Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

SummaryWe compared sedation levels in children following administration of intranasal dexmedetomidine. One hundred and sixteen children aged between 1 and 8 years were enrolled in this prospective, randomised trial. Children were assigned to receive either intranasal dexmedetomidine 1 lg.kg )1 (Group 1) or 2 lg.kg )1 (Group 2). Thirty-one (53%) patients from Group 1 and 38 (66%) patients from Group 2 were satisfactorily sedated at the time of anaesthetic induction. Logistic regression showed a significant interaction effect (p = 0.049), with the odds ratio between Group 2 over Group 1 estimated as 1.1 (95% CI 0.5-2.7) for the 1-4 year age group, and 10.5 (95% CI 1.4-80.2) for the 5-8 year age group. Both doses produced a similar level of satisfactory sedation in children aged 1-4 years, whereas 2 lg.kg )1 resulted in a higher proportion of satisfactory sedation in children aged 5-8 years. There were no adverse haemodynamic effects. We conclude that intranasal dexmedetomidine in a premedication dose of 2 lg.kg )1 resulted in excellent sedation in children. Dexmedetomidine is an a 2 -adrenergic receptor agonist that provides sedation without respiratory depression. Clinical trials have demonstrated that intranasal dexmedetomidine in a dose of 1 lg.kg )1 produces satisfactory sedation in between 53% and 57% of children at anaesthetic induction [1,2]. There are also reports using higher doses of intranasal dexmedetomidine [3]. We compared the sedative effect of 1 lg.kg )1 intranasal dexmedetomidine with those of 2 lg.kg )1 for premedication in children aged 1-8 years and hypothesised that the higher dose would produce satisfactory sedation in more children at the time of anaesthetic induction. MethodsThis study was approved by the local research ethics committee and written informed consent was obtained from the parents or legal guardians of all the patients. Children weighing between 7 and 17 kg, of ASA physical status 1 or 2, aged 1-8 years, who were scheduled for elective surgery at either Queen Mary Hospital, Hong Kong (QMH) or the University of Malaya, Kuala Lumpur Malaysia (UM) were enrolled in the study. If the child understood and discussed the need for premedication, then his ⁄ her assent was also obtained. Exclusion criteria included known allergy or

Newer second generation supraglottic airway devices may perform differently in vivo due to material and design modifications. We compared performance characteristics of the Ambu® AuraGain™ and LMA Supreme™ Second Seal™ in 100 spontaneously breathing anaesthetised patients in this randomised controlled study. We studied oropharyngeal leak pressures (OLP) (primary outcome) and secondarily, ease of insertion, success rates, haemodynamic response, time to insertion, and complications of usage. We found no significant difference in OLP between the AuraGain versus the LMA Supreme, mean (standard deviation, SD) 24.1 (7.4) versus 23.6 (6.2) cmH2O, P=0.720. First-attempt placement rates of the AuraGain were comparable to the LMA Supreme, 43/50 (86%) versus 39/50 (78%), P=0.906, with an overall 98% insertion success rate for the AuraGain and 88% for the LMA Supreme after three attempts, P=0.112. However, the AuraGain was deemed subjectively harder to insert, with only 24/50 (48%) versus 37/50 (74%) of AuraGain insertions being scored 1 = easy (on a 5 point scale), P=0.013, and also took longer to insert, 33.4 (SD 10.9) versus 27.3 (SD 11.4) seconds, P=0.010. The AuraGain needed a smaller volume of air (16.4 [SD 6.8] versus 23.0 [SD 7.4] ml, P <0.001) to attain intracuff pressures of 60 cmH2O, facilitated more successful gastric tube insertion (100% versus 90.9%, P=0.046), and had significantly decreased sore throat incidence (10% versus 38%, P=0.020). One AuraGain and six LMA Supremes failed to be placed within the stipulated 120 seconds trial definition of ‘success’; these patients had risk factors for failed supraglottic insertion. In conclusion, both devices had similar OLPs and performed satisfactorily. However, the AuraGain resulted in less postoperative sore throat despite being harder to, and taking longer to, insert.

Background: Residual neuromuscular block is associated with an increased risk of postoperative pulmonary complications in retrospective studies. The aim of our study was to investigate prospectively the incidence of postoperative pulmonary complications after reversal with either sugammadex (SUG) or neostigmine (NEO) in high-risk older patients. Methods: We randomly allocated 180 older patients with significant morbidity (ASA physical status 3) !75 yr old to reversal of rocuronium with either SUG or NEO. Adverse events in the recovery room and pulmonary complications (defined by a 5-point [0e4; 0¼best to 4¼worst] outcome score) on postoperative Days 1, 3, and 7 were compared between groups. Results: Data from 168 patients aged 80 (4) yr were analysed; SUG vs NEO resulted in a reduced probability (0.052 vs 0.122) of increased pulmonary outcome score (impaired outcome) on postoperative Day 7, but not on Days 1 and 3. More patients in the NEO group were diagnosed with radiographically confirmed pneumonia (9.6% vs 2.4%; P¼0.046). The NEO group showed a non-significant trend towards longer hospital length of stay across all individual centres (combined 9 vs 7.5 days), with a significant difference in Malaysia (6 vs 4 days; P¼0.011). Conclusions: Reversal of rocuronium neuromuscular block with SUG resulted in a small, but possibly clinically relevant improvement in pulmonary outcome in a select cohort of high-risk older patients. Clinical trial registration: ACTRN12614000108617.

SummaryWe compared the performance of the Ambu Ò AuraOnce TM Laryngeal Mask with that of the LMA Classic TM laryngeal mask airway during controlled anaesthesia. Forty patients requiring intermittent positive pressure ventilation were studied using a randomised crossover design. The mean (SD) oropharyngeal leak pressure for the Ambu device (19 (7.5) cmH 2 O) was significantly greater than for the LMA Classic (15 (5.2) cmH 2 O; p ¼ 0.004), and the number of attempts for successful insertions was significantly less (39 (50%) vs 45 (56%), respectively; p ¼ 0.02). There was one failure to obtain a patent airway with the Ambu Laryngeal Mask and none with the LMA Classic. Insertion of the Ambu Laryngeal Mask required more manipulations to achieve a patent airway than did the LMA Classic (6 (15%) vs 1 (2.5%), respectively; p ¼ 0.045), but the time taken for insertion was similar between the two groups. The incidence of trauma, grade of fibreoptic view, peak airway pressure and quality of ventilation during maintenance of anaesthesia were similar in both groups.

BackgroundAmbulatory surgery has recently gain popularity, as it is a good method of optimizinghospital resources utilization. To support ambulatory surgery, anaesthetic goals nowrevolve around patients’ early recovery with minimal pain and nausea, expedientdischarge home and prompt resumption of activities of daily living. In this study, weevaluated the effect of a single pre-induction dose of dexmedetomidine on anaestheticrequirements, postoperative pain and clinical recovery after ambulatory ureteroscopy andureteric stenting under general anaesthesia.MethodsSixty patients were randomised to receive IV dexmedetomidine 0.5 μg.kg-1 (Group DEX, n = 30) or IV saline (Group P, n = 30). General anaesthesia was maintained with Sevoflurane: oxygen: air, titrated to BIS 40–60. Pain intensity, sedation, rescue analgesics, nausea/vomiting and resumption of daily activities were recorded at 1 h, and postoperative day (POD) 1–5.ResultsGroup DEX patients had significant reduction in sevoflurane minimum alveolar concentration (MAC), mean (SD) DEX vs. Placebo 0.6 (0.2) vs. 0.9 (0.1), p = 0.037; reduced postoperative resting pain at 1 h (VAS 0–10) (mean (SD) 1.00 (1.84) vs. 2.63 (2.78), p = 0.004), POD 1 (mean (SD) 1.50 (1.48) vs. 2.87 (2.72), p = 0.002), POD 2 (0.53 (0.97) vs. 1.73 (1.96), p = 0.001) and POD 3 (0.30 (0.75) vs. 0.89 (1.49), p = 0.001). DEX patients also had less pain on movement POD 1 (3.00 (2.12) vs. 4.30 (3.10), p = 0.043) and POD 2 (2.10 (1.98) vs. 3.10 (2.46), p = 0.040), with higher resumption of daily activities by 48 h compared to placebo, 87% vs. 63%, p = 0.04.ConclusionsWe conclude that a single dose of dexmedetomidine was a useful adjuvant in reducing MAC and postoperative pain (at 1 h and POD 1–3), facilitating faster return to daily activities by 48 h.Trial registrationThe Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617001120369, 31st July 2017, retrospectively registered.

Cardiac troponin T (cTnT), even at low concentrations, is a risk factor for 30-day mortality in patients undergoing noncardiac surgery, but it is uncertain whether that risk is generalizable to patients with poor kidney function. We, therefore, evaluated the relationship between cTnT concentration and kidney function on the outcome of 30-day mortality in a post hoc analysis of a prospective cohort study of patients undergoing noncardiac surgery. cTnT was measured for 3 days after surgery and considered abnormal if the peak was $0.02 ng/ml. Of the included 14,037 patients, 267 (1.9%) patients died within 30 days of surgery. The adjusted hazard ratios for death with an abnormal cTnT concentration were 4.37 (95% confidence intervals [95% CI], 3.21 to 6.22), 6.15 (95% CI, 2.95 to 140.9), 6.30 (95% CI, 3.12 to 21.23), 1.33 (95% CI, 0.56 to 4.85), and 1.46 (95% CI, 0.46 to 9.21) for eGFR$60, 45 to ,60, 30 to ,45, 15 to ,30, and ,15 ml/min per 1.73 m 2 or on dialysis, respectively. Compared with patients with eGFR$60 ml/min per 1.73 m 2 , the adjusted hazard ratio was significantly lower for patients with eGFR=15 to ,30 ml/min per 1.73 m 2 (interaction P value=0.02). Redefining abnormal cTnT concentration as $0.03 ng/ml or a change of $0.02 ng/ml did not alter results. Because the risk associated with postoperative cTnT levels may be different for patients with eGFR,30 ml/min per 1.73 m 2 , additional research is required to determine how to interpret perioperative cTnT values for patients with low kidney function.

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