; for the Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) Study Investigators IMPORTANCE Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain. OBJECTIVES To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations. EXPOSURES Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications. RESULTS Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome

Reduction of LMA intracuff pressure to less than 44 mmHg lowers the incidence of postoperative pharyngolaryngeal complications. The LMA cuff pressures should be measured routinely using manometry, and deflating the intracuff pressure to less than 44 mmHg should be recommended as anesthetic best practice.

The LMA Supreme has lower oropharyngeal leak pressures than the LMA ProSeal. The success of the first attempt insertion was higher for the LMA Supreme. The LMA Supreme is a safe, efficacious and easy-to-use disposable supraglottic airway device in elective ambulatory procedures. The higher rate of success on first attempt insertion may make it more suitable as an airway rescue device.

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M anual in-line stabilization (MILS) is recommended during direct laryngoscopy and intubation in patients with known or suspected cervical spine instability. It was hypothesized that anesthesiologists would apply greater pressure during intubations with MILS than without because MILS impairs glottic visualization. Nine anesthetized and pharmacologically paralyzed patients underwent 2 sequential laryngoscopies and intubations, 1 with MILS and 1 without in random order. A transducer array along a Macintosh 3 laryngoscope blade continuously measured the pressures applied, and the glottic view was characterized. Using MILS, glottic visualization was worse in 6 patients, and failure of intubation occurred in 2 of these patients. Maximum laryngoscope pressure at best glottic view was greater with MILS than without (717 T 339 vs 363 T 121 mm Hg, respectively, n = 8). Other measures of pressure application also indicated comparable increases with MILS. Pressures applied to airway tissues by the laryngoscope blade are transmitted secondarily to the cervical spine and lead to craniocervical motion. In the presence of cervical instability, impaired glottic visualization and secondary increases in pressure application with MILS can potentially increase pathologic craniocervical motion. COMMENTCurrent Advanced Trauma Life Support standards state that MILS should be used when direct laryngoscopy (DL) and tracheal intubation are urgently needed in patients with known or suspected cervical spine instability. Manual in-line stabilization is designed to externally restrict head and neck movement, presumably minimizing pathologic cervical spine motion that might otherwise occur at unstable segments. This potential benefit is, however, counterbalanced by the unwelcome fact that MILS impedes glottic visualization.The current well-designed study sought to enroll patients who would be easy to intubate with a Macintosh 3 blade. Exclusion criteria were focused on eliminating patients who might be at increased risk of intubation-related and/or other study-related complications. Faculty anesthesiologists performing the intubations had 19 T 10 years (mean T SD) of postresidency experience, the anesthetic protocol was standardized with patients being given equipotent doses of nondepolarizing neuromuscular blocking agents, and the patient's head and neck were placed in the neutral position just before DL was performed. During each DL and intubation, anesthesiologists were told to obtain the best possible glottic view using only the laryngoscope. Manual in-line stabilization was applied; manual head and neck movement and external laryngeal manipulation (cricoid pressure) were not allowed, the rationale being to ensure that all pressures applied to the airway could be quantitated. (Because the investigators measured pressure directed against the anterior surface of a Macintosh blade, the intubators could not use external posteriorly directed pressure.) Use of an endotracheal tube stylet was also not permitted. The results disclosed that DL with...

Melatonin possesses sedative, hypnotic, analgesic, antiinflammatory, antioxidative, and chronobiotic properties that distinguish it as an attractive alternative premedicant. A qualitative systematic review of the literature concerning the perioperative use of melatonin as an anxiolytic or analgesic in adult patients was carried out using the recommended guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. Nine of the 10 studies showed statistically significant reduction of preoperative anxiety with melatonin premedication compared with placebo. An opioid-sparing effect or reduced pain scores were evident in five studies whereas three studies were contradictory. Thus, melatonin premedication is effective in ameliorating preoperative anxiety in adults, but its analgesic effects remain controversial in the perioperative period. Additional well designed randomized controlled trials are necessary to compare melatonin premedication with other pharmacological interventions, investigate its effect on more varied surgical populations, and to delineate its optimal dosing regimen.

An intracuff pressure of 80 cm H(2)O with the LMA Supreme is associated with a higher OLP compared with 60 cm H(2)O or 40 cm H(2)O without a greater incidence of postoperative pharyngolaryngeal adverse events. For a superior glottic seal when using the LMA Supreme, we recommend intracuff pressures up to 80 cm H(2)O.

We assessed the effectiveness of the 3-in-1 continuous femoral block as a form of postoperative pain relief for unilateral total knee arthroplasty (TKA). Sixty patients undergoing elective unilateral TKA under subarachnoid block were randomized into three groups. Postoperative analgesia was provided with a continuous 3-in-1 femoral nerve catheter with 0.15% ropivacaine in group A, a continuous 3-in-1 femoral nerve catheter with 0.2% ropivacaine in group B, or patient controlled intravenous morphine in group C (control group). Groups A and B received patient controlled intravenous morphine pumps for rescue analgesia. Patients in each group were followed for 72 hours postoperatively. Five patients were excluded after randomization. In the remaining 55 patients there was no statistical difference in pain score between the groups. Total morphine use was highest in group C (P< 0.05). No appreciable difference could be found with sensorimotor blockade, morphine usage and satisfaction scores when comparing groups A and B. Femoral catheter dislodgement rate was 7.9%. There was no statistical difference between the groups when comparing the day of first ambulation and the time to discharge from the hospital. Satisfaction scores were higher in group A (P = 0.028) and group B (P = 0.002) compared to group C. We conclude that a continuous 3-in-1 femoral nerve block with ropivacaine 0.15% or 0.2% for elective unilateral TKA has an opioid-sparing effect.