Daily Anesthesiology Research Analysis

INTRODUCTION: Remimazolam tosylate is an ultra-short-acting benzodiazepine sedative and anaesthetic. The related drug, midazolam, is associated with delirium but it remains unclear whether remimazolam also promotes delirium. We tested the primary hypothesis that remimazolam is non-inferior to propofol for delirium in patients during the initial 3 days after lung resection surgery. Secondary outcomes were the proportion of delirium-positive assessments; duration of stay in the post-anaesthesia care unit; and hospital and Mini-mental State Examination scores at 30 days. METHODS: We randomly allocated patients aged ≥ 65 y to remimazolam or propofol anaesthesia for lung resection surgery. Delirium was assessed by trained assessors blinded to trial treatment using the Confusion Assessment Method in the post-anaesthesia care unit and twice daily for 3 postoperative days. Our non-inferiority margin was a 10% absolute difference in the incidence of postoperative delirium. RESULTS: The modified intent-to-treat population included 455 patients. Delirium occurred in 108/227 (48%) patients allocated to the remimazolam group and 71/228 (31%) in those allocated to the propofol group (risk ratio 1.53, 95%CI 1.21-1.94). The absolute risk difference was 16.5% (95%CI 7.7-25.3%) which considerably exceeded our non-inferiority margin; therefore, non-inferiority was not established. Emergence delirium was more frequent in patients allocated to remimazolam (105/227 (46%) vs. 64/228 (28%); risk ratio 1.65, 95%CI 1.28-2.12), whereas delirium after post-anaesthesia care unit discharge was uncommon and similar between groups (9/227 (4%) vs. 12/228 (5%); risk ratio 0.75, 95%CI 0.32-1.75). Delirium-positive assessments occurred in 129/1377 (9%) patients allocated to the remimazolam group and 102/1440 (7%) in those allocated to the propofol group (risk ratio 1.36, 95%CI 0.96-1.91). DISCUSSION: Remimazolam was not non-inferior to propofol for postoperative delirium in older patients having lung resection surgery and provoked more emergence delirium.

PURPOSE: A recent Delphi consensus highlighted elements for defining refractory septic shock. We assessed whether integrating persistent tissue hypoperfusion with vasopressor dose after protocolized resuscitation improves mortality risk stratification compared with vasopressor dose alone. METHODS: We performed an exploratory secondary analysis of the ANDROMEDA-SHOCK-2 trial. After 6 h of hemodynamic resuscitation, refractoriness was operationalized as a norepinephrine equivalent dose (NEE) > 0.5 µg/kg/min plus an abnormal capillary refill time (> 3 s) and non-decreasing lactate (two-hypoperfusion criteria). A complementary analysis included NEE > 0.5 µg/kg/min combined with either of the tissue perfusion criteria. The primary outcome was 28-day mortality. RESULTS: Among 1363 patients with complete data, 188 (13.8%) had NEE > 0.5 µg/kg/min at 6-h, with 47.9% mortality. Fifty-three patients (3.9%) were classified as refractory septic shock under the two-hypoperfusion criteria and 124 (9.1%) under the ≥ 1-hypoperfusion criterion. Mortality was 73.6% (39/53) among patients meeting two-hypoperfusion criteria, compared with 23.7% (310/1310) among those classified as non-refractory according to these criteria. (aHR, 4.68; 95% CI 3.31-6.64;p < 0.001). Under ≥ 1-hypoperfusion criterion, mortality was 55.0% (68/124), compared with 22.7% (281/1239) among those classified as non-refractory under this approach (aHR, 2.62; 95% CI 1.90-3.46;p < 0.001). Refractory patients under either approach required had fewer life-support free days. Compared with NEE > 0.5 µg/kg/min alone, the two-hypoperfusion construct yielded superior prognostic enrichment for 28-day mortality (LR + , 8.12; 95% CI 4.70-14.03 vs. 2.71; 95% CI 2.10-3.50;p < 0.001). CONCLUSION: In early septic shock, combining persistent tissue hypoperfusion with vasopressor dose improves risk stratification beyond vasopressor dose alone and identifies a subgroup with markedly increased mortality. These hypothesis-generating findings require validation in future studies.

BACKGROUND: Postoperative (PO) pain management after spine surgery is challenging. For such surgeries, erector spinae plane block (ESPB) and intrathecal morphine (ITM) may offer effective PO analgesia. However, the lack of availability of US machines in low-resource settings and proper dose of ITM that confine the side effects may limit the use of either. Nalbuphine presents an effective approach for managing opioid-induced pruritus without diminishing PO pain relief. In first 24 h after lumbar fusion operations under general anesthesia, the researchers examined effectiveness of bilateral ultrasound (US)-guided ESPB on PO pain and analgesic intake in comparison with ITM. METHODS: One hundred twenty patients premedicated with 4 mg intravenous ondansetron were randomized into group E; bilateral US-guided ESPB, group M; ITM (0.2 mg) or group C; control group. Time to first rescue analgesic (ketorolac) was the primary outcome while parameters of PO analgesic regimen and side effects were considered as secondary outcomes. RESULTS: Compared to C group, E & M groups had longer duration to first rescue analgesic and reduced analgesic consumption within 24 h postoperatively (P < 0.001). Twenty-four hours after surgery, the M group had lower pain scores (P < 0.001) and higher rates of nausea and pruritus (P < 0.001) than the other two groups without any cases of respiratory depression. CONCLUSIONS: The analgesic effect of 0.2 mg intrathecal morphine after lumbar fusion operation under general anesthesia provided lower pain scores and lower analgesic demands than erector spinae plane block at the expense of a higher incidence of manageable side effects of intrathecal morphine within the first 24 h postoperatively. IRB: FMASU MD 102/2022. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05338320. The date that the clinical trial was registered in the ClinicalTrials.gov. : April 14, 2022.