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Anesthesia in General Surgery: Clinical Management and Challenges
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Anesthesia in General Surgery: Clinical Management and Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Anesthesiology".

Deadline for manuscript submissions: closed (20 March 2024) | Viewed by 5459

Special Issue Editor

Prof. Dr. Munetaka Hirose

E-Mail Website
Guest Editor
Department of Anesthesiology and Pain Medicine, Hyogo Medical University Faculty of Medicine, Nishinomiya 663-8501, Japan
Interests: anesthesiology; postoperative complications; nociception; surgery; pain management

Special Issue Information

Dear Colleagues,

The role of anesthesia during surgery is to provide a controlled state of unconsciousness, analgesia, muscle relaxation and maintenance of physiological stability. Additionally, appropriate anesthetic management provides better patient recovery. Furthermore, appropriate preoperative and postoperative management is also crucial for improved patient outcomes.  Although several physiological and pharmacological indexes are available to monitor patients’ perioperative conditions, it is not entirely clear which indicators should be utilized for appropriate perioperative management and which indicators are of utmost importance. This Special Issue calls for original research and systematic or narrative reviews that have investigated the features of preoperative, intraoperative and postoperative management, including anesthetic management that influences patient outcomes. It also calls for papers to explore novel interventions that constitute advancements in perioperative management.

Prof. Dr. Munetaka Hirose
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • anesthesia
  • cardiothoracic anesthesia
  • general surgery
  • geriatric anesthesia
  • neurosurgical anesthesia
  • obstetric anesthesia
  • pediatric anesthesia
  • perioperative management
  • postoperative complications
  • postoperative pain

Published Papers (7 papers)

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10 pages, 592 KiB  
Article
Comparison of Left Ventricular End-Diastolic Volume Approximated from Mean Blood Pressure and Stroke Volume and End-Diastolic Volume Calculated from Left Ventricular-Aortic Coupling
by Takahiro Shiraishi, Yuka Matsuki, Yukiko Yamazaki and Kenji Shigemi
J. Clin. Med. 2024, 13(11), 3204; https://doi.org/10.3390/jcm13113204 - 29 May 2024
Viewed by 126
Abstract
Objectives: The purpose of this study was to compare left ventricular end-diastolic volume (EDV), derived from left ventricular arterial coupling (Ees/Ea), and mean arterial blood pressure. Both of these methods of measuring EDV require some invasive procedure. However, the method of measuring EDV [...] Read more.
Objectives: The purpose of this study was to compare left ventricular end-diastolic volume (EDV), derived from left ventricular arterial coupling (Ees/Ea), and mean arterial blood pressure. Both of these methods of measuring EDV require some invasive procedure. However, the method of measuring EDV approximate is less invasive than the EDV coupling measuring method. This is because EDV approximate only requires arterial pressure waveform as an invasive procedure. Methods: This study included 14 patients with normal cardiac function who underwent general anesthesia. The point when blood pressure stabilized after the induction of anesthesia was taken as a baseline according to the study protocol. At the point when systolic arterial blood pressure fell 10% or more from the baseline blood pressure, 300 mL of colloid solution was administered over 15 min. EDV approximate and EDV coupling were calculated for each of the 14 patients at three points during the course of anesthetic. Each value was obtained by calculating a 5 min average. The timing of these three points was 5 min before, 5 min during, and 5 min after infusion loading. Results: The total number of comparable points was 42; 3 points were taken from each of the 14 participants. Both EDV approximate and EDV coupling increased through the infusion load testing. Scatter plots were prepared, and regression lines were calculated from the obtained values. A high correlation was shown between EDV approximate and EDV coupling (R2 = 0.96, p < 0.05). Conclusions: In patients with good cardiac function, EDV approximate can be substituted for EDV coupling, suggesting the possibility that EDV can be continuously and less invasively calculated under the situation of general anesthesia. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
14 pages, 905 KiB  
Article
The Impact of Nociception Monitor-Guided Multimodal General Anesthesia on Postoperative Outcomes in Patients Undergoing Laparoscopic Bowel Surgery: A Randomized Controlled Trial
by Satoshi Okamoto, Hiroki Ogata, Shohei Ooba, Ayano Saeki, Fumiya Sato, Kazunori Miyamoto, Mayu Kobata, Hiroai Okutani, Ryusuke Ueki, Nobutaka Kariya and Munetaka Hirose
J. Clin. Med. 2024, 13(2), 618; https://doi.org/10.3390/jcm13020618 - 22 Jan 2024
Cited by 1 | Viewed by 867
Abstract
Background: Excess surgical stress responses, caused by heightened nociception, can lead to elevated levels of postoperative inflammation, resulting in an increased incidence of complications after surgery. We hypothesized that utilizing nociception monitor-guided multimodal general anesthesia would exert effects on postoperative outcomes (e.g., serum [...] Read more.
Background: Excess surgical stress responses, caused by heightened nociception, can lead to elevated levels of postoperative inflammation, resulting in an increased incidence of complications after surgery. We hypothesized that utilizing nociception monitor-guided multimodal general anesthesia would exert effects on postoperative outcomes (e.g., serum concentrations of C-reactive protein (CRP) after surgery, postoperative complications). Methods: This single-center, double-blinded, randomized trial enrolled ASA class I/II adult patients with normal preoperative CRP levels, scheduled for laparoscopic bowel surgery. Patients were randomized to receive either standard care (control group) or nociception monitor-guided multimodal general anesthesia using the nociceptive response (NR) index (NR group), where NR index was kept below 0.85 as possible. The co-primary endpoint was serum concentrations of CRP after surgery or rates of 30-day postoperative complications (defined as Clavien–Dindo grades ≥ II). Main Results: One hundred and four patients (control group, n = 52; NR group, n = 52) were enrolled for analysis. The serum CRP level on postoperative day (POD) 1 was significantly lower in the NR group (2.70 mg·dL−1 [95% confidence interval (CI), 2.19–3.20]) than in the control group (3.66 mg·dL−1 [95% CI, 2.98–4.34], p = 0.024). The postoperative complication rate was also significantly lower in the NR group (11.5% [95% CI, 5.4–23.0]) than in the control group (38.5% [95% CI, 26.5–52.0], p = 0.002). Conclusions: Nociception monitor-guided multimodal general anesthesia, which suppressed intraoperative nociception, mitigated serum concentrations of CRP level, and decreased postoperative complications after laparoscopic bowel surgery. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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16 pages, 1727 KiB  
Article
Safety and Feasibility of Intraoperative High PEEP Titrated to the Lowest Driving Pressure (ΔP)—Interim Analysis of DESIGNATION
by Sunny G. L. H. Nijbroek, Liselotte Hol, Ary Serpa Neto, David M. P. van Meenen, Sabrine N. T. Hemmes, Markus W. Hollmann and Marcus J. Schultz
J. Clin. Med. 2024, 13(1), 209; https://doi.org/10.3390/jcm13010209 - 29 Dec 2023
Viewed by 788
Abstract
Uncertainty remains about the best level of intraoperative positive end–expiratory pressure (PEEP). An ongoing RCT (‘DESIGNATION’) compares an ‘individualized high PEEP’ strategy (‘iPEEP’)—titrated to the lowest driving pressure (ΔP) with recruitment maneuvers (RM), with a ‘standard low PEEP’ strategy (‘low PEEP’)—using 5 cm [...] Read more.
Uncertainty remains about the best level of intraoperative positive end–expiratory pressure (PEEP). An ongoing RCT (‘DESIGNATION’) compares an ‘individualized high PEEP’ strategy (‘iPEEP’)—titrated to the lowest driving pressure (ΔP) with recruitment maneuvers (RM), with a ‘standard low PEEP’ strategy (‘low PEEP’)—using 5 cm H2O without RMs with respect to the incidence of postoperative pulmonary complications. This report is an interim analysis of safety and feasibility. From September 2018 to July 2022, we enrolled 743 patients. Data of 698 patients were available for this analysis. Hypotension occurred more often in ‘iPEEP’ vs. ‘low PEEP’ (54.7 vs. 44.1%; RR, 1.24 (95% CI 1.07 to 1.44); p < 0.01). Investigators were compliant with the study protocol 285/344 patients (82.8%) in ‘iPEEP’, and 345/354 patients (97.5%) in ‘low PEEP’ (p < 0.01). Most frequent protocol violation was missing the final RM at the end of anesthesia before extubation; PEEP titration was performed in 99.4 vs. 0%; PEEP was set correctly in 89.8 vs. 98.9%. Compared to ‘low PEEP’, the ‘iPEEP’ group was ventilated with higher PEEP (10.0 (8.0–12.0) vs. 5.0 (5.0–5.0) cm H2O; p < 0.01). Thus, in patients undergoing general anesthesia for open abdominal surgery, an individualized high PEEP ventilation strategy is associated with hypotension. The protocol is feasible and results in clear contrast in PEEP. DESIGNATION is expected to finish in late 2023. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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14 pages, 1088 KiB  
Article
Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)—A Prospective, Randomised Controlled Study
by Marc Kriege, Tim Demare, Robert Ruemmler, Irene Schmidtmann, Janosh Wojciechowski, Anneke Busch and Thomas Ott
J. Clin. Med. 2024, 13(1), 16; https://doi.org/10.3390/jcm13010016 - 19 Dec 2023
Viewed by 664
Abstract
Background: The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers [...] Read more.
Background: The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios. Methods: After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min. Results: In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02). Conclusion: The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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12 pages, 1158 KiB  
Article
Anesthesia Management via an Automated Control System for Propofol, Remifentanil, and Rocuronium Compared to Management by Anesthesiologists: An Investigator-Initiated Study
by Osamu Nagata, Yuka Matsuki, Shuko Matsuda, Keita Hazama, Saiko Fukunaga, Hideki Nakatsuka, Fumiyo Yasuma, Yasuhiro Maehara, Shoko Fujioka, Karin Tajima, Ichiro Kondo, Itaru Ginoza, Misuzu Hayashi, Manabu Kakinohana and Kenji Shigemi
J. Clin. Med. 2023, 12(20), 6611; https://doi.org/10.3390/jcm12206611 - 19 Oct 2023
Cited by 1 | Viewed by 1319
Abstract
Background: We previously developed an automated total intravenous anesthesia control system that uses new closed-loop system algorithms to administer propofol, remifentanil, and rocuronium based on the bispectral index and train-of-four data. We recently improved this automated control system by adding a safety mechanism [...] Read more.
Background: We previously developed an automated total intravenous anesthesia control system that uses new closed-loop system algorithms to administer propofol, remifentanil, and rocuronium based on the bispectral index and train-of-four data. We recently improved this automated control system by adding a safety mechanism and using a modified monitoring device. Methods: Patients scheduled for elective surgery were randomly assigned to closed-loop feedback control (automatic group) or the manual administration of propofol, remifentanil, and rocuronium (manual group). The proportion of time during which the proper management of three-agent anesthesia was maintained during surgery was determined as the primary endpoint. Results: The proportion of time during which the three components of sedation, analgesia, and muscle relaxation were adequately controlled was 87.21 ± 12.79% in the automatic group, which was non-inferior to the proportion of 65.19 ± 20.16% in the manual group (p < 0.001). Adverse events during the operative or postoperative observation periods were significantly less frequent in the automatic group (54 patients, 90.0%) than in the manual group (60 patients, 100.0%; p = 0.027). Conclusion: Our three-agent automated control system, which features an improved muscle relaxation monitor and safety mechanism added to the basic control algorithms, maintained sedation, analgesia, and muscle relaxation appropriately in a manner non-inferior to anesthesiologists without compromising safety. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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9 pages, 664 KiB  
Brief Report
The Relationship between the Measured Blood Concentration of Rocuronium in Stable Muscle Relaxation with a Closed-Loop Control and the Estimated Blood Concentration from a Pharmacokinetic Simulation
by Yuko Nakanishi, Yuka Matsuki, Osamu Nagata, Shuko Matsuda and Kenji Shigemi
J. Clin. Med. 2024, 13(11), 3139; https://doi.org/10.3390/jcm13113139 - 27 May 2024
Viewed by 229
Abstract
We developed a system to adjust the rate of a continuous rocuronium (Rb) infusion to achieve 3 ≤ %T1 ≤ 10 with a closed-loop control. Samples were collected from 15 patients, and Rb blood concentrations were measured at the following time points: (1) [...] Read more.
We developed a system to adjust the rate of a continuous rocuronium (Rb) infusion to achieve 3 ≤ %T1 ≤ 10 with a closed-loop control. Samples were collected from 15 patients, and Rb blood concentrations were measured at the following time points: (1) when %T1 recovered to 3% or more after the initial Rb infusion; (2) when %T1 stabilized within the target range; (3) at the cessation of the Rb infusion; (4) 5 min after the sugammadex administration. The predicted Rb blood concentration at each time point was calculated and recorded using the pharmacokinetic parameters of Wierda et al. At time points (1), (2), and (3), the predicted blood concentrations were in good agreement with the measured values, but after the administration of sugammadex, the blood concentrations were higher than the predicted values because the Rb distributed in the tissues migrated into the blood. From the above, it was confirmed that the predicted blood concentration of Rb can be a good indicator for the automatic Rb administration control. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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15 pages, 2943 KiB  
Systematic Review
Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies
by Chun-Kai Jen, Kuo-Ching Lu, Kuan-Wen Chen, Yun-Ru Lu, I-Tao Huang, Yu-Chen Huang and Chun-Jen Huang
J. Clin. Med. 2024, 13(4), 1174; https://doi.org/10.3390/jcm13041174 - 19 Feb 2024
Viewed by 1049
Abstract
Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although [...] Read more.
Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam. Full article
(This article belongs to the Special Issue Anesthesia in General Surgery: Clinical Management and Challenges)
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