Abstract in English:

Abstract Introduction Low Cardiac Output Syndrome (LCOS) remains a significant perioperative challenge in pediatric cardiac surgery. This study evaluated whether a hemodynamic protocol aimed at optimizing continuous central venous Oxygen Saturation (SvcO2) using the PediaSat catheter could reduce postoperative complications in pediatric patients undergoing congenital heart surgery. Methods Conducted at the Instituto do Coração in São Paulo, this randomized clinical trial compared a group receiving SvcO2-based goal-directed therapy via PediaSat (intervention) against conventional care (control). The main objective was assessing 24-hour lactate clearance post-surgery, with secondary outcomes including Vasoactive-Inotropic Score (VIS), Mechanical Ventilation (MV) duration, vasopressor use, and ICU/hospital stay lengths. Results From July 13, 2014, to March 17, 2016, 391 patients were evaluated for eligibility. After applying inclusion and exclusion criteria, 65 patients were included and randomized ‒ 33 to the control group and 32 to the PediaSat group. There were no losses to follow-up in either group. Lactate clearance did not significantly differ between the intervention and control groups. However, the PediaSat group showed significantly shorter mechanical ventilation times, reduced vasopressor use, and shorter ICU stays. No significant differences were observed in hospital stay length or incidence of postoperative complications between the group. Conclusions While optimizing SvcO2 did not affect overall lactate clearance, it was associated with shorter MV duration, decreased vasopressor need, and shorter ICU stays in pediatric cardiac surgery patients. These findings highlight the potential benefits of continuous SvcO2 monitoring in postoperative care.

Abstract in English:

Abstract Introduction: Simulation-based training is particularly beneficial for rare and life-threatening diseases such as Malignant Hyperthermia (MH). In addition, cognitive aids, including flowcharts and checklists, can be used as guidance in crisis, reducing cognitive demand and simplifying patient care. We assessed the technical and non-technical performance of anesthesiology residents when diagnosing and treating a hypothetical case of MH in three different scenarios. Methods: This was an observational, cross-sectional, and controlled study. Pairs of anesthesiology residents participated in a validated high-fidelity MH realistic simulation in one of three different scenarios: 1) Control (no access to cognitive aids), 2) Poster, or 3) Mobile application. Both poster and mobile application provided a flowchart and information related to MH diagnosis and treatment. Demographic data, perceived stress levels, and technical and non-technical skills were registered and compared among the groups. Results: Thirty residents (5-pairs for each scenario) participated in the simulations. The mean score in the technical skill survey was significantly higher in the poster and mobile application groups compared with the control group (83 [4.4], 83 [3.8], and 74 [8.2], respectively, ANOVA, p = 0.047). A significantly higher score for non-technical skills was also found for the poster and mobile application groups compared with the control group (55 [2.5], 57 [0.8], 52 [2.1], respectively, ANOVA, p = 0.03). Conclusion: In a realistic high-fidelity MH simulation, the participants had satisfactory performance regarding technical and non-technical skills. However, the groups with access to cognitive aids achieved better scores, with no difference between the groups with access to the MH poster and the MH mobile application.

Abstract in English:

Abstract Background Loss of lung aeration is frequently observed in adult patients following cardiac surgery with cardiopulmonary bypass. Yet, in children, changes in lung aeration following surgical repair of congenital heart defects, and the effects of Positive End-Expiratory Pressure (PEEP), remain uncertain. Methods Changes in lung aeration were investigated using volumetric computed tomography in 12 children with congenital acianogenic heart diseases and increased pulmonary flow who underwent total surgical repair under cardiopulmonary bypass. Computed tomography of the lungs was obtained preoperatively during spontaneous breathing and postoperatively during mechanical ventilation with positive end-expiratory pressure of 0, 5 and 10 cm H2O. Gas and tissue lung volume and mass, as well non-aerated, poorly aerated and normally aerated lung compartments were measured. Results Median age of patients was 18.3 months, (4 to 24 months), weight was 9.3 ± 2.3 kg. Cardiopulmonary bypass duration was 77 ± 26 minutes. Preoperatively, pulmonary volume was 545 mL (237‒753 mL), whereby tissue and gas volumes were 48.4% (41.7%‒59.6%), and 51.6% (40.4%‒58.3%), respectively. Non-aerated and normally aerated compartments accounted for 15% and 47.9% of lung tissue, respectively. Postoperatively, at zero PEEP, the non-aerated compartment increased to 27%, while normally-aerated compared decreased to 38.5%. Stepwise PEEP application restored normally aerated lung volume to preoperative levels but did not significantly reduce non-aerated parenchyma. Conclusion Loss of lung aeration was pronounced after surgical correction of congenital heart defects. PEEP up to 10 cm H2O restored gas volume but failed to recruit the collapsed parenchyma. Ethical Approval CAPPesq n° 854/01.

Abstract in English:

Abstract Introduction The choice of anesthetic agents plays a crucial role in procedural success. This study aimed to compare the effects of propofol-fentanyl and propofol-dexmedetomidine combinations, focusing on patient and surgeon perspectives in outpatient procedures. Methods A randomized, controlled, triple-blind clinical trial including 128 adult patients undergoing elective outpatient surgical procedures with sedation and local anesthesia. Patients were randomized to receive either propofol-fentanyl (PF, n = 64) or propofol-dexmedetomidine (PDex, n = 64). Primary outcomes were patient satisfaction, assessed using the ISAS-Br score, and the adequacy of sedation, evaluated by the surgeon and measured by a Numerical Rating Scale (NRS) for movement. Respiratory and hemodynamic changes, as well as awakening from anesthesia, adverse events during recovery, and time to hospital discharge were compared. Results No difference between patient satisfaction scores (median ISAS-Br [IQR]: PF 2.64 [2.45‒3.00] vs. PDex 3.00 [2.45‒3.00], p = 0.252). The PF group had a significantly lower movement score (median NRS [IQR]: 0.5 [0.00‒2.25] vs. 2.0 [0.00‒5.00], p = 0.006). The incidence of intraoperative events related to respiration and hemodynamics, as postoperative pain and postoperative nausea/vomiting were similar. A higher proportion of patients sedated with PF awoke in the operating room (75% vs. 35.9%, p < 0.001), and 98.4% of the PF group vs. 92.2% of the PDex group were ready for hospital discharge in less than thirty minutes, p = 0.208. Conclusion Single doses of fentanyl or dexmedetomidine combined with propofol resulted in equivalent patient satisfaction, safety, and discharge times. The propofol-fentanyl combination demonstrated superior sedation adequacy from the surgeon’s perspective and facilitated a faster emergence from anesthesia.

Abstract in English:

Abstract Background Ultrasound (US) allows for rapid bedside airway assessment. We aimed to evaluate the US-measured cutaneous-epiglottic distance (CED) in predicting difficult laryngoscopy (Cormack-Lehane grades 3‒4). We also evaluated the potential association between CED, sex, patient’s body mass index (BMI), and the independent associations between CED and increased odds for Cormack-Lehane grades 3‒4 (secondary outcomes). Methods Patients aged 18‒70 years scheduled for elective surgeries under general anesthesia with tracheal intubation were included. Those with a BMI > 35 kg.m-2 and/or previous history of difficult intubation were excluded. CED was measured with patients anesthetized before tracheal intubation. Age, sex, BMI, type of surgery, and number of attempts until successful tracheal intubation were recorded. Receiver operator characteristic (ROC) curve analysis was performed to evaluate CED’s clinical relevance. Secondary analyses compared the association between CED and BMI in patients with Cormack-Lehane grades 1‒2 versus those with grades 3‒4. The relationship between CED and BMI was assessed using multiple linear regression. Binary logistic regression was employed for predicting Cormack-Lehane grades 3‒4 as a dichotomous outcome with CED and BMI as a covariate. Results ROC curve analysis revealed an area under the curve of 0.899 (p < 0.001). The maximum CED cut-off point (by Youden index) was 25.6 mm. CED and BMI were positively correlated, and both were independently associated with an increased odds for difficult laryngoscopy [odds ratio for CED = 1.81, 95% confidence interval (CI) 1.35‒2.41; BMI = 1.30, 95% CI 1.05‒1.59]. Conclusion US-measured CED has a high discriminatory capability for predicting lower (1‒2) and higher (3‒4) Cormack-Lehane grades during direct laryngoscopy. CED was positively correlated with BMI and was independently associated with higher odds for difficult laryngoscopy.

Abstract in English:

Abstract Background This study aims to explore the role of sex as a confounder and effect modifier in the associations of clinical outcomes, pain-related outcomes, and neurophysiological measurements in chronic knee OA pain subjects. Methods Sociodemographic, clinical, and neurophysiological data were extracted from 113 knee OA subjects with chronic pain. We performed exploratory multivariate regression models assessing the association of physiological outcomes (Quantitative Sensory Testing [QST], Electroencephalography [EEG], and Transcranial Magnetic Stimulation [TMS]) and clinical characteristics (pain, anxiety, and motor function). In each independent model we tested the role of biological sex as confounder and effect modifier (adding the interaction term). Results Females reported higher pain intensity, lower quality of life, diminished pain thresholds, and less EEG alpha power compared to males. Sex negatively confounded the association between pain interference and pain intensity with pain threshold confounding (ranged between -19% to -125%). Moreover, sex acted as an effect modifier, predominantly influencing the relationship between pain interference and frontocentral alpha-delta power in EEG. Similarly, sex modified the association between pain interference and pain threshold. In females EEG and PPT variables explained less variability of pain interference compared to males. Conclusions Our study suggests that sex is a confounder and effect modifier mainly in the relationship between neurophysiological variables and pain-related outcomes in a chronic OA pain population. Females may have weaker associations between pain intensity and mechanistic outcomes (EEG and QST). Thus, the use of these biomarkers in females requires further optimization. We therefore reinforce the need for accounting for biological sex in the analysis, not only as a confounder, but as an effect modifier in further randomized trials and observational studies in the field of pain.

Abstract in English:

Abstract Background Peripheral abdominal nerve blocks are key components of multimodal analgesia, enhancing recovery after cesarean sections. This systematic review and meta-analysis aimed to assess analgesic efficacy of Erector Spinae Plane Block (ESPB) versus Transversus Abdominis Plane Block (TAPB) under ultrasound guidance following Cesarean Section (CS) under spinal anesthesia. Methods A comprehensive search was conducted across PubMed, Scopus, Cochrane Library, and ISI Web of Science to identify relevant trials. The inclusion criteria followed the PICOS framework: Population (women undergoing elective cesarean delivery), Intervention (ESPB), Comparator (TAPB), Outcomes (postoperative pain, opioid consumption, analgesic duration, and satisfaction), and Study Design (randomized controlled trials). Results Seven RCTs (380-patients) met the inclusion criteria. The ESPB group had significantly lower postoperative pain scores at rest and during movement, reduced 24-hour opioid consumption (MD = -2.62 MME; 95% CI -4.11 to -1.13; p = 0.006), and longer analgesic duration (SMD = 1.77; 95% CI 1.11 to 2.44; p < 0.001) than the TAPB group. Patient satisfaction was also significantly higher in the ESPB group (OR = 4.75; 95% CI 2.26 to 9.99; p < 0.001). While most outcomes demonstrated low heterogeneity, significant variability was observed in analgesic duration (I2 = 83%), requiring cautious interpretation. Conclusions The ESP block offers superior pain relief, reduces opioid use, and enhances satisfaction compared to the TAP block in cesarean sections. These findings suggest that the implementation of the ESP block in postoperative analgesia protocols could significantly improve patient outcomes, potentially leading to enhanced recovery and reduced reliance on opioids.

Abstract in English:

Abstract Background Caudal Epidural Block (CEB) is a well-established regional anesthesia technique for abdominal and sub-abdominal pediatric surgeries. However, it has a short duration, often leading to additional analgesic administration. Erector Spinae Plane Block (ESPB), for instance, is an emerging technique that, like CEB, provides analgesic effect to a specific dermatome of the body during surgery and in the postoperative period. Therefore, we performed this systematic review with meta-analysis to compare both techniques. Methods We searched PubMed, Embase and Cochrane Central for Randomized Controlled Trials (RCTs) comparing ESPB versus CEB in pediatric patients undergoing abdominal and sub-abdominal surgeries. The primary outcome was the time to first analgesic request. Secondary outcomes were I) FLACC score; II) Postoperative nausea and vomiting, and III) Urinary retention. Results Nine randomized controlled trials encompassing 507 patients were included in this analysis (1‒9). The patients were predominantly male and under 10 years of age. There was an equal distribution between the two groups regarding the number of patients and patients’ baseline characteristics. The main results were: time to first analgesic request (MD = 3.71; 95% CI: -1.88-9.29; I2 = 99%; p = 0.19); FLACC scores at 2 hours (MD = 0.15; 95% CI: -0.30-0.59; I2 = 0%; p = 0.52); FLACC scores at 24 hours (MD = -0.17; 95% CI: -0.39-0.05; I2 = 41%; I2 = 41%; p = 0.13); urinary retention events (RR = 0.12; 95% CI: 0.02-0.94; I2 = 0%; p = 0.04); and Postoperative Nausea and Vomiting (PONV) which was null in both groups in three studies. However, it is important to clarify that some limitations were identified, such as significant heterogeneity in the following outcomes: time to first analgesic request and FLACC score at 24h, possibly due to different age groups, different types of surgeries, different background analgesia administration, and a relatively small sample size. As for the risk of bias, two studies were found to have some concerns in “bias due to deviations from intended interventions” (8,9). Conclusion Our findings suggest that the administration of ESPB did not statistically differ from CEB regarding the time to first analgesic request. FLACC scores also did not show a statistically significant difference between groups. The ESPB group, however, experienced minor urinary retention events compared to the CEB group. Quality of evidence According to the GRADE assessment, all outcomes evaluated in this study were classified as high-quality evidence. Quality assessment is detailed in Supplementary Table 1.