease Control and Prevention (CDC) shows that from July 2021-2022, over 100,000 individuals living in the United States (US) died from a drug overdose, and 77,237 of those deaths were related to opioid use [3]. This number is expected to rise, and according to the US Surgeon General it is highly conceivable that by 2025 approximately 165,000 Americans will die from an opioid overdose. Alcohol abuse, according to data from the World Health Organization (WHO), results in 3 million deaths worldwide every year, which represents 5.3% of all deaths globally [4].

Kissin, I. (2022). 

Abstract

Purpose: The current study assesses how academic medical journals reflected the prescription opioid death crisis. The principal aim was to answer the question: How long did it take to reach definite bibliometric acknowledgment of deaths from opioid epidemic?

Methods: Death-related bibliometric indices were determined for opioids associated with increased mortality. The main of them is the percentage of articles on an individual opioid associated with death among all PubMed articles on that opioid. The bibliometric indices were followed for six 5-year periods, from 1988 to 2017.  The time course for each of the indices were compared for two groups of opioids: 1) Those used for the treatment of chronic pain (“root cause of the epidemic”) – such as oxycodone, hydrocodone, and tramadol, and 2) Those which were always associated with the death due to addiction — heroin and methadone.  The difference in death-related bibliometric indices between these two groups of opioids was used as an indicator of changes in presentation of opioid deaths.

Results: The articles reporting death associated with oxycodone, tramadol, or hydrocodone became noticeable during 2003-2007, ten years after the beginning of epidemic (1993-1997).  It was only in 2013-2017 mortality associated with these opioids were presented at the levels close to those of heroin or methadone. Only during 2013-2017 (twenty years after the beginning of epidemic) was death associated with oxycodone presented in journals as openly (in the article’s titles) as that associated with heroin, or methadone.

Conclusion: The danger of death from treatment of chronic pain with opioids was not properly appreciated for almost twenty years.

Takorov, I., Lukanova, T., Simeonovski, S., Vylcheva, D., Dimitrov, D., Stanimirov, T., Arnaudov, S., & Abrasheva, M. (2022). 

Abstract

Spontaneous pneumomediastinum is one of the few rare complications of coronavirus disease – 19 (COVID-19) pneumonia. We report a case of a male patient with COVID-19 disease, severe pneumonia and spontaneous pneumomediastinum, supported via high-flow nasal cannula (HFNC) oxygen supplementation. Factors causing pneumomediastinum are discussed, but further research is still necessary.

Caes, L., Wallace, E., Duncan, C. L., & Dick, B. (2022). 

Abstract

Background: Optimal executive functioning is pivotal to successful self-management of chronic pain (e.g., by being able to adapt self-management behaviours to changing situations), thereby contributing to improved health-related quality of life. However, preliminary evidence points to impaired executive functioning in people with chronic pain. Despite adolescence being identified as a sensitive period for the development of appropriate self-management and executive functioning skills, little is known about the associations between chronic pain and executive functioning performance in adolescents. The aim of the study was to pilot a multi-method approach to compare executive functioning, chronic pain, and quality of life between adolescents with and without chronic pain.

Methods: A sample of 22 adolescents with chronic pain (12-18 years, 82% female, mean chronic pain duration = 6.68 years) and 13 pain-free adolescents (age and sex matched) participated. All participants completed a battery of neuropsychological tasks to assess the three key executive functioning components (i.e., inhibition, working memory and cognitive flexibility) and provided self-report on their executive functioning, pain experiences and health-related quality of life.

Results: In addition to confirming the feasibility of the methods, data revealed that 23-62% of adolescents with chronic pain showed problematic performance, using normative scoring, in all three executive functioning components and showed significantly lower performance on all three executive functioning components compared to pain-free adolescents. Self-reported, but not neuropsychologically assessed, working memory and emotional control difficulties were associated with more pain-related interference and lower health-related quality of life.

Conclusion: These preliminary findings reveal the critical need to screen for and address any potential deficits in executive functioning in adolescents with chronic pain to optimise their self-management of pain and subsequent health-related quality of life. The findings also illustrate the feasibility of and need for future systematic, multi-method and prospective investigations in larger samples to further clarify the cyclical associations between chronic pain and executive functioning in adolescents.

Carr, Z. J. (2023). 

Abstract

Background: Systemic sclerosis (SSc) is a rare autoimmune disorder with pathological manifestations affecting multiple organ systems. Few studies have examined perioperative outcomes in patients with this disorder. The primary aim of this retrospective single-center comparative cohort analysis was to estimate the incidence of select perioperative complications in a population of SSc patients. In an exploratory analysis, we analyzed the relationship between SSc and susceptibility to select perioperative complications when treated at a large quaternary-care institution.

Methods: We conducted a single-center retrospective, comparative cohort study to compare perioperative outcomes in a SSc (n=258) and a frequency matched control cohort (n=632). We analyzed for the presence of major composite infection (MCI), major adverse cardiac events (MACE), 30-day readmission, 30-day mortality, in-hospital complications, length of stay and airway management outcomes.

Results: MCI was higher in the SSc compared to the control cohort [adjusted odds ratio (ORadj)=5.02 (95%CI: 2.47-10.20) p<0.001]. Surgical site infection (3.5% vs. 0%, p<0.001), and other infection types (5% vs. 0%, p<0.001) were higher in the SSc cohort. MACE was not significantly different between SSc vs. Control groups [6.2% vs. 7.9%, ORadj=1.33 (95%CI: 0.61-2.91) p=0.48]. Higher rates of limited cervical range of motion (13.6% vs. 3.5%, p<0.001), microstomia (11.5% vs. 1.3%, p<0.001) and preoperative difficult airway designation (8.7% vs. 0.5%, p<0.001) were observed in the SSc cohort. Bag mask ventilation grade was similar between groups (p=0.44). After adjustment, there was no between-group difference in Cormack-Lehane grade 3 and 4 view on direct laryngoscopy in SSc patients [ORadj = 1.86 (95%CI: 0.612 -5.66) p=0.18] but evidence of higher rates of video laryngoscopy [ORadj= 1.87 (95%CI:1.07 – 3.27) p=0.03]. Length of stay [median: 0.2 vs. 0.3 days, p=0.08], 30-day mortality [1.2% vs. 0.6%, ORadj=2.79 (95%CI: 0.50-15.6) p=0.24] and readmission [11.5% vs. 8.1%, ORadj=1.64 (95%CI: 0.96 – 2.82) p=0.07] were not statistically significant.

Conclusions: SSc patients demonstrate mostly similar rates of MACE, 30-day mortality, length of stay intraoperative and airway complications. There is evidence of increased risk of overall 30-day MCI risk and readmission after endoscopic procedures.

Bruce, B. K., Weiss, K. E., Ale, C. M., Allman, M., Harrison, T. E., & Fischer, P. R. (2022). 

Abstract

Importance: Estimates suggest that 1% of all teens struggle with Postural Orthostatic Tachycardia Syndrome.  It can be a devastating condition for the adolescents who do not respond to the currently available pharmacologic and non-pharmacologic interventions. Preliminary data suggests that intensive interdisciplinary treatment may provide an effective intervention that can return these youth to normal functioning including full-time attendance at school, as well as reduce orthostatic symptoms, and psychological distress.  

Objective: To determine the effectiveness and durability of a 3-week interdisciplinary treatment in adolescents with Postural Orthostatic Tachycardia Syndrome in improving orthostatic symptoms, functioning, and psychological distress.

Design: Patients diagnosed with Postural Tachycardia Syndrome admitted to an interdisciplinary treatment program were assessed at admission, discharge and 3-month follow-up to determine presence and severity of orthostatic symptoms, as well as functional status including return to school, and depression.

Setting: An intensive interdisciplinary treatment program in a tertiary hospital outpatient setting.

Participants: Forty-five adolescents ages 12-18 with confirmed diagnoses of Postural Tachycardia Syndrome referred to a tertiary medical center for interdisciplinary treatment. 

Intervention:  A 3-week intensive outpatient interdisciplinary rehabilitation program with significant parental involvement based on a cognitive-behavioral model.

Main Outcome and Measure(s): Self-reported orthostatic symptoms were assessed with the Compass 31; level of functioning was assessed with the Functional Disability Index, depressive symptoms were assessed with the Center for Epidemiological Studies-Depression for Children, and self-reported school attendance was assessed. 

Results: Significant improvements were observed and maintained at the end of treatment and at 3-month follow-up on measures of orthostatic symptoms, physical functioning, and psychological distress.  At admission, 32% of patients had completed high school or were attending school full-time. At 3-month follow-up, 90% were either attending school full-time or had completed their schooling.

De Witte, P., Bruins, P., Boerma, D., & Kemmel, V. (2023). 

Abstract

Background:     Surgical cytoreduction and simultaneous hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) is a common treatment for peritoneal carcinomatosis. During intraperitoneal chemotherapy, mitomycin C is frequently used. Mitomycin C is known to be nephrotoxic. Little is known about the effect of systemically absorbed mitomycin C on renal function during HIPEC surgery.

Methods: In twenty-two patients undergoing cytoreductive surgery and HIPEC for peritoneal carcinomatosis the systemic levels of mitomycin C were measured in plasma. The relation of plasma levels of mitomycin C with duration of surgery and complexity of surgery was evaluated.

Furthermore, we evaluated the relation between systemic mitomycin C levels with renal function.

Results Two patients of the total of 22 patients developed acute kidney injury. In these patients, preoperative creatinine level increased from (1) 109 μmol/L to maximum 890 μmol/L on the 6th postoperative day after which renal replacement therapy was started and (2) from 67 μmol/L to 213 μmol/L. Whereas maximum plasma levels of mitomycin C in these 2 patients were 145 μg/L and 280 μg/L compared to the levels in the other patients (167 μg/L ±80.8). Peak levels of plasma creatinine were on post operative day 2. None of the other patients needed renal replacement therapy. Eight patients showed significant increase of plasma creatinine levels, i.e. >20% increase from preoperative values. We did not observe a correlation between complexity of surgery, increased absorption of mitomycin C, higher mitomycin C plasma levels and signs of kidney injury.

Conclusions:     Systemic absorption of mitomycin C during HIPEC surgery is independent to extension of cytoreductive surgery and duration of surgery. In this small study group, we observed an impairment of renal function which may be related to systemic absorption of mitomycin C. Further research is warranted to answer possible association of mitomycin C levels in patients at risk for development of AKI.

Mykola, O., Oleksandr, T., Bohdan, K., Volodymyr, L., Serhii, S., Larysa, L., Maksym, K., Maksym, S., Alona, S., Serhii, B., & Oleksandra, S. (2022). 

Abstract

Introduction. Pulmonary tuberculosis is a serious problem as in Ukraine as throughout the world. The number of patients with pulmonary tuberculosis is increasing year by year, which is due to the difficulties in early detection of this disease.

The aim. To determine the effectiveness of surgical treatment of patients with pulmonary tuberculosis by using video-assisted thoracoscopic interventions.

Methods. In the Department of Thoracic Surgery of the State University “National Institute of Phthisiology and Pulmonology named after F. G. Yanovsky NAMS of Ukraine” from 2008 to 2022 140 video assisted lung resections were performed in a planned manner for phthisis-surgical patients. The distribution according to the type of resection intervention was as follows: atypical segmental resection – in 30 (21.4 %) cases, typical segmentectomy – in 50 (35.7 %), lobectomy – in 52 (37.2 %), bilobectomy – in 3 (2.1 %), pulmonectomy – in 5 (3.6 %).

The results. The average duration of operative VATS resection interventions was (75.1 ± 22.3) min., intraoperative blood loss was (85.4 ± 1.6) ml, duration of narcotic analgesics prescription in patients with video-assisted thoracoscopic lung resections was (2.20 ± 0.04) days. Early mobilization of patients recorded in 112 (80.0 ± 3.4) cases. The average length of stay of the patient in the intensive care unit after video-assisted thoracoscopic lung resection was (2.6 ± 0.8) days, length of stay of the patient in the hospital in the postoperative period was (12.4 ± 0.5) days. Intraoperative complications were diagnosed in 7 (5.0 ± 1.8) % of patients. The rate of postoperative complications was 22 (15.7 ± 3.1) % of observation. There was no postoperative mortality after minimally invasive surgical interventions. The overall efficiency of performing video-assisted thoracoscopic lung resections was 97.1 %.

Conclusion. The use of video-assisted thoracoscopic is a convenient, effective and low-traumatic method in the treatment of patients with pulmonary tuberculosis. The overall effectiveness of video-assisted thoracoscopic methods for pulmonary tuberculosis was 97.1 %. An adequate assessment of the possibility of performing video-assisted thoracoscopic and the use of methods to prevent complications ensures a predictable course of the intra- and postoperative periods and increases the effectiveness of surgical interventions.

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