Showing papers in "Anesthesiology in 2017"
TL;DR: There were no clinically important interactions between preoperative blood pressures and the relationship between hypotension and myocardial or kidney injury at intraoperative mean arterial blood pressures less than 65 mmHg and anesthetic management can be based on intraoperative pressures without regard to preoperative pressure.
Abstract: Background:How best to characterize intraoperative hypotension remains unclear Thus, the authors assessed the relationship between myocardial and kidney injury and intraoperative absolute (mean arterial pressure [MAP]) and relative (reduction from preoperative pressure) MAP thresholdsMethods:The a
587 citations
TL;DR: Withholding angiotensin-converting enzyme inhibitors/angiotENSin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events.
Abstract: Background:The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown.Methods:In this international prospective cohort study, the authors analyzed data from 14,687 patients (i
247 citations
TL;DR: The prevalence, diagnosis and pathophysiology of perioperative hyperglycemia is reported on and a practical outline for the management of surgical patients with diabetes and hyperglyCEmia is provided.
Abstract: A substantial body of literature demonstrates a clear association between perioperative hyperglycemia and adverse clinical outcomes.1-3 The risk for post-operative complications and increased mortality relates to both long-term glycemic control and to the severity of hyperglycemia on admission and during the hospital stay.2 The underlying mechanism(s) relating hyperglycemia to poor outcomes is not completely understood. Past and current studies point to physiologic changes that occur in the hyperglycemic state that may contribute to poor outcomes. Elevated blood glucose levels impair neutrophil function, cause an overproduction of reactive oxygen species, free fatty acids and inflammatory mediators. These pathophysiologic changes contribute to direct cellular damage, vascular and immune dysfunction.4 Substantial evidence indicates that correction of hyperglycemia with insulin administration reduces hospital complications and decreases mortality in cardiac5 and general surgery patients.6 However, optimal glucose management during the perioperative period is widely debated. Recent randomized controlled trials targeting conventional targets for glycemic control do not demonstrate the significant risk of hypoglycemia7,8 as seen in prior studies using insulin to maintain tight blood glucose control.9 The pendulum of inpatient care has since moved toward more moderate and individualized glycemic targets.
This manuscript reports on the prevalence, diagnosis and pathophysiology of perioperative hyperglycemia and provides a practical outline for the management of surgical patients with diabetes and hyperglycemia.
Metabolic Consequences of Surgical Stress and Anesthesia
During the fasting state, normal subjects maintain plasma glucose levels between 60-100 mg/dl (3.3-5.5 mmol/l). The stress of surgery and anesthesia alters the finely regulated balance between hepatic glucose production and glucose utilization in peripheral tissues. An increase in the secretion of counterregulatory hormones (catecholamines, cortisol, glucagon, and growth hormone) occurs, causing excessive release of inflammatory cytokines including tumor necrosis factor-α, interleukin-6 and interleukin-1β (Figure 1).10 Cortisol increases hepatic glucose production, stimulates protein catabolism and promotes gluconeogenesis, resulting in elevated blood glucose levels.11 Surging catecholamines increase glucagon secretion and inhibit insulin release by pancreatic β-cells.4 Additionally, the increase in stress hormones leads to enhanced lipolysis and high free fatty acid (FFA) concentrations. Increased FFAs have been shown to inhibit insulin-stimulated glucose uptake12 and limit the intracellular signaling cascade in skeletal muscle responsible for glucose transport activity.13 Evidence also suggests that TNF-α interferes with the synthesis and/or translocation of the glucose transporter GLUT-4 reducing glucose uptake in peripheral tissues.14 These processes result in an altered state of insulin action, leading to a relative state of insulin resistance which is most pronounced on the first postoperative day and may persist for 9-21 days following surgery.15
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Figure 1
The Surgical Stress Response
223 citations
TL;DR: This article will focus on the use of perioperative lidocaine infusion for attaining postoperative benefits; intraoperative indications are outside the scope of this article, although several exist.
Abstract: Anesthesiology, V 126 • No 4 729 April 2017 C ONCERN about opioid risks in the postoperative period1 has spurred an increased interest in the use of nonopioid analgesic adjuncts. One drug of potential interest is IV lidocaine, which can be administered intraand/or postoperatively in order to decrease postoperative pain and improve other outcomes. A number of studies and metaanalyses of these studies have been published and show that perioperative lidocaine infusion is indeed effective but that evidence supporting its use varies by surgical procedure. This makes it difficult for anesthesiologists to decide when use of the compound would be clinically indicated. This article will address this issue. First, a brief overview will be provided of the mechanisms that could explain a prolonged postoperative benefit of perioperative lidocaine infusion. Although these mechanisms are poorly understood, it is important for the clinician to understand how such effects conceivably could happen. The clinical literature on perioperative IV lidocaine will then be reviewed, providing evidence for when this approach may and may not be clinically useful. This article will focus on the use of perioperative lidocaine infusion for attaining postoperative benefits; intraoperative indications are outside the scope of this article, although several exist. For example, it is effective in blunting cerebral hemodynamic responses to airway manipulation2 and prevents airway reactivity on emergence in smokers. It also reduces anesthetic requirements by approximately onethird3 and may reduce neuropathic pain through inhibition of activity in injured afferent nerves.4
217 citations
TL;DR: In this article, the authors evaluated whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome and found that vasopressor is superior.
Abstract: Background:Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome.Methods
198 citations
TL;DR: Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.
Abstract: Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.
198 citations
Cleveland Clinic1, University of Copenhagen2, Royal Melbourne Hospital3, Autonomous University of Bucaramanga4, National Health Service5, Autonomous University of Barcelona6, Kingston General Hospital7, University Hospital of Basel8, Sapienza University of Rome9, Hvidovre Hospital10, University of KwaZulu-Natal11, McMaster University12, Population Health Research Institute13
TL;DR: Clinically important hypotension—a potentially modifiable exposure—was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.
Abstract: Background:The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of su
191 citations
TL;DR: Findings in children anesthetized with modern techniques largely confirm those found in an older birth cohort and provide additional evidence that children with multiple exposures are more likely to develop adverse outcomes related to learning and attention.
Abstract: Background
Exposure of young animals to general anesthesia (GA) causes neurodegeneration and lasting behavioral abnormalities; whether these findings translate to children remains unclear. This study used a population-based birth cohort to test the hypothesis that multiple, but not single, exposures to procedures requiring GA prior to age 3 years are associated with adverse neurodevelopmental outcomes.
191 citations
TL;DR: The addition of examples to the definitions of the ASA-Physical Status Classification System increases the correct assignment of patients by anesthesia-trained and nonanesthesia-trained clinicians.
Abstract: Background:Despite its widespread use, the American Society of Anesthesiologists (ASA)-Physical Status Classification System has been shown to result in inconsistent assignments among anesthesiologists. The ASA-Physical Status Classification System is also used by nonanesthesia-trained clinicians an
171 citations
TL;DR: Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively and such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.
Abstract: Background:The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for d
155 citations
TL;DR: There was no difference in the incidence and severity of chronic pain at 6 months in patients undergoing thoracotomy versus thoracoscopy and none of the preoperative psychosocial measurements were associated with chronic pain after thoracic surgery.
Abstract: Background:The goal of this study was to detect the predictors of chronic pain at 6 months after thoracic surgery from a comprehensive evaluation of demographic, psychosocial, and surgical factors.Methods:Thoracic surgery patients were enrolled 1 week before surgery and followed up 6 months postsurg
TL;DR: It is proposed that anesthetics affect the glymphatic pathway transport not simply by inducing unconsciousness but also by additional mechanisms, one of which is the repression of norepinephrine release.
Abstract: Background:The glymphatic pathway transports cerebrospinal fluid through the brain, thereby facilitating waste removal A unique aspect of this pathway is that its function depends on the state of consciousness of the brain and is associated with norepinephrine activity A current view is that all a
TL;DR: Blocking multiple nerves was preferable to blocking any single nerve, periarticular infiltration, or epidural analgesia, and the combination of femoral and sciatic nerve block appears to be the overall best approach.
Abstract: Background:Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and
TL;DR: Neonatal exposure to isoflurane, particularly when repeated, has long-term behavioral consequences affecting both motor and socioemotional aspects of behavior.
Abstract: Background:Experimental evidence correlates anesthetic exposure during early development with neuronal and glial injury and death, as well as behavioral and cognitive impairments, in young animals. Several, although not all, retrospective human studies of neurocognitive and behavioral disorders afte
TL;DR: Activated protein C–associated fibrinolysis and fibrinogenolysis, rather than inhibition of procoagulant pathways, predominate in acute traumatic coagulopathy.
Abstract: Background:Major trauma is a leading cause of morbidity and mortality worldwide with hemorrhage accounting for 40% of deaths. Acute traumatic coagulopathy exacerbates bleeding, but controversy remains over the degree to which inhibition of procoagulant pathways (anticoagulation), fibrinogen loss, an
TL;DR: In this paper, the authors evaluated the effects of normothermic cardiopulmonary bypass on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen supply/demand relationship.
Abstract: Background:Acute kidney injury is a common complication after cardiac surgery with cardiopulmonary bypass. The authors evaluated the effects of normothermic cardiopulmonary bypass on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen supply/demand relationship,
TL;DR: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased, and the risk of epidural hematoma associated with neuraxIAL techniques in parturient at a platelet count less than 70,000 mm–3 remains poorly defined due to limited observations.
Abstract: Background: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. Methods: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. Results: A total of 573 parturients with a platelet count less than 100,000 mm(-3) who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm(-3) is 11%, for 50,000 to 69,000 mm(-3) is 3%, and for 70,000 to 100,000 mm(-3) is 0.2%. Conclusions: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm(-3) remains poorly defined due to limited observations
TL;DR: It is suggested that suprascapular block may be considered an effective and safe interscalene block alternative for shoulder surgery unless it provides better pain control during recovery room stay; however, suprASAPular block has fewer side effects.
Abstract: Background:Interscalene block provides optimal shoulder surgery analgesia, but concerns over its associated risks have prompted the search for alternatives Suprascapular block was recently proposed as an interscalene block alternative, but evidence of its comparative analgesic effect is conflicting
TL;DR: In this article, the authors conducted a systematic literature search of the major medical databases from their inception to April 2016 and found that glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting.
Abstract: Background: Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery.
Methods: The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression. Results: Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8; 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl; CI, 11.4 to 28.6; P < 0.001 or 1.1 mM; CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, -22.1 mg/l; CI, -31.7 to -12.5; P < 0.001), but other adverse outcomes and length of stay were unchanged. No dose-effect relationships were apparent.
Conclusions: The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.
TL;DR: The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context and present a comprehensive review of the strategies for reducing phreno-nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery.
Abstract: Regional anesthesia has an established role in providing perioperative analgesia for shoulder surgery However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery The most important of these include limiting local anesthetic dose and injection volume and performing the injection further away from the C5-C6 nerve roots Targeting peripheral nerves supplying the shoulder, such as the suprascapular and axillary nerves, may be an effective alternative to brachial plexus blockade in selected patients The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article
TL;DR: The authors’ findings suggest that lidocaine may exert potent antitumor activity in hepatocellular carcinoma and combining lidocane with cisplatin may be a novel treatment option for hepato Cell carcinoma.
Abstract: Background:Recent epidemiologic studies have focused on the potential beneficial effects of regional anesthetics, and the differences in cancer prognosis may be the result of anesthetics on cancer biologic behavior. However, the function and underlying mechanisms of lidocaine in hepatocellular carci
TL;DR: Most, but not all, of the large population-based studies find evidence for associations between surgery in early childhood and slightly worse subsequent academic achievement or increased risk for later diagnosis of a behavioral disability.
Abstract: A recent U.S. Food and Drug Administration warning advised that prolonged or repeated exposure to general anesthetics may affect neurodevelopment in children. This warning is based on a wealth of preclinical animal studies and relatively few human studies. The human studies include a variety of different populations with several different outcome measures. Interpreting the results requires consideration of the outcome used, the power of the study, the length of exposure and the efforts to reduce the confounding effects of comorbidity and surgery. Most, but not all, of the large population-based studies find evidence for associations between surgery in early childhood and slightly worse subsequent academic achievement or increased risk for later diagnosis of a behavioral disability. In several studies, the amount of added risk is very small; however, there is some evidence for a greater association with multiple exposures. These results may be consistent with the preclinical data, but the possibility of confounding means the positive associations can only be regarded as weak evidence for causation. Finally, there is strong evidence that brief exposure is not associated with any long term risk in humans.
TL;DR: To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine T. Anderson;Aurora N. Quaye;E.
Abstract: To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine T. Anderson;Aurora N. Quaye;E. Ward;Timothy Wilens;Paul Hilliard;Chad Brummett; Anesthesiology
TL;DR: The role of fibrinolysis as a pathologic mechanism is explored, the different pharmacologic agents used to inhibit fibrinelysis are reviewed, and the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma is focused on.
Abstract: Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
TL;DR: Perioperative Steroid Management: Approaches Based on Current Evidence Melanie Liu, Andrea Reidy, Siavosh Saatee, and Charles Collard present new ideas and discuss the future direction of research in this area.
Abstract: Perioperative Steroid Management: Approaches Based on Current Evidence Melanie Liu;Andrea Reidy;Siavosh Saatee;Charles Collard; Anesthesiology
TL;DR: Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated, and should be considered a conservative estimate of intraoperativeconnected consciousness.
Abstract: BACKGROUND: The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. METHODS: Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. RESULTS: The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. CONCLUSIONS: Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.
TL;DR: This review focuses on nonhuman primates because their brain development is the closest to humans in terms of not only timing and duration, but the complexity as well, and compares those primate findings to previously published work done with rodents.
Abstract: Recently, the U.S. Food and Drug Administration issued an official warning to all practicing physicians regarding potentially detrimental behavioral and cognitive sequelae of an early exposure to general anesthesia during in utero and in early postnatal life. The U.S. Food and Drug Administration concern is focused on children younger than three years of age who are exposed to clinically used general anesthetics and sedatives for three hours or longer. Although human evidence is limited and controversial, a large body of scientific evidence gathered from several mammalian species demonstrates that there is a potential foundation for concern. Considering this new development in public awareness, this review focuses on nonhuman primates because their brain development is the closest to humans in terms of not only timing and duration, but in terms of complexity as well. The review compares those primate findings to previously published work done with rodents.
University Health Network1, University Hospital of Lausanne2, Autonomous University of Barcelona3, University of Paris4, Ghent University5, Athens State University6, Pierre-and-Marie-Curie University7, Stony Brook University8, Misericordia University9, Hebron University10, University of Queensland11, Hochschule Hannover12, University of Oxford13
TL;DR: A systematic review of 1,435 studies was performed in adults receiving invasive mechanical ventilation as mentioned in this paper, where two different administration strategies (adjunctive and substitute) were considered clinically relevant.
Abstract: Nebulization of antiinfective agents is a common but unstandardized practice in critically ill patients.
A systematic review of 1,435 studies was performed in adults receiving invasive mechanical ventilation. Two different administration strategies (adjunctive and substitute) were considered clinically relevant. Inclusion was restricted to studies using jet, ultrasonic, and vibrating-mesh nebulizers. Studies involving children, colonized-but-not-infected adults, and cystic fibrosis patients were excluded.
Five of the 11 studies included had a small sample size (fewer than 50 patients), and only 6 were randomized. Diversity of case-mix, dosage, and devices are sources of bias. Only a few patients had severe hypoxemia. Aminoglycosides and colistin were the most common antibiotics, being safe regarding nephrotoxicity and neurotoxicity, but increased respiratory complications in 9% (95% CI, 0.01 to 0.18; I = 52%), particularly when administered to hypoxemic patients. For tracheobronchitis, a significant decrease in emergence of resistance was evidenced (risk ratio, 0.18; 95% CI, 0.05 to 0.64; I = 0%). Similar findings were observed in pneumonia by susceptible pathogens, without improvement in mortality or ventilation duration. In pneumonia caused by resistant pathogens, higher clinical resolution (odds ratio, 1.96; 95% CI, 1.30 to 2.96; I = 0%) was evidenced. These findings were not consistently evidenced in the assessment of efficacy against pneumonia caused by susceptible pathogens.
Performance of randomized trials evaluating the impact of nebulized antibiotics with more homogeneous populations, standardized drug delivery, predetermined clinical efficacy, and safety outcomes is urgently required. Infections by resistant pathogens might potentially have higher benefit from nebulized antiinfective agents. Nebulization, without concomitant systemic administration of the drug, may reduce nephrotoxicity but may also be associated with higher risk of respiratory complications.
TL;DR: The deep learning model–predicted bispectral index during target-controlled infusion of propofol and remifentanil more accurately compared to the traditional model and seems promising because of its excellent performance and extensibility.
Abstract: Background:The discrepancy between predicted effect-site concentration and measured bispectral index is problematic during intravenous anesthesia with target-controlled infusion of propofol and remifentanil. We hypothesized that bispectral index during total intravenous anesthesia would be more accu
TL;DR: Norepinephrine has been investigated as a potential alterative to phenylephrine for maintaining blood pressure during spinal anesthesia for cesarean delivery with the advantage of less depression of maternal heart rate and cardiac output.
Abstract: Background:Norepinephrine has been investigated as a potential alterative to phenylephrine for maintaining blood pressure during spinal anesthesia for cesarean delivery with the advantage of less depression of maternal heart rate and cardiac output. However, the relative potencies of these two vasop