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• W4304758468 abstract "Remifentanil has been shown to be poorly soluble when added to propofol in high concentrations; however, the physiochemical properties of these admixtures have not been studied in clinically relevant concentrations or settings. This study examined remifentanil-propofol admixtures in commonly used concentrations while subjecting them to delivery through an extension line driven by a syringe pump. A solution of propofol 10 mg/mL combined with remifentanil 5 mcg/mL was run using a Paedfusor propofol target-controlled infusion model for 10- and 20-kg children for 57 minutes at a target plasma concentration of 3 mcg/mL. The solution was delivered through a 30-mL syringe, 180-cm minimum volume extension line, luer-lock cannula, interlink injection site, and 22-g intravenous (IV) cannula into sample pots. Samples were taken at the completion of the loading bolus, 1 minute and 2 minutes after completion of the loading bolus, and every 5 minutes thereafter. The remifentanil concentration in these samples was then assayed using chromatography. There was no difference in the samples based on the duration of infusion to the endpoint of 1 hour or on the patient-weight model used as the remifentanil concentration remained constant. The measurement uncertainty for the assay at 0.5 mcg/mL was +/− 0.2 mcg/mL. The authors concluded the concentration of remifentanil consistently remained constant across 57 minutes of infusion and 2 different pediatric weight profiles.Comment: The practice of mixing various admixtures of remifentanil and propofol in a single syringe is well known and common in dental anesthesia practice. Kramer and Ganzberg1 described the use of a propofol-remifentanil for third molar surgery a decade ago. Likewise, the practice of mixing these 2 drugs has been questioned for nearly a decade, since the physiochemical properties of remifentanil and propofol are altered when mixed and diluted.2,3 This study confirms other recent studies that fail to show evidence of harmful, dilution-related effects caused by mixing remifentanil and propofol in clinically relevant concentrations.4Pediatric IV catheter insertion can be difficult during anesthetic induction due to the technical challenges of small diameter vessels and the need to rapidly gain IV access in anesthetized children. This study sought to identify factors associated with difficult pediatric vascular access in the operating room (OR). A total of 12,728 IV catheter insertions were analyzed. A retrospective analysis was conducted of prospectively collected data from a cohort of pediatric patients who had IV catheters inserted in the OR at an academic tertiary care children's hospital. Associations among patients who were labeled as having difficult vascular access (defined as >2 attempts) were compared with demographic, clinical, and hospital factors. Multivariable analysis showed significantly higher odds of difficult vascular access with Black, non-Hispanic race (1.43; 95% CI, 1.06–1.93; P = .018), younger age (0.93; 95% CI, 0.89–0.98; P = .005), overweight (1.41; 95% CI, 1.04–1.90; P = .025), and obese body mass index (1.56; 95% CI, 1.12–2.17; P = .008), and American Society of Anesthesiologists physical status III (1.54; 95% CI, 1.11–2.13; P = .01). Success rate placement was highest when the attending anesthesiologist placed the catheter (versus certified registered nurse anesthetists, registered nurses, and trainees). Ultrasound use was associated with successful IV catheter placement.Comment: The conclusions of this observational study are not as obvious as they might seem at first glance. Most publications on difficult IV access in children has examined care provided in the emergency department while few have studied children undergoing procedures in the OR. The OR setting provides several unique factors, including children who are typically volume depleted due to fasting, prior initiation of anesthetic induction, and highly experienced anesthesia providers performing the catheterizations. This study took place at a tertiary care children's hospital, so it is unknown if their findings are generalizable to other institutions. Also, the number of IV attempts was self-reported, and there was no differentiation of the data to account for fasting status. There was also no way to determine whether inhalation induction was used before IV catheter insertion.Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. This study examined the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. Preoperative medication usage was obtained by interview, while hospitalized patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. Postoperative hospital benzodiazepine use was associated with greater delirium. Neither postoperative hospital antipsychotic nor opioid use before delirium was associated with delirium. The authors concluded that the administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between in-hospital, postoperative medication use, and cognition at 1 month, independent of delirium, was not detected.Comment: This study examined hospitalized patients undergoing major elective surgery. Although conclusions cannot be directly extrapolated to dental outpatient sedation and anesthesia, a recent Japanese study of elderly patients undergoing moderate sedation for dentistry showed cerebral blood flow is diminished by 9% in patients with dementia following IV midazolam titrated to an Observer's Assessment of Alertness/Sedation Scale (OAA/S) score of 2 (responds only after mild physical stimulation).5 Additionally, a joint consensus statement from the American Society for Enhanced Recovery and Perioperative Quality Initiative strongly recommends minimizing the use of benzodiazepines in older patients at risk for postoperative delirium.6The role of intraoperative magnesium for the prevention of emergence agitation or delirium is unclear. The aim of this study was to investigate the effect of magnesium sulfate on emergence agitation or emergence delirium in pediatric patients. Electronic databases, including PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science, were searched to identify studies that evaluated the effects of magnesium on postoperative emergence agitation or emergence delirium. The primary outcome was the incidence of these phenomena during the postanesthesia stay. The secondary outcome was the agitation or delirium score upon admission to the postanesthesia care unit. A total of 712 pediatric patients from 10 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 29.7% in the magnesium group and 50.5% in the control group. The pooled effect size revealed that the administration of magnesium sulfate significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery with general anesthesia (odds ratio, 0.31; 95% CI, 0.15–0.64; P = .002). Additionally, children in the magnesium group reported significantly lower agitation or delirium scores than those in the control group (standardized mean difference, −0.70; 95% CI, −1.15 to −0.24; P = .003). The authors concluded the administration of magnesium sulfate reduced the incidence and severity of emergence agitation or emergence delirium in pediatric patients after the use of general anesthesia during surgery.Comment: This study is consistent with an earlier prospective, randomized, controlled, double-blind study of 70 children undergoing adenotonsillectomy, in which patients received a 30-mg/kg bolus of IV magnesium sulphate after induction of sevoflurane anesthesia followed by a continuous infusion of 10 mg/kg. This regimen was not associated with increased postoperative side effects or delayed recovery.7" @default.
• W4304758468 created "2022-10-13" @default.
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• W4304758468 date "2022-09-01" @default.
• W4304758468 modified "2023-10-16" @default.
• W4304758468 title "A Review of Current Literature of Interest to the Office-Based Anesthesiologist" @default.
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• W4304758468 doi "https://doi.org/10.2344/1878-7177-69.3.48" @default.
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