Daily Anesthesiology Research Analysis

INTRODUCTION: Concerns about opioid-related adverse effects have increased interest in opioid-free anaesthesia, but the benefits compared with opioid-inclusive techniques, especially in the presence of regional anaesthesia, remain uncertain. METHODS: We undertook a systematic review with a network meta-analysis of randomised controlled trials comparing six strategies in adults: opioid-free anaesthesia and opioid-inclusive anaesthesia using remifentanil alone or other opioids, each with or without regional anaesthesia. Primary outcome was postoperative pain. Secondary outcomes were: postoperative opioid use; post-anaesthesia care unit discharge time; hospital duration of stay; and incidence of complications. RESULTS: We included 885 trials from 59 countries. Techniques incorporating regional anaesthesia consistently ranked highest for postoperative pain. Regional anaesthesia combined with an opioid-free intra-operative strategy achieved some of the highest surface under the cumulative ranking curve values for pain at 2 h, 12 h and 48 h (93%, 85% and 75%, all low certainty). When regional anaesthesia was used, differences between opioid-free and opioid-inclusive techniques were minimal (moderate certainty). For opioid consumption, regional anaesthesia with an opioid-free strategy ranked best at 2 h (moderate certainty), 12 h (low certainty) and 48 h (low certainty), with surface under the cumulative ranking curve values > 98%. Techniques without regional anaesthesia were associated with higher pain scores and greater opioid requirements. Opioid-free approaches, especially when combined with regional techniques, were associated with lower rates of postoperative nausea and vomiting. DISCUSSION: Regional anaesthesia was the key determinant of improved postoperative pain control, and intra-operative opioids added little additional benefit when regional techniques provided adequate coverage. Without regional anaesthesia, neither opioid-free nor opioid-inclusive strategies showed consistent analgesic superiority. However, opioid-free techniques reduced postoperative nausea and vomiting. These findings support preferential use of regional anaesthesia where feasible and suggest that avoiding intra-operative opioids may facilitate recovery, particularly when regional techniques are employed effectively. WHAT WE DID: We looked at many studies from around the world that compared different ways of giving anaesthesia (the medicine that keeps you asleep during surgery). We compared six types of anaesthesia, including some that used opioids (strong pain medicines) and some that did not. We also looked at whether a special kind of numbing, called regional anaesthesia, was used. We checked how well each method worked for pain after surgery and other outcomes like sickness and time in hospital. WHY DID WE DO IT: Doctors are worried about the side effects of opioids, so they want to know if people can stay comfortable after surgery without using them. We wanted to find out which combinations of anaesthesia give the best pain control and the fewest problems after surgery. WHAT WE FOUND: The best pain control happened when regional anaesthesia was used, no matter what other medicines were given. When regional anaesthesia was already helping, using or avoiding opioids during the operation didn't make much difference to pain afterwards. People who did not get regional anaesthesia had more pain and needed more opioids later. Opioid‐free techniques (especially when combined with regional anaesthesia) led to less sickness and vomiting after surgery. Overall, the results show that regional anaesthesia is the most important part for good pain control. Avoiding opioids during the operation may also help people feel better afterwards, especially when regional anaesthesia is used.

PURPOSE: Rapid and complete reversal of residual neuromuscular blockade (rNMB) is essential for safe postoperative recovery in patients with myasthenia gravis (MG) undergoing video-assisted thoracoscopic (VATS) thymectomy. Although sugammadex provides a novel approach for reversing rocuronium-induced neuromuscular blockade, its efficacy in this high-risk population under routine-practice conditions-where reversal timing relies on clinical judgment-remains incompletely characterized. This multicenter randomized controlled trial (RCT) compared the efficacy of sugammadex versus neostigmine for reversing rNMB in patients with mild MG undergoing VATS thymectomy, specifically under this pragmatic, experience-guided scenario. PATIENTS AND METHODS: In this prospective, superiority-design RCT, MG patients scheduled for VATS thymectomy were randomized 1:1 to receive either sugammadex (2 mg/kg) or neostigmine (0.05 mg/kg with atropine 0.02 mg/kg) for reversal of rocuronium-induced neuromuscular blockade. All patients received a standard induction dose of rocuronium (0.6 mg/kg). The attending anesthesiologist, blinded to both the reversal agent and all quantitative neuromuscular monitoring data, managed blockade using a minimal-dose strategy (boluses only for clinical signs of inadequate block). This blinded anesthesiologist determined reversal timing based on clinical judgment, with administration contingent upon independent verification of a TOF count ≥ 2. The primary outcome was recovery time (interval from reversal agent administration to normalized TOF ratio of ≥ 0.9), analyzed with the Mann-Whitney RESULTS: Among 62 randomized patients (31 per group), all patients received reversal at a train-of-four (TOF) count of ≥2 (median count at reversal: 3 in both groups). Sugammadex achieved significantly faster recovery (median 2.62 [IQR 1.83-3.28] minutes; range 0.92-5.80 minutes) versus neostigmine (14.63 [12.22-16.30] minutes; range 10.97-28.81 minutes), with an estimated median difference of 12.01 minutes (95% CI: 9.50-14.52; CONCLUSION: In patients with MG undergoing VATS thymectomy, this pragmatic trial simulating routine practice demonstrates that sugammadex provides faster and more reliable reversal of moderate neuromuscular blockade (median TOF count 3) than neostigmine, leading to clinically meaningful reductions in recovery time (by 12.01 minutes), extubation time, and rNMB incidence.

BACKGROUND: Maintenance of oxygenation during microdirect laryngoscopy and bronchoscopy (MDLB) is an anesthetic challenge for pediatric anesthesia providers. High flow nasal cannula (HFNC) as transnasal humidified rapid insufflation ventilatory exchange (THRIVE) is a safe method to deliver humidified oxygen to pediatric patients; however, its role in pediatrics for preventing apneic desaturation while under anesthesia is unclear. This study evaluated THRIVE for pediatric patients undergoing airway procedures. The primary aim was to assess the frequency of patients who had at least one "relative desaturation" event, assessed as a 4 % drop from a patient's average baseline saturation using the measure of oxygen desaturation index (ODI). The secondary aims assessed frequencies of total relative desaturation events, absolute desaturations below 90 % and surgical interruptions due to airway conditions. METHODS: This was a prospective, randomized controlled trial conducted across three pediatric sites (Lucile Packard Children's Hospital [Stanford University, Palo Alto, CA], UC Davis Children's Hospital [University of California, Davis, CA], and Boston Children's Hospital [Harvard University, Boston, MA]). Participants between the ages of 2 months to 18 years underwent airway examinations or airway procedures under general anesthesia. Participants were randomized in a 1:1 ratio to THRIVE or standard of care (SOC). RESULTS: A total of 144 participants were included. ODI measurements of relative desaturation in the THRIVE group and SOC group showed no differences in number of the participants who ever desaturated (p = 0.18). There was a difference in total number of relative desaturation events, accounting for multiple events per participant (p = 0.04). There were no differences in surgical interruptions due to airway conditions. CONCLUSION: THRIVE was not superior to SOC for reducing the number of patients who experienced desaturations or surgical interruptions, though it may have some benefit for reducing the total number of desaturation events in those who desaturate.