Search Results (17)

Background/Objectives: Postoperative nausea and vomiting (PONV) remains a frequent and clinically relevant complication following open lumbar discectomy (OLD) under general anesthesia. The present study represents a secondary, post hoc analysis of a randomized controlled trial originally designed to investigate the effects of infiltration anesthesia (IA) on postoperative pain perception and opioid consumption. The objective of this analysis was to explore the incidence of PONV in patients undergoing OLD under adequacy of anesthesia (AoA)-guided general anesthesia, with or without IA. Methods: This secondary analysis included 94 patients undergoing OLD under AoA-guided general anesthesia with fentanyl titration based on the surgical pleth index (SPI). Patients were randomized to receive IA with 0.2% ropivacaine (RF) or bupivacaine (BF) plus 50 µg fentanyl, or no IA (control). PONV was assessed as early (in the post-anesthesia care unit), late (in the neurosurgical ward), and overall (within 48 h postoperatively). Opioid consumption and Apfel risk scores were also analyzed. All analyses related to PONV were exploratory. Results: PONV occurred in 12.8% of patients, with no significant differences between study groups. Postoperative morphine consumption was significantly lower in the RF group than in the control group (2.7 ± 5.3 mg vs. 7.1 ± 5.9 mg; p < 0.05). Higher pre-induction SPI values were observed in patients who experienced early PONV (73.1 ± 9.7 vs. 59.5 ± 17.2; p < 0.05); however, this exploratory finding requires confirmation in larger studies. Conclusions: In this secondary, post hoc analysis, no significant differences in PONV incidence were observed between anesthetic groups in patients undergoing OLD under AoA-guided general anesthesia. The observed association between pre-induction SPI values and early PONV should be interpreted cautiously and requires confirmation in adequately powered prospective studies. Full article

Background/Objectives: Intolerable postoperative pain perception (IPPP) may occur in patients undergoing vitreoretinal surgery (VRS), while general anesthesia (GA) is often preferred over regional techniques due to multiple contraindications. Intraoperative administration of intravenous rescue opioid analgesics (IROA) during GA increases the risk of perioperative adverse events; however, this requirement can be reduced through preventive analgesia. The Adequacy of Anesthesia (AoA) concept, based on entropy EEG and the Surgical Pleth Index (SPI), allows real-time titration of IROA to maintain optimal nociception/anti-nociception balance and create comparable intraoperative conditions across patients. This study aimed to identify risk factors for IPPP after VRS performed under AoA-guided GA combined with intravenous preventive analgesia using COX-3 inhibitors. Methods: A total of 165 patients scheduled for VRS were randomized to receive AoA-guided GA combined with intravenous preventive analgesia using either paracetamol plus metamizole, paracetamol alone, or metamizole alone. Results: Data from 153 patients were analyzed. Neither age, body mass index, smoking status, arterial hypertension, diabetes mellitus, intraoperative noxious maneuvers, demand for IROA, nor length of surgery correlated with the incidence of IPPP under AoA-guided GA. The combination of paracetamol and metamizole resulted in the lowest rate of IPPP among all groups. Conclusions: AoA-guided GA combined with COX-3 inhibitors appears to standardize intraoperative nociception/anti-nociception balance in patients undergoing VRS, effectively mitigating most known risk factors for IPPP, with female sex independently associated with its occurrence. We recommend the optimization of perioperative pharmacotherapy through individualized AoA-guided GA with intravenous COX-3 inhibitors to minimize IPPP incidence. Full article

Recent advances in intraoperative nociception monitoring, such as the Surgical pleth index (SPI, GE Healthcare, Helsinki, Finland), may help optimize opioid use. Obese patients are particularly susceptible to opioid-related side effects, making this approach of interest in bariatric surgery. In this randomized pilot study, we investigated whether SPI-guided fentanyl administration would influence intraoperative opioid use and postoperative pain. We enrolled 49 patients undergoing laparoscopic gastric sleeve surgery under sevoflurane-based general anesthesia with multimodal perioperative analgesia, randomized to conventional fentanyl dosing at the anesthetist’s discretion (n = 25) or SPI-guided dosing (n = 24). The primary endpoint was intraoperative fentanyl consumption. Secondary outcomes included time to extubation, hemodynamic events, pain scores in the first 90 min postoperatively and rescue analgesia. Fentanyl use did not differ significantly between groups (SPI: 400 ± 101 mcg vs. control: 450 ± 56 mcg, p = 0.100). Extubation was faster with SPI guidance (8.1 ± 1.6 vs. 9.6 ± 1.3 min, p < 0.001). Hemodynamic events and rescue analgesia were less frequent in the SPI group, though not statistically significant. Pain scores were comparable, and no opioid-related adverse effects occurred. In our study, SPI-guided opioid administration did not reduce overall intraoperative fentanyl requirements compared with conventional practice but was associated with a modestly shorter time to extubation. Full article

Background/Objectives: Some patients undergoing vitreoretinal surgery (VRS) require general anesthesia (GA), despite the possibility of developing intolerable postoperative pain perception (IPPP). Intraoperative rescue opioid analgesia (IROA) administration during GA poses a risk of perioperative nausea and vomiting (PONV), which may result in suprachoroidal hemorrhage with permanent visual impairment. Adequacy of Anesthesia (AoA) optimizes intraoperative IROA titration. Intravenous preemptive analgesia (IPA) with cyclooxygenase-3 (COX-3) inhibitors is added to GA to reduce the IROA dose. In this additional analysis, we assessed the impact of preemptive analgesia with COX-3 inhibitors, administered alongside GA with AoA-guided IROA, on the incidence of PONV, oculocardiac reflex (OCR), and oculoemetic reflex (OER) in patients undergoing VRS as secondary outcomes. Methods: A total of 165 patients scheduled for VRS were randomly assigned to receive AoA-guided GA combined with IPA at a single dose of 1 g of paracetamol (acetaminophen) or 2.5 g of metamizole or both. A total of nine patients were excluded due to technical problems with the intraoperative surgical pleth index (SPI) measurement, inability to report postoperative pain, and postoperative arousal resulting in a loss of follow-up in Stage 5. Results: Regardless of the group assignment, AoA guidance of GA resulted in PONV in 4%, OCR in 10%, and OER in 0% of the 153 analyzed patients undergoing VRS. No significant differences were observed between the groups regarding the type of IPA. PONV was observed in 2.11% (3/142) of patients with zero, one, or two risk factors of PONV, as compared to 27% (3/11) of patients with at least three PONV risk factors, assessed using the Apfel score. Conclusions: IPA with both paracetamol and metamizole did not demonstrate a benefit in reducing the analyzed adverse events compared with their single use in patients undergoing VRS under AoA guidance during GA. Surprisingly, PONV was hardly observed in patients with zero, one, or two PONV risk factors assessed by the Apfel score who underwent AoA-guided VRS during GA with IPA using one or two COX-3 inhibitors. Full article

Background/Objectives: Strabismus surgery in pediatric patients is associated with a high incidence of postoperative nausea and vomiting (PONV). Patients showing pain are more prone to develop PONV. As the infratrochlear nerve (ITN) block can ameliorate perioperative pain following strabismus surgery, we hypothesized that ITN block may influence PONV in pediatric patients undergoing strabismus surgery. Methods: The medical charts of pediatric patients older than 2 years with exotropia who underwent strabismus surgery under general anesthesia, with or without ITN block, were reviewed retrospectively. The incidence of PONV, intraoperative surgical pleth index (SPI), state entropy (SE), response entropy (RE), the changes in hemodynamics, and perioperative use of metoclopramide and ketoprofen were investigated. Results: The study population comprised 116 patients (58 for the No-block group vs. 58 for the ITN group). The incidence of PONV was significantly lower in the ITN block group compared to the No-block group (5.2% vs. 22.4%, respectively; p = 0.015). The SPI at conjunctiva incision, muscle dissection and traction were significantly lower in the ITN block group than in the No-block group. SE was comparable between the two groups, but RE at muscle dissection and traction was significantly lower in the ITN block group than in the No-block group. The use of metoclopramide and ketoprofen was also lower in the ITN block group than in the No-block group. Conclusions: ITN block reduced PONV as well as perioperative pain in pediatric patients undergoing strabismus surgery. Full article

Adequacy of anesthesia concept (AoA) in the guidance of general anesthesia (GA) is based on entropy, and it also reflects the actual depth of anesthesia and the surgical pleth index (SPI). Therefore, this study aimed to analyze the potential existence of relationships between SPI values at certain stages of the AoA-guided GA for vitreoretinal surgeries (VRS) and the incidence of intolerable postoperative pain perception (IPPP). A total of 175 patients were each assigned to one of five groups. In the first, the VRS procedure was performed under GA without premedication; in the second group, patients received metamizole before GA; in the third, patients received acetaminophen before GA; in the fourth group, patients received Alcaine before GA; and, in the peribulbar block group, the patients received a peribulbar block with a mix of the solutions of lignocaine and bupivacaine. Between the patients declaring mild and statistically significant differences in the IPPP in terms of SPI values before induction (52.3 ± 18.8 vs. 63.9 ± 18.1, p < 0.05) and after emergence from GA (51.1 ± 13 vs. 68.1 ± 8.8; p < 0.001), it was observed that the patients postoperatively correlated with heart rate variations despite the group allocation. The current study proves the feasibility that preoperative SPI values help with predicting IPPP immediately after VRS under AoA guidance and discrimination (between mild diagnoses and IPPP when based on postoperative SPI values) as they correlate with heart rate variations. Specifically, this applies when the countermeasures of IPPP and hemodynamic fluctuations are understood to be of importance in reducing unwelcome adverse events. Full article

Despite the possibility of postoperative pain occurrence, in some patients, vitreoretinal surgeries (VRSs) require performance of general anesthesia (GA). The administration of intraoperative intravenous rescue opioid analgesics (IROA) during GA constitutes a risk of perioperative adverse events. The Adequacy of Anesthesia (AoA) concept consists of an entropy electroencephalogram to guide the depth of GA and surgical pleth index (SPI) to optimize the titration of IROA. Preemptive analgesia (PA) using cyclooxygenase-3 (COX-3) inhibitors is added to GA to minimize the demand for IROA and reduce postoperative pain. The current analysis evaluated the advantage of PA using COX-3 inhibitors added to GA with AoA-guided administration of IROA on the rate of postoperative pain and hemodynamic stability in patients undergoing VRS. A total of 165 patients undergoing VRS were randomly allocated to receive either GA with AoA-guided IROA administration with intravenous paracetamol/metamizole or with preemptive paracetamol or metamizole. Preemptive paracetamol resulted in a reduction in the IROA requirement; both preemptive metamizole/paracetamol resulted in a reduced rate of postoperative pain as compared to metamizole alone. We recommend using intraoperative AOA-guided IROA administration during VRS to ensure hemodynamic stability alongside PA using both paracetamol/metamizole to reduce postoperative pain. Full article

Postoperative nausea and vomiting (PONV) constitutes an adverse event after endoscopic sinus surgery (ESS) under general anesthesia (GA) with intravenous opioids, such as remifentanil (RMF). Monitoring the nociception/antinociception balance using the surgical pleth index (SPI) or pupillary dilatation reflex (PRD) helps guide intravenous RMF infusion. We aimed to investigate whether their employment could help reduce the incidence of PONV in patients undergoing ESS. The data of 30 patients from the GA group, 31 from the SPI group, and 28 from the PRD group were analyzed. The initial RMF infusion rate of 0.25 µg/kg body weight/minute was increased by 50% when the SPI, PRD, or Boezaart Bleeding Scale (BBS) were elevated by >15, >5%, or >2 points, respectively, until they normalized. PONV was present in 7/89 patients (7.9%): 2/31 patients (6.5%) of the SPI group, 1/30 patients (3.3%) of the GA group, and 4/28 patients (14.3%) of the PRD group. Neither PRD nor SPI guidance for RMF administration reduced the incidence of PONV compared to standard practice. Further studies are required in order to investigate the possibility of PONV eradication in patients undergoing ESS under GA when it is possibly combined with paracetamol/metamizole preventive analgesia, as well as those using antiemetic prophylaxis based on the Apfel Score and premedication with midazolam. Full article

Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general–regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)—patients who received general anaesthesia alone; Group PBB—GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T—GA with preventive, topical 2% proparacaine; Group M—GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P—GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2—preoperative assessment, PA administration, and the induction of GA; Stage 3—intraoperative observation; Stage 4—postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups. Full article

Abdominal wall blocks (AWBs) can reduce pain during surgery and lessen opioid demand. Since it is difficult to know the exact level of intraoperative pain, it is not known how much the opioid dose should be reduced. In this study, using the surgical pleth index (SPI), which indicates pain index from sympathetic fibers, the amount of remifentanil consumption was investigated. We conducted single-port laparoscopic hernia repair in 64 patients, as follows: the regional block group (R group) was treated with AWB, while the control group (C group) was only subjected to general anesthesia. In both groups, the remifentanil concentration was adjusted to maintain the SPI score between 30 and 40 during surgery. The primary parameter was the amount of remifentanil. A total of 52 patients completed the study (24 in the R group, 28 in the C group). The remifentanil dose during surgery was decreased in the R group (29 ± 21 vs. 56 ± 36 ng/kg/min; p = 0.002). Visual analogue scale score and additional administrated analgesics were also low in the R group. As such, AWB can reduce the remifentanil dose while maintaining the same pain level. Full article

Despite acceptance of the surgical pleth index (SPI) for monitoring the intraoperative balance between noxious stimulation and anti-nociception under general anesthesia, its efficacy for predicting postoperative moderate-to-severe pain remains unclear. We searched electronic databases (e.g., Google Scholar, MEDLINE, Cochrane Library, and EMBASE) to identify articles focusing on associations of SPI at the end of surgery with immediate moderate-to-severe pain in the postanesthesia care unit from inception to 7 July 2022. A total of six observational studies involving 756 adults published between 2016 and 2020 were eligible for quantitative syntheses. Pooled results revealed higher values of SPI in patients with moderate-to-severe pain than those without (mean difference: 7.82, 95% CI: 3.69 to 11.95, p = 0.002, I² = 46%). In addition, an elevated SPI at the end of surgery was able to predict moderate-to-severe pain with a sensitivity of 0.71 (95% confidence interval (CI): 0.65–0.77; I² = 29.01%) and a specificity of 0.58 (95% CI: 0.39–0.74; I² = 79.31%). The overall accuracy based on the summary receiver operating characteristic (sROC) curve was 0.72. In conclusion, this meta-analysis highlighted the feasibility of the surgical pleth index to predict postoperative moderate-to-severe pain immediately after surgery. Our results from a limited number of studies warrant further investigations for verification. Full article

Vitreoretinal surgeries require the administration of general anesthesia (GA) in selected groups of patients. The administration of intraoperative rescue narcotic analgesia (IRNA) during GA poses the risk of postoperative nausea and vomiting (PONV). The surgical pleth index (SPI), a crucial component of the adequacy of anesthesia (AoA) guidance of GA, optimizes the intraoperative titration of IRNA. The current analysis evaluated the risk factors for the occurrence of PONV and the oculo-cardiac reflex (OCR) in patients undergoing pars plana vitrectomy (PPV) under AoA guidance. In total, 175 patients undergoing PPV were randomly allocated to receive either GA with SPI-guided IRNA administration using fentanyl alone or in addition to different preoperative analgesia techniques. Any incidence of PONV or OCR was recorded. Obesity, overweight, smoking status, motion sickness, postoperative intolerable pain perception, female gender, fluid challenge and arterial hypertension did not correlate with an increased incidence of PONV or OCR under AoA guidance. Diabetes mellitus, regardless of insulin dependence, was found to correlate with the increased incidence of PONV. The AoA regimen including SPI guidance of IRNA presumably created similar conditions for individual subjects, so no risk factors of the occurrence of PONV or OCR were found, except for diabetes mellitus. We recommend using AoA guidance for GA administration to reduce OCR and PONV rates. Full article

Inadequate intraoperative analgesia causes the deterioration of the condition of the surgical field (CSF) as a result of hemodynamic instability. Analgesia monitors are used to guide remifentanil) infusion to optimize intraoperative analgesia. The main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using surgical Pleth index (SPI)- or pupillometry (PRD)-guided remifentanil administration for managing the volume of total intraoperative blood loss (TEIBL), CSF, and length of operation (LOP) in comparison with the standard practice in patients undergoing endoscopic sinus surgery (ESS). The 89 patients in our study were grouped as follows: 30 patients were assigned to the general analgesia (GA) group, 31 patients were assigned to the SPI group, and 28 patients were assigned to the PRD group. The speed of remifentanil infusion was accelerated by 50% when SPI, PRD, or BSS were increased by >15 points, >5%, or >2, respectively, in adjacent groups until their normalization. The SPI group showed significantly lower TEIBL in comparison to the GA group (165.2 ± 100.2 vs. 283.3 ± 193.5 mL; p < 0.05) and a higher mean arterial pressure (MAP; 73.9 ± 8 vs. 69.2 ± 6.8 mmHg; p < 0.05). In the PRD group, a shorter LOP compared with the GA group was observed (63.1 ± 26.7 min vs. 82.6 ± 33.1 min; p < 0.05). It was noted that the PRD group had a lower total remifentanil consumption than the SPI group (1.3 ± 1.4 vs. 1.8 ± 0.9 mg; p < 0.05). In ASA I-III patients undergoing ESS, intraoperative monitoring based on state entropy and SPI values can optimize the CSF and reduce TEIBL, whereas monitoring based on state entropy and PRD measurements can optimize the cost effectiveness of anesthetic drugs and the use of the operation room. Full article

In patients undergoing colonoscopy procedures (CPs), inadequate dosing of hypnotic drugs (HD) and opioid analgesics (OA) during intravenous sedoanalgesia (ISA) may lead to intraprocedural awareness with recall (IAwR), intraprocedural (IPP) and postprocedural pain (PPP), as well as postoperative nausea and vomiting (PONV). The aim of this study was to evaluate whether the titration of HD and OA based on the observance of changing values of state entropy (SE) and surgical pleth index (SPI) (adequacy of anesthesia—AoA), state entropy alone, or standard practice may reduce the number of adverse events. One hundred and fifty-eight patients were included in the final analysis. The rate of IAwR and IPP was statistically more frequent in patients from the C group in comparison with the AoA and SE groups (p < 0.01 and p < 0.05, respectively). In turn, the rate of PPP, PONV, and patients’ and operators’ satisfaction with ISA between groups was not statistically significant (p > 0.05). Changes in hemodynamic parameters, demand for HD, and OA were statistically significant, but of no clinical value. In patients undergoing CPs under ISA using propofol and FNT, as compared to standard practice, intraprocedural SE monitoring reduced the rate of IAwR and IPP, with no influence on the rate of PPP, PONV, or patients’ and endoscopists’ satisfaction. AoA guidance on propofol and FNT titration, as compared to SE monitoring only, did not reduce the occurrence of the aforementioned studied parameters, imposing an unnecessary extra cost. Full article

Background and Objectives: Patients with traumatic injuries have often been excluded from studies that have attempted to pinpoint modifiable factors to predict the transient disturbance of the cognitive function in the postoperative settings. Anesthetists must be aware of the high risk of developing postoperative delirium and cognitive dysfunction (POCD) in patients undergoing emergency surgery. Monitoring the depth of anesthesia in order to tailor anesthetic delivery may reduce this risk. The primary aim of this study was to improve the prevention strategies for the immediate POCD by assessing anesthetic depth and nociception during emergency surgery. Material and Methods: Of 107 trauma ASA physical status II–IV patients aged over 18 years undergoing emergency noncardiac surgery, 95 patients were included in a prospective randomized study. Exclusion criteria were neurotrauma, chronic use of psychoactive substances or alcohol, impaired preoperative cognitive function, pre-existing psychopathological symptoms, or expected surgery time less than 2 h. Entropy and Surgical Pleth Index (SPI) values were constantly recorded for one group during anesthesia. POCD was assessed 24 h, 48 h, and 72 h after surgery using the Neelon and Champagne (NEECHAM) Confusion Scale. Results: Although in the intervention group, fewer patients experienced POCD episodes in comparison to the control group, the results were not statistically significant (p < 0.08). The study showed a statistically significant inverse correlation between fentanyl and the NEECHAM Confusion Scale at 24 h (r = −0.32, p = 0.0005) and 48 h (r = −0.46, p = 0.0002), sevoflurane and the NEECHAM Confusion Scale at 24 h (r = −0.38, p = 0.0014) and 48 h (r = −0.52, p = 0.0002), and noradrenaline and POCD events in the first 48 h (r = −0.46, p = 0.0013 for the first 24 h, respectively, and r = −0.46, p = 0.0002 for the next 24 h). Conclusions: Entropy and SPI monitoring during anesthesia may play an important role in diminishing the risk of developing immediate POCD after emergency surgery. Full article