Academy Library and Information Service Current Awareness Bulletin - Anaesthetics April 2021
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Academy Library and Information Service
Current Awareness Bulletin – Anaesthetics
April 2021
This Current Awareness Bulletin is produced by Academy Library and Information Service GWH staff with a
range of resources to support practice. It will include recently published systematic reviews, research articles
and details of library resources.
You may be able to access some articles if you have an OpenAthens account. Click on the logo above to register.
For further information or support, please contact the Academy Library on 01793 604596 or email:
gwh.alis@nhs.net.
Resources
BMJ Best Practice uses the latest evidence-based research, guidelines and expert opinion to offer step-by-
step guidance on diagnosis, prognosis, treatment and prevention.
DynaMed study summaries provide brief and clinically oriented descriptions of clinical research studies,
placed in context within the clinical framework. Key elements of a DynaMed study summary include the
study conclusion, level of evidence rating, study type, reference, and study details.
Trip is a clinical search engine designed to allow users to quickly and easily find and use high-quality
research evidence to support their practice and/or care. As well as research evidence we also allow
clinicians to search across other content types including images, videos, patient information leaflets,
educational courses and news.
Synopses/Summaries
American Society of Anesthesiologists (ASA)
Standards for Basic Anesthetic Monitoring (2021)
Available online at this link
These standards apply to all anesthesia care although, in emergency circumstances, appropriate life
support measures take precedence. These standards may be exceeded at any time based on the judgment
of the responsible anesthesiologist. They are intended to encourage quality patient care, but observing
them cannot guarantee any specific patient outcome. They are subject to revision from time to time, as
warranted by the evolution of technology and practice. They apply to all general anesthetics, regional
anesthetics and monitored anesthesia care. This set of standards addresses only the issue of basic
anesthetic monitoring, which is one component of anesthesia care. In certain rare or unusual
circumstances, 1) some of these methods of monitoring may be clinically impractical, and 2) appropriate
use of the described monitoring methods may fail to detect untoward clinical developments. Brief
interruptions of continual† monitoring may be unavoidable. These standards are not intended forapplication to the care of the obstetrical patient in labor or in the conduct of pain management.
Washington University Emergency Medicine Journal Club
Topical Anesthetics for Corneal Abrasions (2021)
Available online at this link
This month’s journal club will look at the short-term use of topical anesthetics for the pain associated with
corneal abrasions. Traditional teaching warns against the use of these agents due to a reported risk of
worsening corneal injury, but there is scant evidence to support this. We will look at four fairly recent
articles that compared treatment with and without topical anesthetics to try to come to a more evidence-
based conclusion.
Systematic Reviews
Cochrane Database of Systematic Reviews
Ab interno trabecular bypass surgery with Trabectome for open‐angle glaucoma (2021)
Hu, K., Shah, A., Virgili, G., Bunce, C., Gazzard, G.
Available online at this link
Glaucoma is the leading cause of irreversible blindness. Minimally invasive surgical techniques, such as ab
interno trabecular bypass surgery, have been introduced to prevent glaucoma from progressing.
Objectives In light of the potential benefits for people with open‐angle glaucoma and the widespread
uptake of the technique, it is important to critically evaluate the evidence for whether treatment with ab
interno trabecular bypass surgery with Trabectome is both efficacious and safe.
Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing
breast cancer surgery (2021)
Chhabra, A., Roy Chowdhury, A., Prabhakar, H., Subramaniam, R., Arora, MKumar, Srivastava, A., Kalaivani,
M.
Available online at this link
Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the
mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of
tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and
general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia
numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need
for general anaesthesia.
EvidenceUpdates
Comparison of Liposomal Bupivacaine and Conventional Local Anesthetic Agents in Regional Anesthesia:
A Systematic Review (2021)
Available online at this link
Pain is one of the most common adverse events after surgery. Regional anesthesia techniques are
effective for pain control but have limited duration of action. Liposomal bupivacaine is a long-acting
formulation of bupivacaine. We conduct this systematic review to assess whether liposomal bupivacaine
may prolong the analgesic duration of regional anesthesia compared to conventional local anesthetic
agents.
Original Research
1. A concept mobility device with multi-positional configurations and child-kind restraint for safe
perioperative transfer and induction of anaesthesia in children with autistic spectrum disorder – a
cross sectional study.
Hee Hwan Ing BMC Health Services Research 2021;21(1):1-10.
Available online at this link2. Adolescent gynaecology: anaesthetic and peri-operative care implications.
Crouch N. S Anaesthesia 2021;76 Suppl 4:39-45.
Adolescents represent a quarter of the world's population, yet their specific healthcare needs have often not
been acknowledged. Whilst many operations in this population will be performed in specialist tertiary
centres and children's hospitals, it is likely that care will be sought in a variety of healthcare settings, and so it
is important to have an understanding of the particular approach to this age group. Paediatric and
adolescent gynaecology emerged as a speciality in 2000 with the inauguration of the British Society for
Paediatric and Adolescent Gynaecology, a specialist society of the Royal College of Obstetricians and
Gynaecologists. This is a multidisciplinary group, comprising paediatricians, paediatric surgeons,
psychologists and nurses, although the majority of the members are gynaecologists. In this review, we will
describe the peri-operative implications of adolescent gynaecological surgery and the considerations that
need to be applied to this specific age group, such as consent, the operative setting and key personnel. We
will also discuss specialist situations which are likely to fall to an adolescent gynaecology setting, such as
management of those with Mullerian abnormalities, which often present with pelvic pain in adolescence. We
discuss those with a history of ritual female genital cutting (female genital mutilation), trans men and those
with significant learning difficulties. In all circumstances, teamwork, reflection and pragmatism are key. (©
2021 Association of Anaesthetists.)
Available online at this link
3. Adolescent gynaecology: anaesthetic and peri-operative care implications.
Crouch N. S Anaesthesia 2021;76 Suppl 4:39-45.
Adolescents represent a quarter of the world's population, yet their specific healthcare needs have often not
been acknowledged. Whilst many operations in this population will be performed in specialist tertiary
centres and children's hospitals, it is likely that care will be sought in a variety of healthcare settings, and so it
is important to have an understanding of the particular approach to this age group. Paediatric and
adolescent gynaecology emerged as a speciality in 2000 with the inauguration of the British Society for
Paediatric and Adolescent Gynaecology, a specialist society of the Royal College of Obstetricians and
Gynaecologists. This is a multidisciplinary group, comprising paediatricians, paediatric surgeons,
psychologists and nurses, although the majority of the members are gynaecologists. In this review, we will
describe the peri-operative implications of adolescent gynaecological surgery and the considerations that
need to be applied to this specific age group, such as consent, the operative setting and key personnel. We
will also discuss specialist situations which are likely to fall to an adolescent gynaecology setting, such as
management of those with Mullerian abnormalities, which often present with pelvic pain in adolescence. We
discuss those with a history of ritual female genital cutting (female genital mutilation), trans men and those
with significant learning difficulties. In all circumstances, teamwork, reflection and pragmatism are key.
Available online at this link
4. Adolescent gynaecology: anaesthetic and peri‐operative care implications
Crouch N. S Anaesthesia 2021;76(S4):39-45.
Adolescents represent a quarter of the world’s population, yet their specific healthcare needs have often not
been acknowledged. Whilst many operations in this population will be performed in specialist tertiary
centres and children’s hospitals, it is likely that care will be sought in a variety of healthcare settings, and so
it is important to have an understanding of the particular approach to this age group. Paediatric and
adolescent gynaecology emerged as a speciality in 2000 with the inauguration of the British Society for
Paediatric and Adolescent Gynaecology, a specialist society of the Royal College of Obstetricians and
Gynaecologists. This is a multidisciplinary group, comprising paediatricians, paediatric surgeons,
psychologists and nurses, although the majority of the members are gynaecologists. In this review, we will
describe the peri‐operative implications of adolescent gynaecological surgery and the considerations that
need to be applied to this specific age group, such as consent, the operative setting and key personnel. We
will also discuss specialist situations which are likely to fall to an adolescent gynaecology setting, such as
management of those with Mullerian abnormalities, which often present with pelvic pain in adolescence. We
discuss those with a history of ritual female genital cutting (female genital mutilation), trans men and those
with significant learning difficulties. In all circumstances, teamwork, reflection and pragmatism are key.
Available online at this link5. Aerosol barriers in pediatric anesthesiology: Clinical data supports FDA caution.
Tighe Nathaniel T. G Paediatric anaesthesia 2021;31(4):461-464.
BACKGROUNDThe onset of the COVID19 pandemic drove the rapid development and adoption of physical
barriers intended to protect providers from aerosols generated during airway management. We report our
initial experience with aerosol barrier devices in pediatric patients and raise concerns that they may increase
risk to patients.METHODSIn March 2020, we developed and implemented simulation training and use of
plastic aerosol barrier devices as a component of our perioperative COVID-19 workflow. As part of our
quality improvement process, we obtained detailed feedback via a web-based survey after cases were
performed while using these aerosol barriers.RESULTSBetween March and June 2020, 36 pediatric patients
age 1mo-18years with anatomically normal airways and either PCR confirmed or suspected COVID-19 were
intubated under an aerosol barrier as part of urgent or emergent anesthetic care at our institution.
Experienced providers had more difficulty than expected in six (16.7%) of the cases with four cases requiring
multiple attempts to secure the airway and two cases involving pronounced difficulty in a single attempt. The
aerosol barrier was perceived as a contributing factor to difficulty in all cases.CONCLUSIONThe use of
barriers may result in unanticipated difficulties with airway management, particularly in pediatric patients,
which could lead to hypoxemia or other patient harm. Our initial experience in pediatric patients is the first
such report in patients and provides clinical data which corroborates the simulation data prompting the FDA
to withdraw support of barriers.
Available online at this link
6. An analysis of the academic capacity of anaesthesia in the UK by publication trends and academic
units.
Ratnayake G. Anaesthesia 2021;76(4):500-513.
Available online at this link
7. Anaesthetic challenges for a patient with huge superior mediastinal mass in prone position.
Yeap Tat Boon BMJ case reports 2021;14(4):No page numbers.
Anaesthesia for patients with huge mediastinal mass is very challenging due to the cardiorespiratory
embarrassment that may occur. We present a patient with this condition, which was complicated by total
airway obstruction, intraoperatively. We discuss the importance of patient positioning and the role of
spontaneous ventilation. (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and
permissions. Published by BMJ.)
Available online at this link
8. Anaesthetic considerations for fertility-sparing surgery and uterine transplantation.
Kasaven L. S Anaesthesia 2021;76 Suppl 4:46-55.
A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted
reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation.
Regardless of clinical indication, women now have the reproductive autonomy to make fully informed
decisions regarding their future fertility. In particular, there has been an increasing interest and demand
among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves
continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging
field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is
it important to understand the surgical procedures now undertaken, but also the intra-operative
management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also
describes important anaesthetic challenges including peri-operative care for women undergoing complex
fertility-sparing surgeries such as uterus transplantation. (© 2021 Association of Anaesthetists.)
Available online at this link
9. Application of auriculotemporal nerve block and dextrose prolotherapy in exercise therapy of TMJ
closed lock in adolescents and young adults.
Zhou Hongzhi Head & face medicine 2021;17(1):11.
BACKGROUNDTemporomandibular joint (TMJ) 'closed lock' is a clinical condition causing TMJ pain and
limited mouth opening (painful locking). Recent studies suggest an increasing prevalence of degenerative
joint disease associated with the onset of TMJ closed lock in adolescents and young adults. Early
interventions are recommended, but the curative effect of standard therapies remains controversial. In thisretrospective study, an alternative method of non-surgical treatment of TMJ closed lock is presented, and its
long-term efficacy has been observed.METHODSForty adolescents and young adults, aged 16 to 30 years old,
with distinct combination of symptoms of TMJ closed lock, were enrolled. Patients received anesthetic
blockages of the auriculotemporal nerve, then performed mandibular condylar movement exercise for
10 min, and subsequently received hypertonic dextrose prolotherapy in retro-discal area of TMJ. Clinical
assessments at baseline and at follow-up (2 weeks, 2 months, 6 months, and 5 years) included intensity and
frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing.RESULTSCone
beam CT images of the TMJs revealed joint space changes in all patients and degenerative bone changes in
20% (8/40) of the patients. The patients were diagnosed as having disc displacement without reduction with
limited opening. Successful reduction of displaced disc had been achieved in the treatment. And pain at rest
and pain on mastication had substantially decreased in all patients and mandibular function and mouth
opening had significantly improved since 2 weeks' follow-up. The overall success rate kept at a high level of
97.5% (39/40) at 6 months and 5 years' follow-up.CONCLUSIONSThe technique combining mandibular
condylar movement exercise with auriculotemporal nerve block and dextrose prolotherapy is
straightforward to perform, inexpensive and satisfactory to young patients with TMJ closed lock.
Available online at this link
10. Appropriate use of essential medicines in the elderly: a comparison of the WHO essential
medicines list and PIM criteria
Ma Xin European Journal of Clinical Pharmacology 2021;77(4):509-516.
PurposeThe elderly are not only threatened by bad medicines (overtreatment) but also by undertreatment
with “good” medicines. Symmetry is required in any patient-centred approach to properly treat older
people. The purpose of this study was to perfect the development of an EML and criteria according to the
advantages of each and promote the appropriate use of essential medicines in the elderly.MethodWe
compared the EML with four PIM criteria and calculated the proportion of essential medicines included in
the criteria. We also summarized the rationale for including medicines in each criterion and analysed higher
risk drugs and drug risks.ResultsOf essential medicines, 26% are included in at least one criterion as PIM. In
11 drug categories of the EML, more than 50% of drugs of each category are included in at least one
criterion, and in four categories, all drugs are included. The potentially inappropriate essential medicines
(PIEMs) for the elderly focus on cardiovascular drugs and central nervous system drugs. Fifty-nine drugs have
been explicitly identified as increasing the risk of falls, increasing mortality and/or having inappropriate long-
term use, and the main risk of PIEMs is falls (30.3% of PIEMs). Additionally, 17.9% of essential medicines are
labelled as positive drugs in START and/or FORTA (A/B).ConclusionImproving medication information for the
elderly in the EML and establishing an essential medicines list for the elderly will promote appropriate drug
use in older people worldwide.
Available online at this link
11. Association of Anaesthesia-ECT time interval with ECT clinical outcomes: A retrospective cohort
study.
Tan Xiao Wei Journal of Affective Disorders 2021;285:58-62.
Available online at this link
12. Availability of a smartphone version of eGENA, the German digital cognitive aid for crisis
management in anaesthesiology.
Richter T. Anaesthesiologie & Intensivmedizin 2021;62(4):V37-V44.
Available online at this link
13. Back to the future of academic anaesthesia: publication outputs of UK anaesthetists.
Yeung J. Anaesthesia 2021;76(4):455-459.
Available online at this link
14. Comparison of cardiovascular response between patients on warfarin and hypertensive patients
not on warfarin during dental extraction.
Kubota Kazumasa Clinical oral investigations 2021;25(4):2141-2150.
OBJECTIVETo evaluate cardiovascular response in patients on warfarin and hypertensive patients not on
warfarin during dental extraction.MATERIALS AND METHODSThis retrospective study included 53 patientswho had undergone dental extraction while on warfarin (mean age 78.8 ± 6.3 years, 26 men) and 66 with
hypertension who had undergone dental extraction but were not on warfarin (mean age 77.4 ± 6.8 years, 22
men). Vital signs were monitored in both groups during extraction.RESULTSThe highest systolic blood
pressure (SBP) values (mean 150.1 ± 21.1 mmHg) were observed in patients on warfarin before (9.0%) and
after (10.3%) administration of local anesthesia (LA), during extraction (39.7%), and during (33.3%) and after
(7.7%) suturing (n = 78; p < 0.01), and in hypertensive patients not receiving warfarin (160.6 ± 24.8 mmHg)
before (19.2%) and after (27.3%) administration of LA, during extraction (29.3%), and during (18.2%) and
after (6.1%) suturing (n = 99; p < 0.01). The highest SBP was linearly correlated with SBP before
administration of LA in patients on warfarin (highest SBP = 0.9415 × SBP before LA + 23.243, R2 = 0.75481)
and in hypertensive patients not on warfarin (highest SBP = 1.0027 × SBP before LA + 15.789, R2 =
0.60341).CONCLUSIONSThe highest SBP was not distributed evenly between patients on warfarin and
hypertensive patients not on warfarin during dental extraction and was strongly associated with SBP before
LA regardless of anticoagulant status.CLINICAL RELEVANCEThorough management of SBP is required in
patients on warfarin to avoid thromboembolism and major hemorrhagic complications. Knowing the SBP
value before dental treatment would help predict the risk of cardiovascular complications.
Available online at this link
15. Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus
0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial
Plexus Block: A Randomized Controlled Trial.
Safa Ben Anesthesia and analgesia 2021;132(4):1129-1137.
BACKGROUNDBupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral
nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly
compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume
ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic
and concentration provides superior analgesia (duration and quality) for low-volume US-ISB.METHODSSixty
eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5
mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals
were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician.
All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome
was duration of analgesia defined as the time from the end of injection to the time that the patients
reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site.RESULTSThe mean
duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine
was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There
were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with
the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of
ropivacaine 0.5% over bupivacaine of minimal clinical significance.CONCLUSIONSIn the context of single-
injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of
ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did
not prolong the duration of US-ISB.
Available online at this link
16. Current status and solutions for gender equity in anaesthesia research.
Flexman A. M. Anaesthesia 2021;76:32-38.
Available online at this link
17. Developmental exposure to general anaesthesia: missed connections?
Baxter Mark G. British journal of anaesthesia 2021;126(4):756-758.
Available online at this link
18. Effect of Dural Puncture Epidural Technique Combined With Programmed Intermittent Epidural
Bolus on Labor Analgesia Onset and Maintenance: A Randomized Controlled Trial.
Song Yujie Anesthesia and analgesia 2021;132(4):971-978.
BACKGROUNDThe dural puncture epidural (DPE) technique is associated with faster onset than the
conventional epidural (EP) technique for labor analgesia. The programmed intermittent epidural bolus (PIEB)
mode for maintaining labor analgesia allows for lower anesthetic drug consumption than the continuousepidural infusion (CEI) mode. Whether DPE technique with PIEB mode offers additional benefits for analgesia onset, local anesthetic drug consumption, and side effects versus EP or DPE techniques with CEI mode remains unclear.METHODSNulliparous women with a visual analog scale (VAS) pain score >50 mm and cervical dilation
experience ischemia-reperfusion injury during microsurgical reconstruction. Lidocaine may have a protective
effect in free flap surgery, but our results were not statistically significant, so further studies will be required.
Available online at this link
21. Effect of rectus sheath block vs. spinal anaesthesia on time-to-readiness for hospital discharge
after trans-peritoneal hand-assisted laparoscopic live donor nephrectomy: A randomised trial.
Bhatia Kailash European journal of anaesthesiology 2021;38(4):374-382.
Background: The role of spinal anaesthesia in patients having a transperitoneal hand-assisted laparoscopic
donor nephrectomy in an enhanced recovery setting has never been investigated.; Objective: We explored
whether substituting a rectus sheath block (RSB) with spinal anaesthesia, as an adjunct to a general
anaesthetic technique, influenced time-to-readiness for discharge in patients undergoing hand-assisted
laparoscopic donor nephrectomy.; Design: Prospective randomised open blinded end-point (PROBE) study
with two parallel groups.; Setting: Tertiary University Hospital.; Patients: Ninety-seven patients undergoing a
trans-peritoneal hand-assisted laparoscopic donor nephrectomy.; Intervention: Patients (n=52) were
randomly assigned to receive a general anaesthetic and a surgical RSB with 2 mg kg-1 of levobupivacaine at
the time of surgical closure or a spinal anaesthetic with hyperbaric bupivacaine 12.5 mg and diamorphine
0.5 mg (n=45) before general anaesthesia.; Primary Outcome: The primary outcome was the time-to-
readiness for discharge following surgery.; Results: Median [IQR] times-to-readiness for discharge were 75
[56 to 83] and 79 [67 to 101] h for RSB and spinal anaesthesia and there was no significant difference in
times-to-readiness for discharge (median difference 4 (95% CI, 0 to 20h; P = 0.07)). There were no significant
differences in pain scores at rest (P = 0.91) or on movement (P = 0.66). Median 24-h oxycodone
consumptions were similar (P = 0.80). Nausea and vomiting scores were similar (P = 0.57) and urinary
retention occurred in one vs. four patients with RSB and spinal anaesthesia, respectively (P = 0.077).;
Conclusion: Substitution of RSB with spinal anaesthesia using 12.5 mg hyperbaric bupivacaine and 0.5 mg
diamorphine, together with a general anaesthetic failed to confer any benefit on time-to-discharge readiness
following transperitoneal hand-assisted laparoscopic donor nephrectomy. RSB provided similar analgesia in
the immediate postoperative period with a low frequency of side-effects in this cohort.; Trial Registration:
ClinicalTrial.gov identifier: NCT02700217. (Copyright © 2020 European Society of Anaesthesiology and
Intensive Care. Unauthorized reproduction of this article is prohibited.)
Available online at this link
22. Effect on the behaviour of dexmedetomidine as anaesthetic premedication in the paediatric
population: a prospective observational study.
Monteiro M. Revista espanola de anestesiologia y reanimacion 2021;68(4):179-182.
Premedication in the pediatric population is of vital importance to reduce anxiety and facilitate anesthetic
induction. Midazolam and ketamine have been used for this purpose, drugs that have shown long-term
changes in neurodevelopment. Dexmedetomidine promotes a sedative, analgesic effect and lacks neurotoxic
effects, its intranasal application is easy and minimally invasive. We studied the sedative and behavioral
effect of intranasal dexmedetomidine 2 mcg/kg in ASA 1 and 2 children for elective surgery. They were
evaluated at 10, 20 and 30 minutes of administered, in the separation of the parents and placement of the
mask for inhalation induction with behavioral and sedation scores (classified from 1 to 4), we considered
acceptable for admission to operating room categories 3 and 4. RESULTS: Thirty patients between 1 and 10
years old were included in the period from September 2017 to April 2018. The sedation score obtained at
30minutes was acceptable in 46.6% of the patients and the behavior score was in 96% of the cases. In 63% of
cases the acceptance of the facial mask placement for inhalation induction was achieved. The procedure was
well tolerated in all cases and parents were satisfied in 100% of the cases. (Copyright © 2020 Sociedad
Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All
rights reserved.)
Available online at this link
23. Effects of general anaesthesia during pregnancy on neurocognitive development of the fetus: a
systematic review and meta-analysis.
Bleeser Tom British journal of anaesthesia 2021;:No page numbers.
Background: The US Food and Drug Administration warned that exposure of pregnant women to general
anaesthetics may impair fetal brain development. This review systematically evaluates the evidence
underlying this warning.; Methods: PubMed, EMBASE, and Web of Science were searched from inceptionuntil April 3, 2020. Preclinical and clinical studies were eligible. Exclusion criteria included case reports,
in vitro models, chronic exposures, and exposure only during delivery. Meta-analyses were performed on
standardised mean differences. The primary outcome was overall effect on learning/memory. Secondary
outcomes included markers of neuronal injury (apoptosis, synapse formation, neurone density, and
proliferation) and subgroup analyses.; Results: There were 65 preclinical studies included, whereas no clinical
studies could be identified. Anaesthesia during pregnancy impaired learning and memory (standardised
mean difference -1.16, 95% confidence interval -1.46 to -0.85) and resulted in neuronal injury in all
experimental models, irrespective of the anaesthetic drugs and timing in pregnancy. Risk of bias was high in
most studies. Rodents were the most frequently used animal species, although their brain development
differs significantly from that in humans. In a minority of studies, anaesthesia was combined with surgery.
Monitoring and strict control of physiological homeostasis were below preclinical and clinical standards in
many studies. The duration and frequency of exposure and anaesthetic doses were often much higher than
in clinical routine.; Conclusion: Anaesthesia-induced neurotoxicity during pregnancy is a consistent finding in
preclinical studies, but translation of these results to the clinical situation is limited by several factors. Clinical
observational studies are needed.; Prospero Registration Number: CRD42018115194. (Copyright © 2021
British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)
Available online at this link
24. Effects of smoking on the optimal effect-site concentration of remifentanil required for preventing
cough during anesthetic emergence in male patients undergoing laparoscopic or robotic
cholecystectomy.
Kim Ha Yeon Medicine 2021;100(13):1.
ABSTRACTTarget-controlled infusion of remifentanil is known to reduce cough effectively during emergence
from general anesthesia. The effect of smoking on emergence cough remains controversial. Therefore, we
aimed to investigate the effect-site concentration (Ce) of remifentanil in the male patients undergoing
laparoscopic or robotic cholecystectomy for suppressing emergence cough in smokers and non-
smokers.Twenty smokers and 24 non-smokers (sex, male; age range, 20-65 years) were enrolled in this study.
Anesthesia was maintained using sevoflurane and remifentanil. The Ce of remifentanil in 50% (EC50) and
95% (EC95) of the patients required for suppressing emergence cough were determined for each group
(smokers and non-smokers) using Dixon up-and-down method and isotonic regression method with a
bootstrapping approach.Dixon up-and-down method revealed that the EC50 value was significantly higher in
smokers (3.51 ± 0.60 ng/mL) than in non-smokers (2.71 ± 0.30 ng/mL) (P < 0.001). In smokers and non-
smokers, isotonic regression revealed EC50 to be 4.40 (83% CI, 4.17-4.58) ng/mL and 2.58 (83% CI, 2.31-
2.87) ng/mL, respectively, and EC95 to be 4.76 (95% CI, 4.73-4.78) ng/mL and 3.15 (95% CI, 3.04-3.18) ng/mL,
respectively.The Ces of remifentanil required to prevent cough during emergence were significantly higher in
smokers than in non-smokers. Therefore, clinicians should pay attention to the smoking history of a patient
to prevent cough during emergence.
Available online at this link
25. Efficacy of active forced air warming during induction of anesthesia to prevent inadvertent
perioperative hypothermia in intraoperative warming patients: Comparison with passive warming,
a randomized controlled trial.
Yoo Jae Hwa Medicine 2021;100(12):1.
BACKGROUNDThis study aimed to evaluate the efficacy of peri-induction forced air warming to prevent
inadvertent perioperative hypothermia, defined as a reduction in body temperature to 120 minutes.METHODSIn total, 130 patients scheduled for elective surgery under general anesthesia lasting
>120 minutes were divided into 2 groups: peri-induction warming (n = 65) and control (n = 65). Patients in the
peri-induction warming group were warmed during the anesthetic induction period using a forced-air
warmer set at 47°C, whereas patients in the control group were covered passively with a cotton blanket. All
patients were warmed with a forced-air warmer during surgery. Body temperature was measured using a
tympanic membrane thermometer in the pre- and postoperative periods and using a nasopharyngeal
temperature probe during surgery. Patients were evaluated for shivering scale score, thermal comfort scale
score, and satisfaction score in the post-anesthesia care unit.RESULTSThe incidence rates of intraoperative
and postoperative hypothermia were lower in the peri-induction warming group than in the control group
(19.0% vs 57.1%, P < .001; 3.3% vs 16.9%, P = .013, respectively). Body temperature was higher in the peri-induction warming group (P < .001). However, intraoperative blood loss, as well as postoperative thermal
comfort scale score, shivering scale score, and patient satisfaction score, were similar between groups. Post-
anesthesia care unit duration was also similar between groups.CONCLUSIONSPeri-induction active forced air
warming is an effective, simple, and convenient method to prevent inadvertent perioperative hypothermia in
intraoperatively warmed patients undergoing major surgery lasting >120 minutes.
Available online at this link
26. Empirical ratio of the combined use of S-ketamine and propofol in electroconvulsive therapy and
its impact on seizure quality.
Sartorius Alexander European Archives of Psychiatry & Clinical Neuroscience 2021;271(3):457-463.
Copyright of European Archives of Psychiatry & Clinical Neuroscience is the property of Springer Nature and
its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright
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This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the
original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
Available online at this link
27. Epidural Administration of Ropivacaine Reduces the Amplitude of Transcranial Electrical Motor-
Evoked Potentials: A Double-Blinded, Randomized, Controlled Trial.
Furutani Kenta Anesthesia and analgesia 2021;132(4):1092-1100.
BACKGROUNDAn epidurally administered local anesthetic acts primarily on the epidural nerve roots and can
act directly on the spinal cord through the dural sleeve. We hypothesized that epidurally administered
ropivacaine would reduce the amplitude of transcranial electrical motor-evoked potentials by blocking nerve
conduction in the spinal cord. Therefore, we conducted a double-blind, randomized, controlled
trial.METHODSThirty adult patients who underwent lung surgery were randomly allocated to 1 of 3 groups,
based on the ropivacaine concentration: the 0.2% group, the 0.375% group, and the 0.75% group. The
attending anesthesiologists, neurophysiologists, and patients were blinded to the allocation. The epidural
catheter was inserted at the T5-6 or T6-7 interspace by a paramedian approach, using the loss of resistance
technique with normal saline. General anesthesia was induced and maintained using propofol and
remifentanil. Transcranial electrical motor-evoked potentials were elicited by a train of 5 pulses with an
interstimulus interval of 2 milliseconds by using a constant-voltage stimulator and were recorded from the
tibialis anterior muscle. Somatosensory-evoked potentials (SSEPs) were evoked by electrical tibial nerve
stimulation at the popliteal fossa. After measuring the baseline values of these evoked potentials, 10 mL of
epidural ropivacaine was administered at the 0.2%, 0.375%, or 0.75% concentration. The baseline amplitudes
and latencies recorded before administering ropivacaine were defined as 100%. Our primary end point was
the relative amplitude of the motor-evoked potentials at 60 minutes after the epidural administration of
ropivacaine. We analyzed the amplitudes and latencies of these evoked potentials by using the Kruskal-
Wallis test and used the Dunn multiple comparison test as the post hoc test for statistical
analysis.RESULTSThe data are expressed as the median (interquartile range). Sixty minutes after epidurally
administering ropivacaine, the motor-evoked potential amplitude was lower in the 0.75% group (7% [3%-
18%], between-group difference P < .001) and in the 0.375% group (52% [43%-59%]) compared to that in the
0.2% group (96% [89%-105%]). The latency of SSEP was longer in the 0.75% group compared to that in the
0.2% group, but the amplitude was unaffected.CONCLUSIONSEpidurally administered high-dose ropivacaine
lowered the amplitude of motor-evoked potentials and prolonged the onset latencies of motor-evoked
potentials and SSEPs compared to those in the low-dose group. High-dose ropivacaine can act on the motor
pathway through the dura mater.
Available online at this link
28. Evaluation of different mandibular blocks for the removal of lower third molars: a meta-analysis of
randomised clinical trials.
Cavallini Carolina-Noemi Clinical oral investigations 2021;25(4):2129-2139.
Objectives: To describe the efficacy and number of side effects for the Gow-Gates mandibular block (GGMB)
and Vazirani-Akinosi mandibular block (VAMB) compared to inferior alveolar nerve block (IANB) in patients
requiring lower third molar (L3M) extraction.; Materials and Methods: A systematic search was performed in
three electronic databases and complemented with a manual search. The inclusion criteria were randomised
clinical trials in healthy patients who underwent at least one L3M extraction. Screening and article selectionwere carried out by two independent reviewers. After data extraction, a meta-analysis was performed for
the success rate, number of positive aspirations, and onset time outcomes.; Results: Six randomised clinical
trials were included out of the 367 potentially eligible papers. No significant differences were found in terms
of success rate using GGMB (risk ratio [RR] 1.04; 95% confidence interval [CI] 0.92 to 1.18; P = 0.48) nor
VAMB (RR 0.96; 95% CI 0.86 to 1.06; P = 0.41). The VAMB group exhibited a lower number of positive
aspirations than the IANB group (RR 0.08; 95% CI 0.01 to 0.55; P = 0.01), but there was no statistically
significant difference between the GGMB and IANB groups (RR 1.06; 95% CI 0.13 to 8.78; P = 0.96). The
delayed onset was even longer in GGMB (mean difference [MD] 3.32 min; 95% CI 1.98 to 4.66; P < 0.001) and
VAMB (MD 0.90 min; 95% CI 0.37 to 1.43; P = 0.0001) than IANB.; Conclusions: GGMB and VAMB seem to be
effective and safe anaesthetic techniques for the removal of L3M, but these blocks exhibited a more delayed
onset time than IANB.; Clinical Relevance: GGMB and VAMB are safe and effective anaesthetic techniques for
the removal of L3M. However, IANB can still be considered the first option since GGMB and VAMB exhibited
more delayed onset times and variable buccal nerve anaesthesia.
Available online at this link
29. Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review
study.
Jo Young Tak Medicine 2021;100(14):e24508.
Abstract: Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected
adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been
little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors
associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions
from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions
involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis
was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed
in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was
significantly different between delirium-positive and delirium-negative groups after Bonferroni correction.
The regression model also indicated that etomidate use to be significantly associated with post-ECT
delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an
association that appeared unrelated to other possible measured variables. Practitioners should take into
account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation
before sufficient therapeutic gain is achieved. (Copyright © 2021 the Author(s). Published by Wolters Kluwer
Health, Inc.)
Available online at this link
30. Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.
Barry Garrett S. British journal of anaesthesia 2021;126(4):862-871.
BACKGROUNDRebound pain is a common, yet under-recognised acute increase in pain severity after a
peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed.
This retrospective cohort study investigated the incidence and factors associated with rebound pain in
patients who received a PNB for ambulatory surgery.METHODSAmbulatory surgery patients who received a
preoperative PNB between March 2017 and February 2019 were included. Rebound pain was defined as the
transition from well-controlled pain (numerical rating scale [NRS] ≤3) while the block is working to severe
pain (NRS ≥7) within 24 h of block performance. Patient, surgical, and anaesthetic factors were analysed for
association with rebound pain by univariate, multivariable, and machine learning methods.RESULTSFour
hundred and eighty-two (49.6%) of 972 included patients experienced rebound pain as per the definition.
Multivariable analysis showed that the factors independently associated with rebound pain were younger
age (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.97-0.99), female gender (OR 1.52 [1.15-2.02]),
surgery involving bone (OR 1.82 [1.38-2.40]), and absence of perioperative i.v. dexamethasone (OR 1.78
[1.12-2.83]). Despite a high incidence of rebound pain, there were high rates of patient satisfaction (83.2%)
and return to daily activities (96.5%).CONCLUSIONSRebound pain occurred in half of the patients and
showed independent associations with age, female gender, bone surgery, and absence of intraoperative use
of i.v. dexamethasone. Until further research is available, clinicians should continue to use preventative
strategies, especially for patients at higher risk of experiencing rebound pain.
Available online at this link31. Failure of painful eye movements to respond to topical anesthetics supports the diagnosis of optic
neuritis.
Jehle Dietrich The American journal of emergency medicine 2021;:264.e1-264.e3.
Available online at this link
32. False individual patient data and zombie randomised controlled trials submitted to Anaesthesia.
Carlisle J. B. Anaesthesia 2021;76(4):472-479.
Available online at this link
33. From the Operating Room to the Front Lines: Shared Experiences of Nurse Anesthetists During the
Coronavirus Pandemic.
Everson Marjorie AANA Journal 2021;89(2):109-116.
Coronavirus disease 2019 (COVID-19) has resulted in severe health, economic, social, political, and cultural
consequences while thrusting Certified Registered Nurse Anesthetists (CRNAs) at the forefront of battling an
often invisible enemy. A mixed-methods study was conducted to assess the impact of the COVID-19
pandemic on CRNA practice. The purpose of the qualitative component of the study, a focused ethnography,
was to use personal and group interviews to determine the shared experiences of CRNAs who worked during
the COVID-19 pandemic. Six themes were identified: (1) CRNAs are part of the solution, (2) doing whatever it
takes, (3) CRNAs are valued contributors, (4) removal of barriers promotes positive change, (5) trying times,
and (6) expertise revealed. The quantitative component of the study will be discussed in a separate article.
Available online at this link
34. General anaesthesia during infancy reduces white matter micro-organisation in developing rhesus
monkeys.
Young Jeffrey T. British journal of anaesthesia 2021;126(4):845-853.
Background: Non-human primates are commonly used in neuroimaging research for which general
anaesthesia or sedation is typically required for data acquisition. In this analysis, the cumulative effects of
exposure to ketamine, Telazol® (tiletamine and zolazepam), and the inhaled anaesthetic isoflurane on early
brain development were evaluated in two independent cohorts of typically developing rhesus macaques.;
Methods: Diffusion MRI scans were analysed from 43 rhesus macaques (20 females and 23 males) at either
12 or 18 months of age from two separate primate colonies.; Results: Significant, widespread reductions in
fractional anisotropy with corresponding increased axial, mean, and radial diffusivity were observed across
the brain as a result of repeated anaesthesia exposures. These effects were dose dependent and remained
after accounting for age and sex at time of exposure in a generalised linear model. Decreases of up to 40% in
fractional anisotropy were detected in some brain regions.; Conclusions: Multiple exposures to commonly
used anaesthetics were associated with marked changes in white matter microstructure. This study is
amongst the first to examine clinically relevant anaesthesia exposures on the developing primate brain. It
will be important to examine if, or to what degree, the maturing brain can recover from these white matter
changes. (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)
Available online at this link
35. General anaesthesia during infancy reduces white matter micro-organisation in developing rhesus
monkeys.
Young Jeffrey T. BJA: The British Journal of Anaesthesia 2021;126(4):845-853.
Available online at this link
36. General anaesthetic and airway management practice for obstetric surgery in England: a
prospective, multicentre observational study.
Odor P. M Anaesthesia 2021;76(4):460-471.
There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent
changes to patient baseline characteristics and airway management guidelines. This analysis of data from the
direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during
obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare
with earlier surveys and best-practice recommendations. Consenting patients who received general
anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline
characteristics, airway management, anaesthetic techniques and major complications were collected.Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted.
Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the
induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the
neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367
(11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in
312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and
associated with difficult, but not failed intubation. There was more evidence of change in practice for
induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the
most popular). There was evidence of improvement in practice, with increased monitoring and reversal of
neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this
population, videolaryngoscopy was rarely used (1.9%). (© 2020 The Authors. Anaesthesia published by John
Wiley & Sons Ltd on behalf of Association of Anaesthetists.)
Available online at this link
37. General anaesthetic and airway management practice for obstetric surgery in England: a
prospective, multicentre observational study.
Odor P. M Anaesthesia 2021;76(4):460-471.
There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent
changes to patient baseline characteristics and airway management guidelines. This analysis of data from the
direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during
obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare
with earlier surveys and best-practice recommendations. Consenting patients who received general
anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline
characteristics, airway management, anaesthetic techniques and major complications were collected.
Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted.
Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the
induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the
neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367
(11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in
312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and
associated with difficult, but not failed intubation. There was more evidence of change in practice for
induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the
most popular). There was evidence of improvement in practice, with increased monitoring and reversal of
neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this
population, videolaryngoscopy was rarely used (1.9%).
Available online at this link
38. General anaesthetic and airway management practice for obstetric surgery in England: a reply.
Odor P. M Anaesthesia 2021;76(4):580.
Available online at this link
39. General anaesthetic and airway management practice for obstetric surgery in England:
prospective, multicentre observational study.
Dibb K. Anaesthesia 2021;76(4):579.
Available online at this link
40. Iconoclasm and evidence implementation. The case for change in obstetric general anaesthesia.
Wilson M. J. A. Anaesthesia 2021;76(4):448-451.
Available online at this link
41. Impact of the intersection of anaesthesia and gender on burnout and mental health, illustrated by
the COVID-19 pandemic.
Lorello G. R Anaesthesia 2021;76 Suppl 4:24-31.
Physician burnout and poor mental health are prevalent and often stigmatised. Anaesthetists may be at
particular risk and this is further increased for women anaesthetists due to biases and inequities within the
specialty. However, gender-related risk factors for and experiences of burnout and poor mental healthremain under-researched and under-reported. This negatively impacts individual practitioners, the
anaesthesia workforce and patients and carries significant financial implications. We discuss the impact of
anaesthesia and gender on burnout and mental health using the COVID-19 pandemic as an example
illustrating how women and men differentially experience stressors and burnout. COVID-19 has further
accentuated the gendered effects of burnout and poor mental health on anaesthetists and brought further
urgency to the need to address these issues. While both personal and organisational factors contribute to
burnout and poor mental health, organisational changes that recognise and acknowledge inequities are
pivotal to bolster physician mental health. (© 2021 Association of Anaesthetists.)
Available online at this link
42. Inspiratory stridor of newborns and infants admitted to a paediatric ENT outpatient clinic:
diagnostic approach and therapeutic outcome
Moreddu Eric European Journal of Pediatrics 2021;180(4):1177-1183.
The main objective was to analyse the use of rigid laryngotracheoscopy under general anaesthesia (GA) and
endoscopic surgery in the management of inspiratory stridor in patients referred to a paediatric ENT
outpatient clinic. The secondary objective was to analyse the aetiological diagnoses made and their
therapeutic management. This is a prospective study including all newborns and infants, corresponding to
190 patients, presenting for the first time in consultation for inspiratory stridor from January 2015 to
December 2017. A consultation form was filled out after each consultation and added to a database; a
management algorithm was used to determine which patients required a rigid laryngotracheoscopy. A 17.9%
(n = 34) of the patients required rigid laryngotracheoscopy, of whom 12.6% (n = 24) underwent concomitant
endoscopic surgery. A 65.8% (n = 125) of the patients were diagnosed with laryngomalacia, 21.1% (n = 40)
with isolated posterior excess of mucosa, 9.5% (n = 18) with another diagnosis and 3.7% (n = 7) with a normal
examination. The presence of comorbidity was associated (p < 0.001) with the use of rigid
laryngotracheoscopy and endoscopic surgery.Conclusion: Rigid laryngotracheoscopy under GA was required
in one in five to six patients. Conservative management with strict follow-up may be appropriate in a large
number of patients, especially those with laryngomalacia.What is Known:• Previous research has established
that laryngomalacia is the main aetiology of stridor.• Comorbidities are linked with a poor tolerance of
stridor.What is new:• About one in five to six patients seen in consultation for stridor will require a trip to
the operative room (and one in eight will require endoscopic surgery).• Laryngomalacia and isolated
posterior excess of mucosa account for 85–90% of the patients seen in consultation for stridor.
Available online at this link
43. Intra-operative nociceptive responses and postoperative major complications after
gastrointestinal surgery under general anaesthesia: A prospective cohort study.
Ogata Hiroki European journal of anaesthesiology 2021;:No page numbers.
Background: Surgical procedures stimulate nociception and induce physiological responses according to the
balance between nociception and antinociception. The severity of surgical stimuli is associated with major
postoperative complications. Although an intra-operative quantitative index representing surgical
invasiveness would be useful for anaesthetic management to predict and prevent major complications, no
such index is available.; Objectives: To identify associations between major complications after
gastrointestinal surgery and intra-operative quantitative values from intra-operative nociception
monitoring.; Design: A multi-institutional observational study.; Setting: Two university hospitals.; Patients:
Consecutive adult patients undergoing gastrointestinal surgery under general anaesthesia.; Main Outcome
Measures: Averaged values of nociceptive response index from start to end of surgery (mean NR index) and
risk scores of the Surgical Mortality Probability Model (S-MPM) were calculated. Pre and postoperative
serum C-reactive protein (CRP) levels were obtained. After receiver-operating characteristic (ROC) curve
analysis, all patients were divided into groups with high and low mean nociceptive response index.
Associations between mean nociceptive response index and postoperative major complications, defined as
Clavien-Dindo grade at least IIIa, were examined using logistic regression analysis.; Results: ROC curve
analysis showed a nociceptive response index cut-off value for major complications of 0.83, and we divided
patients into two groups with mean nociceptive response index less than 0.83 and at least 0.83. The
incidence of major complications was significantly higher in patients with mean nociceptive response index
at least 0.83 (23.1%; n = 346) than in patients with mean nociceptive response index less than 0.83 (7.7%;
n = 443; P < 0.001). Multivariate analysis revealed emergency surgery, S-MPM risk score, mean nociceptive
response index and postoperative CRP levels as independent risk factors for major complications.;You can also read
