Asian journal of anesthesiology最新文献

Background: Despite multiple studies suggesting the significant benefits of epidural lysis for failed back surgery syndrome (FBSS), comparative evaluations with different approaches of epidural lysis remain limited. The present study aims to investigate the efficacy of caudal catheter-based epidural lysis of adhesions techniques versus transforaminal epidural lysis in treating pain and disability after L5-S1 lumbar surgery.

Methods: This study was a double-blinded randomized clinical trial conducted on patients diagnosed with FBSS after lumbar spine surgery at the level of L5-S1 and complained of pain for more than 3 months. These patients who were referred to the Imam Reza Hospital pain clinic in Mashhad, Iran, in 2023, were randomly assigned to one of two groups: one undergoing caudal epidural lysis of adhesions with a catheter, and the other received L5-S1 transforaminal epidural lysis. The intensity of patients' pain and their motor and sensory function were evaluated before intervention and 4 weeks, and 12 weeks post-intervention. Outcomes were compared within and between the two groups using the Numerical Rating Scale (NRS) and the Oswestry Disability Index (ODI) questionnaire to assess their functional status.

Results: During follow-up, the ODI, back NRS, and leg NRS scores were significantly lower in patients who underwent epidural lysis with catheter compared to the transforaminal group ( P < 0.05). The caudal catheter group showed success rates of ODI, back NRS, and leg NRS factors among 73.5%, 79.4%, and 70.6% of patients, respectively. The transforaminal lysis group was successful in 54.5%, 48.5%, and 48.5% of patients in terms of ODI, back NRS, and leg NRS factors, respectively. Additionally, at the 12-week follow-up, the rate of treatment success in terms of ODI (χ 2 = 4.53, P = 0.02) and back NRS (χ 2 = 5.78, P = 0.01) was significantly higher in the caudal lysis group compared to the transforaminal lysis group. However, no significant difference was observed in leg NRS outcomes at 12 weeks after treatment (χ 2 = 0.25, P = 0.109).

Conclusion: In conclusion, this study indicates that caudal epidural lysis with a catheter is more effective than transforaminal lysis in terms of pain reduction and functional improvement for patients with L5-S1 level FBSS.

Background: The erector spinae plane block (ESPB) is a frequently applied analgesic method in perioperative and acute pain conditions. However, there is an unpredictable and inconsistent effect, especially in chronic pain conditions, such as postherpetic neuralgia (PHN). Furthermore, aspects of the spread of local anesthetic and its action were unclear mechanisms.

Methods: We included 22 patients with PHN, and the patients were randomly assigned to a transverse (TV) or parasagittal (PS) approach group. Both groups of patients underwent ultrasound-guided ESPB and were confirmed with cone-beam computed tomography.

Results: The results showed that both approaches of ESPB spread cranially by 2.89 ± 1.45 and 2.46 ± 0.97 (mean ± standard deviation, TV vs. PS) and caudally by 3.67 ± 2.24 and 3.85 ± 1.34 sides of the interfascial plane, as well as to the muscle itself. A higher rate of epidural spread (55.6%) was observed in the TV group. All patients experienced significant pain reduction within 1 hour after ESPB; however, this analgesic effect was not sustained at 2 or 4 weeks.

Conclusion: ESPB analgesia likely involves spread to the dorsal rami, with occasional paravertebral and epidural extension. Although the TV approach showed more frequent epidural spread, it did not improve analgesic efficacy. Both approaches provided significant short-term pain relief but no sustained benefit beyond several weeks.

Background: Large language models (LLMs) can generate case-specific clinical guidance informed by SHapley Additive exPlanations (SHAP)-driven intensive care unit (ICU) mortality risk. Temperature is a key adjustable setting that influences output variability and determinism. We evaluated whether adjusting temperature affects the quality and interpretability of GPT-4o clinical reports, and whether similar effects appear in the smaller GPT-4o-mini. Methods: Thirty ICU cases were selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 3.1) database, equally distributed across low, moderate, and high mortality risk groups. SHAP values and predicted risks were provided to GPT-4o using three prompting strategies (P1, P2, and P3) at three temperature settings (0.2, 0.6, and 1.0). We evaluated report quality using the IMPACT (Integration, Mastery, Precision, Applicability, Comprehensiveness, and Timeliness) framework and noted differences across report sections. We also tested GPT-4o-mini under the same conditions for comparison. Results: Only the multi-turn prompting strategy (P3) exhibited improved report quality at higher temperatures, with especially noticeable gains in sections such as Interpretation of Risk Factors. No significant temperature-related changes were observed under P1 or P2 in GPT-4o. In GPT-4o-mini, report quality remained consistent across all temperature settings, demonstrating that the beneficial effects of temperature modulation are evident only in higher-capacity models with sufficient reasoning capability. Conclusion: Temperature tuning in high-capacity LLMs like GPT-4o enhances the richness and precision of clinical reports without sacrificing clarity, offering a pragmatic means to improve support for critical care documentation.

Background: One-lung ventilation (OLV) is commonly required during thoracic surgery and is associated with significant changes in respiratory mechanics and hemodynamics. The optimal ventilation mode during OLV remains controversial. This trial compared pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) with respect to respiratory mechanics and gas exchange during OLV. Methods: In this single-blind randomized trial, 40 adult patients undergoing thoracic surgery requiring OLV were allocated to receive either PCV or VCV in two groups. During OLV, patients in the PCV group were ventilated with pressure adjustment to achieve a target tidal volume (VT) of 6 mL/kg, while the VCV group received a fixed VT of 6 mL/kg. Respiratory and hemodynamic parameters were recorded every 15 minutes, and arterial blood gas analysis was performed every 30 minutes. Results: Mean airway pressure (P-mean) during OLV was significantly lower in the PCV group compared with the VCV group (P < 0.05), while dynamic compliance (C-dyn) was significantly higher in the PCV group (P < 0.05). Expiratory VT was also higher in the PCV group (P < 0.05). Mean arterial pressure was consistently higher in the PCV group during OLV (P < 0.05). No significant differences were observed between the two groups in arterial oxygenation indices (P > 0.05). Conclusion: PCV improved respiratory mechanics during OLV in thoracic surgery by reducing P-mean and increasing C-dyn, without improving gas exchange. These findings reflect short-term intraoperative physiological differences and should not be extrapolated to postoperative clinical outcomes.

Background: Pre-procedural fasting is routinely recommended before coronary angiography and percutaneous coronary intervention (PCI), largely based on guidelines developed for procedures involving sedation or anesthesia. However, prolonged fasting may cause dehydration, hypoglycemia, electrolyte disturbances, acute kidney injury, and patient discomfort, particularly when procedures are delayed. Recent randomized and observational studies suggest that non-fasting strategies may be safe in selected patients undergoing elective or semi-urgent coronary procedures, with no apparent increase in aspiration or other major adverse events. This paper aims to compare the feasibility and efficacy of fasting versus non-fasting protocols in patients undergoing elective coronary angiography.

Methods: In this single-center, prospective, parallel-group, blinded endpoint, randomized controlled trial, we randomized participants in a 1:1 ratio to either the fasting or non-fasting group using a simple randomization method to evaluate the effects of fasting versus non-fasting protocols before elective coronary angiography. The primary endpoints of this study were the occurrence of fasting-related and procedure-related complications, including aspiration, vomiting, hypoglycemia (defined as a blood glucose level below 70 mg/dL), agitation, and post-procedural serum creatinine measurements.

Results: From January 2024 to March 2025, 110 eligible patients were enrolled and randomized to either the fasting group (n = 55) or the non-fasting group (n = 55). All randomized participants completed the study and were included in the final analysis. Baseline demographic and clinical characteristics were comparable between the two groups. Only one case of vomiting was observed in the non-fasting group, with no cases of aspiration, hypoglycemia, or agitation reported in either group. There was no significant difference in serum creatinine levels between the non-fasting and fasting groups (1.10 ± 0.18 mg/dL vs. 1.10 ± 0.24 mg/dL; P = 0.473). Similarly, the mean length of hospital stay was comparable between groups (2.3 ± 1.5 days vs. 2.4 ± 1.5 days; P = 0.849).

Conclusion: In this randomized controlled trial, liberal fasting practices before elective coronary angiography were not associated with an observed increase in short-term adverse events.

Opioid-induced constipation (OIC) is among the most frequent and persistent adverse effects of opioid therapy and may reduce analgesic adherence, worsen quality of life, and increase resource use. This article summarizes the 2026 Taiwan expert guidance for the diagnosis and management of OIC, prepared by the Taiwan OIC Advisory Board with multidisciplinary input and reference to international guidelines and Taiwan clinical practice. The guidance recommends the Rome IV criteria as the diagnostic standard, supported by the Bowel Function Index as an adjunctive assessment and monitoring tool, and recommends K59.03, drug-induced constipation, as the principal ICD-10-CM/PCS diagnostic code. Management begins before opioid initiation, with patient and caregiver education, baseline bowel assessment, and prophylactic laxatives in high-risk settings. When OIC is diagnosed, lifestyle measures and stimulant or osmotic laxatives are first-line therapy, with reassessment after one to two weeks. Peripherally acting μ-opioid receptor antagonists, of which naldemedine is currently the available agent in Taiwan, are preferred for laxative-refractory OIC and may be used alone or in combination with laxatives. Persistent symptoms should prompt consideration of opioid adjustment and further evaluation. A practical algorithm is proposed to harmonize OIC recognition, coding, and treatment escalation in Taiwan while remaining adaptable to individual patient needs.

Background: The novel extended-release formulation of microsphere-based bupivacaine (MBB) has demonstrated a dose-dependent pharmacodynamic efficacy in the rat neuropathic pain model. This longitudinal, sham-operated control study evaluated its long-term neurotoxicity profile under functional and histopathological quantification in a rat sciatic nerve block model.

Methods: Twenty-eight Sprague-Dawley rats underwent skin incision and muscle separation to expose the sciatic nerve at both mid-thigh levels. A catheter was then implanted adjacent to the left sciatic nerve. Following a smooth recovery on postoperative day 7, 1.5 mL of 50 mg/kg MBB was injected through the catheter. Meanwhile, Rotarod, hotplate, and von Frey fi lament tests were then assessed before and 7 days after injection to test the functional neurotoxicity with respect to the sensory and motor impairment. Rats were sacrificed for serial histopathological examination on post-injection D7 (day 7) (n = 8), D14 (day 14) (n = 8), and D28 (day 28) (n = 12).

Results: There were no significant histopathologic changes in the sciatic nerve and muscles of the sham-operated rats. Rotarod, hotplate, and von Frey filament tests were comparable at D0 and D7. MBB induced a transient and mild inflammatory reaction in the neural tissues, which completely resolved by D14. On D7 post-administration, moderate to severe infiltration of mononuclear cells and accumulation of multinucleated giant cells and neutrophils. Quantification of the improvement rate significantly improved from 40% on D7 to 70% by D28.

Conclusion: Our histopathological and behavioral studies demonstrated that injecting a single dose of 50 mg/kg MBB over the sciatic nerve trunk exhibited transient but mild neurotoxicity and more profound myotoxicity. Serial sections indicated a trend toward resolution over a 28-day span, although most rats still exhibited slight to mild inflammation in the muscular tissue, presumably due to the catheter in situ, which recovered 4 weeks later.

Ketamine is an N-methyl-D-aspartate antagonist which possesses anti-nociceptive and local anesthetic properties. The aim of the meta-analysis is to assess the analgesic efficacy of perineural ketamine as an adjuvant to local anesthetics for regional nerve blocks. Randomized controlled trials (RCTs) comparing ketamine as an adjuvant to local anesthetic solution in regional nerve blocks in adult patients undergoing elective surgeries were systematically searched from databases-PubMed, Embase, CENTRAL from inception till June 2024. The primary objective was the duration of analgesia. Secondary objectives included postoperative opioid requirement, onset and duration of nerve block, and complications. A total of 25 RCTs (1,178 patients) were included. Duration of analgesia was significantly longer (mean difference [MD], 142.86 minutes; 95% confidence interval [CI], [107.75, 177.97]; P < 0.001) and opioid requirement was lower (standardized mean difference [SMD], -1.42; 95% CI, [-1.95, -0.89; P < 0.0001) when ketamine was used as an adjuvant for regional nerve blocks. Duration of sensory block was prolonged significantly in the ketamine group (MD, -15.07 minutes; 95% CI, [4.34, 25.80]; P = 0.006), and duration of motor block was similar. The complication rates were similar, but it was higher in the peripheral nerve block on subgroup analysis. The use of ketamine as an adjuvant to local anesthetics in regional nerve blocks for surgeries leads to longer duration of analgesia, sensory block, and lower opioid requirement with similar complication rates.

The number and complexity of office-based aesthetic procedures in Taiwan have increased, and many now involve intravenous sedation or general anesthesia. In response, the Taiwan Society of Anesthesiologists (TSA) developed this consensus statement to provide a national safety framework for anesthesia and sedation in aesthetic medicine clinics. The recommendations were formulated by reviewing prior TSA guidance, including the Society's 2020 consensus on mild-to-moderate sedation and the 2021 recommendation on safe total intravenous anesthesia and target-controlled infusion, together with relevant international guidance and best practices. The final recommendations were refined through structured expert review and committee consensus. The document addresses nine domains: scope and indications, definitions of sedation depth, personnel qualifications, patient evaluation including fasting and informed consent, monitoring standards, principles of drug administration, emergency preparedness, post-sedation recovery and discharge, and quality assurance based on the Tracking and Reporting Outcomes Of Procedural Sedation system. These recommendations aim to help aesthetic medicine clinics in Taiwan deliver safer, high-quality, patient-centered anesthesia and sedation services.