Daily Anesthesiology Research Analysis

OBJECTIVES: This study aimed to investigate the safety and effectiveness of opioid-free anaesthesia (OFA) versus conventional opioid anaesthesia (OA) for postoperative pain management and recovery in patients undergoing laparoscopic surgery. DESIGN: Systematic review and meta-analysis. DATA SOURCES: The databases of PubMed, Embase, Cochrane Library and Web of Science were searched from inception to August 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included any randomised controlled trial comparing OFA (at least two drugs or two more alternatives to opioids) with OA for laparoscopic surgery. The primary outcomes included postoperative pain scores, measured on a Numerical Rating Scale or Visual Analogue Scale ranging from 0 to 10, at 0-2 hours and 24 hours postoperatively; postoperative analgesic consumption, measured in morphine equivalent doses (mg); and quality of recovery, assessed using the QoR-40 score (ranging from 40 to 200). The secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), antiemetic use, extubation time (measured in minutes), post-anaesthesia care unit discharge time (measured in minutes), shivering, bradycardia, hypotension and pruritus. DATA EXTRACTION AND SYNTHESIS: Meta-analyses were performed using Stata16 software, using the DerSimonian and Laird's method and inverse variance to summarise effect sizes for each outcome under a random effects model for all outcomes. Outcomes were reported as OR for binary outcome indicators and mean difference (MD) for continuous outcome indicators, with corresponding 95% CIs. RESULTS: Ultimately, 12 studies involving 983 patients undergoing laparoscopic surgery were included in this systematic evaluation and meta-analysis. The results of the meta-analysis showed an association of OFA with reduced early postoperative 0-2-hour pain response (MD -1.29; 95% CI -2.23 to -0.36; CONCLUSIONS: OFA may be more beneficial for postoperative pain management and recovery in patients undergoing laparoscopic surgery compared with conventional OA. Future studies could further extend these findings to other surgical populations. PROSPERO REGISTRATION NUMBER: CRD42023414848.

BACKGROUND: Fluid loading with crystalloids is the conventional treatment of major hemorrhage but might tend to create fluid overload. We studied hemodynamic profiles of fluid replacement therapies during major surgical hemorrhage and compared the ability of pulse pressure variation (PPV), plethysmographic variation index (PVI), cardiac output (CO) and Guyton´s approach to detect hypovolemia. METHODS: In this single center randomized controlled trial, fluid replacement therapy to treat hemorrhage in 42 patients was randomized to consist of either 5% albumin (12 mL/kg) or 20% albumin (3 mL/kg) over 30 min, both completed by Ringer lactate replacing blood loss in a 1:1 ratio, or Ringer solution alone in a 3:1 ratio. Measurements included CO, PPV, PVI, arterial and central venous pressures, heart rate (HR) and subsequent calculation of Guyton´s physiological parameters. CO was measured by an esophageal Doppler probe. RESULTS: The Ringer-only fluid program resulted in slight hypovolemia (mean, 313 mL), decreased mean arterial pressure (MAP), increased HR, PPV values and vasopressor requirement. The 5% and 20% albumin programs were more effective in filling the vascular system, as evidenced by higher mean circulatory filling pressure and unchanged or decreased PPV over the 5 h observation period. The 20% albumin increased the systemic vascular resistance and the resistance to venous return. Receiver operating characteristics curves indicated that hypovolemia > 500 mL could only be accurately detected by PPV when 5% albumin was used, that PVI was reliable when Ringer was infused, and that CO indicated the hypovolemia when 20% albumin was administered. CONCLUSIONS: The trends in PPV, PVI, and CO reflected the changes in intravascular volume, but how well they indicated hypovolemia > 500 mL may differ depending on the choice of infusion fluid. Identifying hypovolemia using non-invasive hemodynamic monitors remains challenging and associated with low predictive values. TRIAL REGISTRATION NUMBER: NCT05391607, May 26, 2022.

PURPOSE: The quality of postoperative recovery under enhanced recovery after surgery protocols has always been the focus of anesthesiologists. It has been proven that esketamine application during the perioperative period can reduce the use of opioid drugs and improve the quality of postoperative recovery. The present study explored the effect of the esketamine-based opioid-sparing anesthesia protocol on the quality of postoperative recovery in patients undergoing elective urological surgery. PATIENTS AND METHODS: A randomized, double-blind, controlled clinical trial was adopted. Patients aged 18-65 years, with American Society of Anesthesiologists physical status grades I-III, scheduled for elective laparoscopic partial nephrectomy or unilateral nephrectomy in urological surgery, were randomly divided into the OSA group and the control group. The OSA group received 0.25 mg/kg of esketamine for anesthesia induction during the operation, and maintenance was carried out at a rate of 0.125 mg·kg⁻¹·h⁻¹. The primary outcome measure was the Quality of Recovery Scale-15 score 24 hours after the operation. RESULTS: The total Quality of Recovery Scale-15 score was significantly higher in the OSA than in control groups 24 hours after the operation (114 [108, 116] vs 106 [102, 109], CONCLUSION: The esketamine-based opioid-sparing anesthesia protocol can improve the quality of early postoperative recovery and the level of anesthesia recovery, and accelerate rehabilitation in patients undergoing elective urological surgery.