Assis, Maria Luisa Machado

Study Design. Literature review and institutional analysis. Objective. This review examines the potential advantages of awake spinal surgery under neuroaxial anesthesia in minimizing positioning-related complications compared with traditional general anesthesia. Summary of Background Data. Spinal surgeries performed in the prone position under general anesthesia are associated with perioperative complications, such as ocular injury and vision loss, nerve damage, and pressure ulcers. Materials and Methods. A comprehensive literature search was conducted for articles published from 1986 to 2023 focusing on awake spinal surgery and positioning-related complications. In addition, insights from the Mayo Clinic team were incorporated to assess the potential benefits of awake spine surgery. Results. The review identified several positioning-related complications associated with prone positioning during spine surgery, including perioperative visual loss, neuropathies, pressure ulcers, and intra-abdominal hypertension leading to systemic cardiovascular effects and potential organ dysfunction. Advances at the Mayo Clinic have enabled the use of awake spinal surgery under neuroaxial anesthesia for complex procedures such as robotic transforaminal lumbar interbody fusion. The use of awake lumbar spine surgery has demonstrated advantages, including reduced positioning-related complications, immediate patient feedback to avoid harmful maneuvers, shorter operating room times, and improved hemodynamic stability. Conclusions. Awake lumbar spine surgery offers notable advantages in reducing positioning-related complications and presents a promising alternative to general anesthesia.

BACKGROUND: The supraglottic airway device (SGD) was introduced as a breakthrough in airway management. The Fastrach emerged as the first commercially available intubating SGD, drawing extensive investigation. I-gel is a more recent device that has gained popularity, can be used as an intubating SGD, and replaced Fastrach in many institutions. However, there is uncertainty regarding the comparison between these devices in terms of efficacy for intubation and ventilation, and safety in an airway rescue situation. METHODS: PubMed, EMBASE, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing I-gel and Fastrach SGD in adult patients undergoing intubation. The primary outcome was the first-pass success rate for tracheal intubation. Secondary outcomes were tracheal intubation time, SGD insertion time and success, and complications. We computed risk ratios (RRs) to assess binary end points and weighted mean differences (WMDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome and its subgroup analysis ( P < .05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes ( P < .01 was considered statistically significant). RESULTS: This study included a total of 14 RCTs encompassing 1340 patients. The results indicated a significant difference in the first-pass success rate favoring Fastrach (RR, 0.81; 95% CI, 0.67–0.98; P = .03; I² = 91%). In the subgroup analysis, when a flexible scope was utilized through I-gel, providers achieved a better tracheal intubation first-pass success rate (RR, 1.05; 95% CI, 1.01–1.11; P = .03; I² = 0%), compared with the Fastrach. Overall intubation success rates (RR, 0.92; 99% CI, 0.82–1.04; P = .08, I² = 92%) and time (WMD - 1.03 seconds; 99% CI, -4.75 to 2.69; P = .48; I² = 84%) showed no significant difference irrespective of the device used. There was no significant difference regarding device insertion time by the providers (WMD -6.48 seconds; 99% CI, -13.23 to 0.27; P = .01; I 2 = 98%). Success rates of the providers’ initial SGD insertion and complications such as sore throat (RR, 1.01; 99% CI, 0.65–1.57; P = .95, I² = 33%) and blood presence post-SGD removal (RR, 0.89; 99% CI, 0.42–1.86; P = .68, I² = 0%) showed no significant difference. CONCLUSIONS: Based on our findings, a higher first-pass success rate was observed with the use of Fastrach when compared to I-gel. However, the use of I-gel might result in a better intubation success rate with the flexible scope-guided intubation. There are no significant differences in performance in terms of the success rate for intubation overall, time for device insertion, or time to intubation or complications regardless of the device used.

Purpose To assess the efficacy and safety of dexmedetomidine as an adjuvant to intra‐articular (IA) injections of local anesthetics (LA) in adult patients undergoing knee arthroscopy. Methods We searched MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing IA dexmedetomidine plus LA versus LA alone for knee arthroscopy in adults. We used the DerSimonian and Laird random‐effects model for all outcomes and conducted a sensitivity analysis with the leave‐one‐out method, as well as a subgroup analysis for the type of LA. We used R version 4.1.2 for all statistical analyses. Results We included 16 RCTs encompassing 799 patients, of whom 49.8% received IA dexmedetomidine. In the pooled analysis, time to first analgesia rescue was prolonged in almost 4 hours with the use of dexmedetomidine (mean difference [MD] 229 minutes; P < .001). We found statistically significant differences favoring dexmedetomidine in pain scores at rest and movement throughout the first 2, 6, 12, and 24 hours postoperatively ( P < .001). Although the MD ranged from –0.3 to –0.9 cm, corresponding to a 3% to 9% reduction in pain scores, this change is not clinically significant compared with the minimal clinically important difference (MCID). Additionally, the intervention group showed a statistically significant reduction in cumulative opioid consumption over 24 hours (MD –4.5 mg; P < .001). However, this reduction did not meet the threshold for the MCID. There was no difference between groups on the incidence of hypotension ( P = .190), bradycardia ( P = .430), and postoperative nausea and vomiting ( P = .550). Conclusions Adding dexmedetomidine to LA in IA injections for knee arthroscopy significantly extended analgesia duration. Additionally, it lowered pain scores and opioid use, although these effects did not reach the MCID. Furthermore, this addition did not increase the risk of adverse events. Level of Evidence Level II, meta‐analysis of Level I and II studies.