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Background The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response and postoperative sore throat. Methods Fifty-four patients undergoing thyroidectomy were randomly assigned to two groups. The patients in Group R were received 0.75% ropivacaine, which was sprayed on the tracheal mucosa, epiglottis, tongue base, and glottis to achieve uniform surface anesthesia. As control, patients in Group C were received the same volume saline. The primiary outcome was the incidence and grade of cough during peri-extubation. Results The incidence (34.62% vs. 76.92%, P  = 0.002) of cough during extubation were lower in Group R compared to Group C. Meanwhile, the sore throat visual acuity score at 12 h after surgery was lower in Group R than that in Group C (2.00 vs. 3.50, P  = 0.040). Conclusion Topical anesthesia with 0.75% ropivacaine before intubation can significantly reduce the incidence of cough during peri-extubation. Meanwhile, it reduced hemodynamic fluctuations and postoperative throat pain without influence patients recovery. Trial registration Chinese Clinical Trial Registry, ChiCTR1800014412 (date of registration January 2018).

Background and Aims: Anaesthesia for children undergoing magnetic resonance imaging (MRI) ranges from moderate to deep sedation in order to facilitate uninterrupted completion of the scan. While various intravenous and inhalational techniques of anaesthesia have their own merits and demerits, there is a paucity of comparative literature between the two in children undergoing diagnostic MRI. Materials and Methods: This prospective observational cohort study was conducted at the Radiology suite of a 2800-bedded tertiary care hospital, wherein 107 unpremedicated children between the ages of 6 months to 15 years received either sedation with propofol infusion (Group GSP, n = 57) or inhalational anaesthesia with a laryngeal mask airway (Group GAL, n = 50). Primary outcome measures included time to induction and time to recovery. Secondary outcomes comprised the incidence of respiratory and non-respiratory adverse events in the two groups. Results: The median time to induction was significantly shorter in GSP than GAL [7.00 (IQR 5.0, 10.0) versus 10.00 minutes (IQR 8.8, 13.0), P < 0.001]; the incidence of desaturation [8 (16.0%) in GAL, 1 (1.8%) in GSP, P = 0.012], laryngospasm [11 (22.4%) in GAL, 1 (1.8%) in GSP, P = 0.001] and emergence delirium (5 (10%) in GAL, 0 in GSP, P = 0.047) were significantly greater in the GAL group. There was no difference in the time to emergence, nausea and vomiting or bradycardia between the two groups. Conclusion: Sedation with propofol infusion during paediatric MRI scan offers a short turnover time and favourable adverse event profile when compared to inhalational anaesthesia with an LMA.

The quality of recovery (QoR) of remimazolam-based and propofol-based total intravenous anesthesia was compared as measured by QoR-15 scores. A prospective, double-blind, randomized controlled, non-inferiority trial. An operating room, a post-anesthesia care unit (PACU), and a hospital ward. Female patients (n = 140; 20–65 years) scheduled for open thyroidectomy were enrolled and randomly assigned to the remimazolam or propofol group. The remimazolam group received continuous remimazolam infusions and effect-site target-controlled remifentanil infusions. The propofol group received effect-site target-controlled infusions of propofol and remifentanil. The primary outcome was QoR-15 on postoperative day 1 (POD1). The mean difference between the groups was compared against a non-inferiority margin of −8. Secondary outcomes were QoR-15 on POD2, hemodynamic data, time to lose and recover consciousness, sedation score upon PACU admission, pain, and postoperative nausea and vomiting profiles at the PACU and ward. Group-time interaction effects in hemodynamic data and QoR-15 were analyzed using a linear mixed model. The total QoR-15 score on POD1 in the remimazolam group was non-inferior to that in the propofol group (mean [SD] 111.2 [18.8] vs. 109.1 [18.9]; mean difference [95% CI] 2.1 [−4.2, 8.5]; p = 0.002 for non-inferiority). The QoR-15 score on POD2 was comparable between the groups, and no group-time interaction was observed. At the end of anesthesia, after extubation, and upon arrival at the PACU, mean arterial pressure was significantly higher in the remimazolam group. Remimazolam group was more sedated at the time of admission to PACU. Pain intensity and the requirement for analgesics were lower in the remimazolam group than in the propofol group. Remimazolam-based total intravenous anesthesia provided a similar QoR to propofol. Remimazolam and propofol can be used interchangeably for general anesthesia in female patients undergoing thyroid surgery. •Evidence regarding quality of recovery after remimazolam-based total intravenous anesthesia has been limited.•Remimazolam-based total intravenous anesthesia was explored in female patients undergoing open thyroidectomy.•Remimazolam-based total intravenous anesthesia demonstrated similar quality of recovery to propofol.•Hypotensive incidence at cessation of anesthetics was lower in patients administered with remimazolam compared to propofol.•Remimazolam-based total intravenous anesthesia was associated with reduced pain intensity and analgesic requirement.

Understanding how the brain recovers from unconsciousness can inform neurobiological theories of consciousness and guide clinical investigation. To address this question, we conducted a multicenter study of 60 healthy humans, half of whom received general anesthesia for 3 hr and half of whom served as awake controls. We administered a battery of neurocognitive tests and recorded electroencephalography to assess cortical dynamics. We hypothesized that recovery of consciousness and cognition is an extended process, with differential recovery of cognitive functions that would commence with return of responsiveness and end with return of executive function, mediated by prefrontal cortex. We found that, just prior to the recovery of consciousness, frontal-parietal dynamics returned to baseline. Consistent with our hypothesis, cognitive reconstitution after anesthesia evolved over time. Contrary to our hypothesis, executive function returned first. Early engagement of prefrontal cortex in recovery of consciousness and cognition is consistent with global neuronal workspace theory. Anesthesia is a state of reversable, controlled unconsciousness. It has enabled countless medical procedures. But it also serves as a tool for scientists to study how the brain regains consciousness after disruptions such as sleep, coma or medical procedures requiring general anesthesia. It is still unclear how exactly the brain regains consciousness, and less so, why some patients do not recover normally after general anesthesia or fail to recover from brain injury. To find out more, Mashour et al. studied the patterns of reemerging consciousness and cognitive function in 30 healthy adults who underwent general anesthesia for three hours. While the volunteers were under anesthesia, their brain activity was measured with an EEG; and their sleep-wake activity was measured before and after the experiment. Each participant took part in a series of cognitive tests designed to measure the reaction speed, memory and other functions before receiving anesthesia, right after the return of consciousness, and then every 30 minutes thereafter. Thirty healthy volunteers who did not have anesthesia also completed the scans and tests as a comparison group. The experiments showed that certain normal EEG patterns resumed just before a person wakes up from anesthesia. The return of thinking abilities was an extended, multistep process, but volunteers recovered their cognitive abilities to nearly the same level as the volunteers within three hours of being deeply anesthetized. Mashour et al. also unexpectedly found that abstract problem-solving resumes early in the process, while other functions such as reaction time and attention took longer to recover. This makes sense from an evolutionary perspective. Sleep leaves individuals vulnerable. Quick evaluation and decision-making skills would be key to respond to a threat upon waking. The experiments confirm that the front of the brain, which handles thinking and decision-making, was especially active around the time of recovery. This suggests that therapies targeting this part of the brain may help people who experience loss of consciousness after a brain injury or have difficulties waking up after anesthesia. Moreover, disorders of cognition, such as delirium, in the days following surgery may be caused by factors other than the lingering effects of anesthetic drugs on the brain.

The emergence profiles in patients undergoing total intravenous anesthesia with either propofol or remimazolam with flumazenil reversal were compared. A prospective, double-blind, randomized trial. An operating room and a post-anesthesia care unit (PACU). Adult patients (n = 100) having American Society of Anesthesiologists (ASA) physical status of I-III undergoing general anesthesia were enrolled and randomly assigned to the propofol or the remimazolam group. The propofol group received target-controlled infusion of propofol, and the remimazolam group received continuous infusion of remimazolam. Continuous infusion of remifentanil was used in both groups. For emergence, flumazenil was used in increments of 0.2 mg in the remimazolam group. The primary outcome was the time required for the patient to obey verbal commands. The secondary outcomes included the time to bispectral index (BIS) over 80, the time to laryngeal mask airway (LMA) removal, the Richmond Agitation-Sedation Scale (RASS) scores in the PACU, and adverse events throughout the study period. The time taken to obey verbal commands was significantly longer in the propofol group than the remimazolam group (14 [9, 19]) vs. 5 [3, 7]) minutes, P < 0.001; median difference -9, 95% confidence interval -11 to -6). The times to BIS over 80 and to LMA removal were also significantly longer in the propofol group. In addition, the RASS score upon arrival to the PACU differed significantly between the two groups (P = 0.006). Re-sedation in the PACU was observed in 11 (22%) of the patients in the remimazolam group. Remimazolam-based total intravenous anesthesia with flumazenil reversal may be effective in reducing emergence time, but a significant incidence of re-sedation was observed in the PACU. Further studies are needed to determine adequate dose and timing of routine flumazenil use and minimize the risk of re-sedation. •Remimazolam is a novel ‘ultra-short-acting’ benzodiazepine.•Remimazolam has a short history of use in total intravenous anesthesia.•Remimazolam's effect can be reversed by flumazenil.•Propofol has no specific antagonist.•Remimazolam can provide accelerated emergence after continuous infusion.

Background Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety. Methods A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia. Discussion Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments. Trial registration ISRCTN62903453. September 09, 2021.

The QoR-15 scale is a validated tool to assess the quality of postoperative recovery (QoR). Our objective was to assess the association between the early QoR-15 values and the occurrence of one-month postoperative complications. We used the data from a prospective single-centre cohort study conducted in the Angers University Hospital from July 2019 to February 2020 that validated the French version of the QoR-15 (FQoR-15). Preoperative room, ward, and home. 363 French-speaking adult patients, undergoing elective surgery, were enrolled (217 (59,8%) men, median age 60 (range 44 to 71) years old), including 139 (38.3%) ambulatory surgeries. Patients completed the QoR-15 scale the day before, at 24 and 48 h after surgery. Postoperative complications were recorded according to the PostOperative Morbidity Survey (POMS) classification till 30 days after surgery. The QoR was classified as excellent (QoR-15 > 135), good (122 ≤ QoR-15 ≤ 135), moderate (90 ≤ QoR-15 ≤ 121) or poor (QoR-15 < 90). Days alive and out of hospital up to 30 days after surgery was also recorded. According to the POMS classification, 176 (48.5%) patients had at least one complication up to 30 days after surgery. Among the 69 (19.0%) patients with a poor recovery at H24, 58 (84.1%) had at least one complication up to 30 days after surgery compared to 10 (23.8%) among the 42 (11.6%) in the excellent recovery group (p < 0.0001). The QoR-15 score at H24 allowed suitable discrimination of the occurrence of at least one complication up to 30 days after surgery (AUC 0.732 (95% CI 0.680 to 0.784)). The early QoR-15 scale after surgery is moderately associated with the occurrence of postoperative complications up to 30 days after elective surgeries (i.e. it has predictive validity). •Postoperative complications are common and affect the patient's recovery•Early identification of patients at risk of postoperative complications can enable clinicians to optimize care•QoR-15 is a validated tool to assess the quality of postoperative recovery•176 (48,5%) patients had at least one postoperative complication at 30 days•Early postoperative QoR-15 score is moderately associated with late postoperative complications

Mechanisms driving emergence from general anesthesia are not well understood. The noradrenergic brain nucleus locus coeruleus (LC) modulates arousal and may have effects on general anesthetic state. Using virally delivered designer receptors to specifically control LC norepinephrine (NE) neurons, we investigated the causal relationship between LC-NE activity and general anesthetic state under isoflurane. Selective activation of LC-NE neurons produced cortical electroencephalography (EEG) activation under continuous deep isoflurane anesthesia. Specifically, LC-NE activation reduced burst suppression in EEG and drove a rightward shift in peak EEG frequency with reduced δ EEG power and increased θ EEG power, measures of cortical arousal. LC-NE activation also accelerated behavioral emergence from deep isoflurane anesthesia; this was prevented with β or α1 noradrenergic antagonists. Moreover, these adrenoreceptor antagonists alone were sufficient to markedly potentiate anesthetic duration when delivered centrally or peripherally. Induction of anesthesia also was retarded by LC-NE activation. Our results demonstrate that the LC-NE system strongly modulates the anesthetic state, and that changes in LC-NE neurotransmission alone can affect the emergence from isoflurane general anesthesia. Taken together, these findings extend our understanding of mechanisms underlying general anesthesia and cortical arousal, and have significant implications for optimizing the clinical safety and management of general anesthesia.

This review discusses the clinical and neurophysiological features of general anesthesia and their relationships to sleep and coma, focusing on the neural mechanisms of unconsciousness induced by selected intravenous anesthetic drugs. In the United States, nearly 60,000 patients per day receive general anesthesia for surgery. 1 General anesthesia is a drug-induced, reversible condition that includes specific behavioral and physiological traits — unconsciousness, amnesia, analgesia, and akinesia — with concomitant stability of the autonomic, cardiovascular, respiratory, and thermoregulatory systems. 2 General anesthesia produces distinct patterns on the electroencephalogram (EEG), the most common of which is a progressive increase in low-frequency, high-amplitude activity as the level of general anesthesia deepens 3 , 4 (Figure 1). How anesthetic drugs induce and maintain the behavioral states of general anesthesia is an important question in medicine and neuroscience. 6 Substantial insights . . .

Inguinal hernia repair is the most common general surgery procedure and can be performed under local or general anesthesia. We hypothesized that using local rather than general anesthesia would improve outcomes, especially for older adults. This is a retrospective review of 97,437 patients in the Veterans Affairs Surgical Quality Improvement Program who had open inguinal hernia surgery under local or general anesthesia. Outcomes included 30-day postoperative complications, operative time, and recovery time. Our cohort included 22,333 (23%) Veterans who received local and 75,104 (77%) who received general anesthesia. Mean age was 62 years. Local anesthesia was associated with a 37% decrease in the odds of postoperative complications (95% CI 0.54–0.73), a 13% decrease in operative time (95% CI 17.5–7.5), and a 27% shorter recovery room stay (95% CI 27.5–25.5), regardless of age. Using local rather than general anesthesia is associated with a profound decrease in complications (equivalent to “de-aging” patients by 30 years) and could significantly reduce costs for this common procedure. •Local anesthesia is associated with fewer complications for inguinal hernia repair.•Local anesthesia reduces operative and recovery time for inguinal hernia repair.•Using local instead of general anesthesia may reduce cost for hernia repair. We found that using local rather than general anesthesia for inguinal hernia surgery was associated with significantly fewer complications and less time in the operating room and post-anesthesia care units, regardless of patient age. The importance of this finding is the potential reduction in postoperative morbidity, mortality, and costs for the most common general surgery procedure performed in the US.