It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated ...with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia.
In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7.
Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 95% CI, 0.69 to 1.19; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min i.e., -00:19 95% CI, -0:38 to 0 and mean difference, 9 min 95% CI, -0:18 to -0:01, respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 85% vs. 131 of 174 75%; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups.
The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach.
Summary
Background and Objective
Serious adverse cardiorespiratory events complicate super selective ophthalmic artery chemotherapy for retinoblastoma in anesthetized children. Their mechanism ...remains unclear but may be attributed to an autonomic nervous reflex induced by the catheter close to the ophthalmic artery. Inadequate depth of anesthesia during catheter stimulation might be an aggravating factor. Thus, we tested whether deep general anesthesia reduced the incidence of serious cardiorespiratory events.
Methods
Children were prospectively included in this observational study. Standardized deep general anesthesia with sevoflurane, rocuronium, and sufentanil was administered. Sevoflurane MAC was kept between 1.5 and 1.7 and additional sufentanil administered. Serious cardiorespiratory event criteria were predefined and included arterial hypotension, bradycardia, and severe decrease in lung compliance. They were recorded and the factors influencing their occurrence were investigated.
Results
One hundred fifteen procedures were performed on 32 children. The median MAC of sevoflurane was 1.5 and median BIS value was 44. Serious cardiorespiratory events occurred in 20% of procedures and were mainly severe decrease in lung compliance (83% of events). All of them required active treatment. One procedure was aborted due to cardiorespiratory compromise and required an epinephrine infusion. All severe decreases in lung compliance occurred within 2 minutes after catheter insertion in the ophthalmic artery. No recorded demographic and endovascular characteristics were associated with serious cardiorespiratory events.
Conclusion
Serious cardiorespiratory events occur commonly during super selective ophthalmic artery chemotherapy. Standardized deep anesthesia with analgesia did not appear to be protective. No predictive factors were identified, but these events systematically arose within 2 minutes after ophthalmic artery catheter insertion. Anesthetists and neuroradiologists should be prepared to manage these serious complications and parents should be informed of the risks.
Summary
Background
Few data are available in the literature on risk factors for postoperative vomiting (POV) in children.
Objective
The aim of the study was to establish independent risk factors for ...POV and to construct a pediatric specific risk score to predict POV in children.
Methods
Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC), to optimize sensitivity and specificity.
Results
The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 95% CI 1.75–3.45; ≥6 and ≤13 years: aOR 3.09 95% CI 2.23–4.29), duration of anesthesia (aOR 1.44 95% IC 1.06–1.96), surgery at risk (aOR 2.13 95% IC 1.49–3.06), predisposition to POV (aOR 1.81 95% CI 1.43–2.31), and multiple opioids doses (aOR 2.76 95% CI 2.06–3.70, P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 95% CI 0.67–0.78 when applied to the validation dataset.
Conclusions
Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV.
To provide an update to the 1999 French guidelines on “Muscle relaxants and reversal in anaesthesia”, a consensus committee of sixteen experts was convened. A formal policy of declaration and ...monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded.
The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system.
The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations.
Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
IntroductionTreatment of acute stroke has drastically changed in the last 10 years. Endovascular therapy is now the standard of care for patients with a stroke caused by a large vessel occlusion in ...the anterior circulation. The impact of the type of anaesthesia (general anaesthesia or conscious sedation) during endovascular therapy on the outcome of the patients is still a matter of debate. Previous studies are mostly retrospective and/or focused on the early postprocedure outcome and/or without blood pressure goals and/or single-centre small size studies. We therefore designed a multicentre study hypothesising that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anaesthesia.Methods/analysisThe General Anesthesia vs Sedation for Stroke (GASS) Trial is a randomised, parallel, single-blind, multicentre study of 350 patients undergoing endovascular therapy for the treatment of stroke. Patients will be randomly allocated to receive either a general anaesthesia or a conscious sedation. The primary outcome measure is the modified Rankin score assessed 3 months after the treatment. Data will be analysed on the intention-to-treat principle.Ethics/disseminationThe GASS Trial has been approved by an independent ethics committee for all study centres. Participant recruitment begins in September 2016. Results will be published in international peer-reviewed medical journals.Trial registration number NCT02822144.
ObjectiveWe hypothesised that videolaryngoscopy modifies practice of tracheal intubation.DesignRandomised single-blinded study (video and no-video groups).SettingThree institutions: one academic, one ...non-profit and one profit.ParticipantsPatients >18 years, requiring orotracheal intubation, without predicted difficult intubation. Non-inclusion criterion was patients requiring a rapid-sequence intubation. 300 patients were included, 271 randomised, 256 analysed: 123 in the no-video and 133 in the video groups.InterventionTracheal intubation using a McGrath Mac videolaryngoscope, the sequence being video recorded.Primary and secondary outcome measuresThe primary outcome was the proportion of intubations where assistance is necessary on request of the operator. Secondary outcomes included intraoperative variables (intubation difficulty scale and its components, percentage of glottic opening score, oesophageal Intubation, duration of intubation, removal of the screen cover in the no-video group, global evaluation of the ease of intubation, bispectral index, heart rate and blood pressure), intraoperative and postoperative complications (hoarseness or sore throat) and cooperation of the anaesthesiology team.ResultsRequirement for assistance was not decreased in the Video group: 36.1% (95% CI 27.9 to 44.9) vs 45.5% (95% CI 36.5 to 54.7) in the no-video group, p=0.74; OR: 0.7 (95% CI 0.4 to 1.1) and absolute risk: 0.10 (95% CI −0.03 to 0.22). Intubation difficulty scale was similar in both groups (p=0.05). Percentage of glottic opening score was better in the Video group (median of 100 (95% CI (100 to 100) and 80 (95%CI (80 to 90) in the no-video group; p<0.001) as Cormack and Lehane grade (p=0001). Ease of intubation was considered better in the video group (p<0.001). Other secondary outcomes were similar between groups. Screen cover was removed in 7.3% (95% CI (2.7 to 11.9)) of the cases in the video group. No serious adverse event occurred. Communication and behaviour within the anaesthesia team were appropriate in all cases.ConclusionIn patients without predicted difficult intubation, videolaryngoscopy did not decrease the requirement for assistance to perform intubation.Trial registration numberNCT02926144; Results.
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