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Marine algae are thought to be a source of various metabolites that have a wide range of positive effects on human health. The pharmacological properties of algal metabolites, including their antioxidant, anti-inflammatory, cholesterol homeostasis, protein clearance, and anti-amyloidergic effects, lend credence to their protective efficacy against oxidative stress, neuroinflammation, mitochondrial dysfunction, and impaired proteostasis, all of which are involved in the pathophysiology of neurodegenerative disorders. There are currently no clinical trials on the effects of marine algae on neuroinflammation; however, considering the significant biological activities that have been established by in vitro and animal research, we expect that there will be clinical trials on this topic in the not-too-distant future. The most recent and important findings on the potentially neuroprotective effects of the anti-inflammatory properties of marine algae were chosen for this study. Next, we conducted a literature review on the neuroprotective potential of algal compounds, along with the underlying pharmacological mechanism, and finally, we evaluated recent advances in therapeutics.

With the growing popularity of propofol mediated deep sedation for upper gastrointestinal (GI) endoscopic procedures, challenges are being felt and appreciated. Research suggests that management of the airway is anything but routine in this setting. Although many studies and meta-analyses have demonstrated the safety of propofol sedation administered by registered nurses under the supervision of gastroenterologists (likely related to the lighter degrees of sedation than those provided by anesthesia providers and is under medicolegal controversy in the United States), there is no agreement on the optimum airway management for procedures such as endoscopic retrograde cholangiopancreatography. Failure to rescue an airway at an appropriate time has led to disastrous consequences. Inability to evaluate and appreciate the risk factors for aspiration can ruin the day for both the patient and the health care providers. This review apprises the reader of various aspects of airway management relevant to the practice of sedation during upper GI endoscopy. New devices and modification of existing devices are discussed in detail. Recognizing the fact that appropriate monitoring is important for timely recognition and management of potential airway disasters, these issues are explored thoroughly. [ABSTRACT FROM AUTHOR]

Background: Dexamethasone has many desirable pharmacologic properties for perioperative use. Its antiemetic potential has been a focus of many recent trials.Methods: Trials comparing dexamethasone to 5-HT3-receptor antagonists (5HT3-RA) for 24 h postoperative vomiting incidences published till August 2017 were searched in the medical database. Comparisons for antiemetic efficiency variables (vomiting incidence, nausea incidence, rescue antiemetic need, and patients with complete response) during early (until 6 h) and late postoperative phase were made. Comparative analgesic requirements were also evaluated.Results: Twenty randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar (Fixed-effects, P = 0.86, I2 = 2.94%). Trial sequential analysis (TSA) confirmed non-inferiority of dexamethasone for 24-h vomiting incidence. (α = 5%, β = 20%, δ = 10%) with “information size” being 1619 (required > 573). Equivalence was also verified from early and delayed nausea rate as well using TSA. Pooled results did not demonstrate superiority/inferiority of 5-HT3-RAs over dexamethasone in all other antiemetic efficacy variables (early and delayed). Heterogeneity was found to be low in all of the comparisons. Linear-positive dose-response curve for dexamethasone 24-h vomiting and nausea incidence was seen (correlation coefficient being 0.21 and 0.28, respectively). Dexamethasone reduced the analgesic need (MH-odds of 0.64 (95% CI being 0.44 to 0.93) P = 0.02, I2 = 0)). Possibility of publication bias could not be ruled out (Egger’s test, X-intercept = 1.41, P = 0.04).Conclusions: Dexamethasone demonstrates equal antiemetic efficacy compared to 5-HT3 receptor antagonists. The agents perform equally well both in early postoperative phase and up to 24 h after surgery. Use of dexamethasone replacing 5-HT3 RAs offers an additional advantage of lowering the opioid requirements during the perioperative period. [ABSTRACT FROM AUTHOR]

Abstract: Haloperidol is an antipsychotic with well‐known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta‐analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5‐HT3‐receptor antagonists (5‐HT3‐RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double‐blinded trials were included in the final analysis. Twenty‐four‐hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I2 = 0%). Trial‐sequential analysis confirmed noninferiority of haloperidol over 5‐HT3‐RAs (α = 5%, β = 20%, δ = 10%), with “information size” being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5‐HT3‐RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial‐sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X‐intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well‐established 5‐HT3‐RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5‐HT3‐RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting. [ABSTRACT FROM AUTHOR]

Background: Thoracic interfascial plane blocks and modification (PECS) have recently gained popularity for analgesic potential during breast surgery. We evaluate/consolidate the evidence on opioid-sparing effect of PECS blocks in comparison with conventional intravenous analgesia (IVA) and paravertebral block (PVB). Materials and Methods: Prospective, randomized controlled trials comparing PECS block to conventional IVA or PVB in patients undergoing breast surgery published till June 2017 were searched in the medical database. Comparisons were made for 24-h postoperative morphine consumption and intraoperative fentanyl-equivalent consumption. Results: Final analysis included nine trials (PECS vs. IVA 4 trials and PECS vs. PVB 5 trials). PECS block showed a decreased intraoperative fentanyl consumption over IVA by 49.20 mcg (95% confidence interval [CI] =42.67-55.74) (I² = 98.47%, P < 0.001) and PVB by 15.88 mcg (95% CI = 12.95-18.81) (I² = 95.51%, P < 0.001). Postoperative, 24-h morphine consumption with PECS block was lower than IVA by 7.66 mg (95% CI being 6.23-9.10) (I² = 63.15, P < 0.001) but was higher than PVB group by 1.26 mg (95% CI being 0.91-1.62) (I² = 99.53%, P < 0.001). Two cases of pneumothorax were reported with PVB, and no complication was reported in any other group. Conclusions: Use of PECS block and its modifications with general anesthesia for breast surgery has significant opioid-sparing effect intraoperatively and during the first 24 h after surgery. It also has higher intraoperative opioid-sparing effect when compared to PVB. During the 1st postoperative day, PVB has slightly more morphine sparing potential that may however be associated with higher complication rates. The present PECS block techniques show marked interstudy variations and need standardization. [ABSTRACT FROM AUTHOR]

Background/Aims: The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures. Materials and Methods: Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates. Results: A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively. Conclusions: The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy. [ABSTRACT FROM AUTHOR]

Background and Aims: Three-in-one and femoral nerve blocks are proven modalities for postoperative analgesia following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the efficacy of magnesium (Mg) as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction. Methods: Sixty patients undergoing arthroscopic ACL reconstruction were randomly allocated to Group I (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of intravenous [IV] saline), Group II (3-in-1 block with 30 ml of 0.25% bupivacaine preceded by 1.5 ml of solution containing 150 mg Mg IV) or Group III (3-in-1 block with 30 ml containing 0.25% bupivacaine and 150 mg of Mg as adjuvant preceded by 1.5 ml of IV saline). Post-operatively, patients received morphine when visual analogue scale (VAS) score was ≥4. Quantitative parameters were compared using one-way ANOVA and Kruskal-Wallis test and qualitative data were analysed using Chi-square test. Results: Demographics, haemodynamic parameters, intra-operative fentanyl requirement, post-operative VAS scores and total morphine requirement were comparable between groups. Time to first analgesic requirement was significantly prolonged in Group III (789 ± 436) min compared to Group I (466 ± 290 min) and Group II (519 ± 274 min), (P = 0.02 and 0.05). Significantly less number of patients in Group III (1/20) received morphine in the first 6 h post-operatively, compared to Group I (8/20) and Group II (6/20) (P = 0.008 and 0.03). No side effects were observed. Conclusion: Mg as an adjuvant to bupivacaine in 3-in-1 block for ACL reconstruction significantly prolongs the time to first analgesic requirement and reduces the number of patients requiring morphine in the immediate post-operative period. [ABSTRACT FROM AUTHOR]

Background: Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter. Methods: In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted. Results: Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen. Conclusion: As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered. [ABSTRACT FROM AUTHOR]

Postoperative nausea and vomiting (PONV) is an important clinical problem. Aprepitant is a relatively new agent for this condition which may be superior to other treatment. A systematic review was performed after searching a number of medical databases for controlled trials comparing aprepitant with conventional antiemetics published up to 25 April 2015 using the following keywords: 'Aprepitant for PONV', 'Aprepitant versus 5-HT3 antagonists' and 'NK-1 versus 5-HT3 for PONV'. The primary outcome for the pooled analysis was efficacy of aprepitant in preventing vomiting on postoperative day (POD) 1 and 2. 172 potentially relevant papers were identified of which 23 had suitable data. For the primary outcome, 14 papers had relevant data. On POD1, 227/2341 patients (9.7%) patients randomised to aprepitant had a vomiting episode compared with 496/2267 (21.9%) controls. On POD2, the rate of vomiting among patients receiving aprepitant was 6.8% compared with 12.8% for controls. The OR for vomiting compared with controls was 0.48 (95% CI 0.34 to 0.67) on POD1 and 0.54 (95% CI 0.40 to 0.72) on POD2. Aprepitant also demonstrated a better profile with a lower need for rescue antiemetic and a higher complete response. Efficacy for vomiting prevention was demonstrated for 40 mg, 80 mg and 125 mg without major adverse effects. For vomiting comparison there was significant unexplainable heterogeneity (67.9% and 71.5% for POD1 and POD2, respectively). We conclude that (1) aprepitant reduces the incidence of vomiting on both POD1 and POD2, but there is an unexplained heterogeneity which lowers the strength of the evidence; (2) complete freedom from PONV on POD1 is highest for aprepitant with minimum need for rescue; and (3) oral aprepitant (80 mg) provides an effective and safe sustained antivomiting effect. [ABSTRACT FROM AUTHOR]

Background: The most common drugs used in an operating room are the "Inhalation agents" for maintenance of anesthesia yet their measurement methods during the procedure are not well-validated. Conventional methods of measuring the vaporizer weight after each use suffers from practical limitations of high error and time constraints. Aims: We compared two alternative methods available (Dion's method and Drager Inc. patent protocol) for their degree of concordance and correlation in real-time consumption of sevoflurane for pediatric procedures. Methodology: One hundred pediatric patients scheduled for ophthalmological examination under anesthesia were included in the study. Anesthesia was induced and maintained using sevoflurane with oxygen and nitrous oxide (1:1) on Primus workstation (Drager Inc., Germany). Total sevoflurane consumed for each procedure was calculated using Dion's equation and the values obtained from Drager Primus were noted and compared. Results: Both methods showed a very strong correlation (0.895 [P < 0.001]). Dion's method underestimated consumption by 2.59 ml with limits of agreement between 5.188 ml and -0.008 ml. Both test results showed a strong correlation, but poor concordance. Conclusions: Dion's method strongly correlates with Drager protocol although concordance between the two methods for measuring anesthetic gas consumption is poor. Dion's method underestimates the consumption and with slight modification addressing this underestimation, it can be electronically incorporated in other workstations to overcome limitations of real-time measurement of inhalation agent consumption. [ABSTRACT FROM AUTHOR]

Pediatric oral tumors have always been challenging for the even most skilled anesthesiologists. The conventional method of awake intubation is not realistic in this age group. The management is to chart out a plan to intubate the child post induction. We describe successful management of a case of giant of ossifying fibroma in a child with sickle cell trait where non-conventional innovate approach helped us to secure the airway pre-operatively and avoid possible medical complications. [ABSTRACT FROM AUTHOR]

Background: Inhalation agents account for significant cost of short daycare procedures. The estimation of this cost to pre-calculate expected expenditure is not available in literature. As for intravenous agents, their relations to weight and other demographic parameters are also not well established. The present study aims to evaluate the above concern. Materials and Methods: A total of 100 pediatric (ASA I, II) patients scheduled for ophthalmological examination under anesthesia (EUA) were included in the study. Following premedication, anesthesia in all children was induced using incremental concentrations of sevoflurane at a flow of 6 l with 1:1 oxygen:nitrous oxide ratio. Upon induction, the flows were reduced to 2 l, keeping sevoflurane at 1 to 2 minimum alveolar concentration (MAC). Using Dion's equation, the costs for induction and maintenance with sevoflurane were calculated for each patient. Results: The cost per minute of sevoflurane was found to be Rs. 13.23. Unlike intravenous agents, no significant correlation was found to exist between sevoflurane consumption with age or weight. The sevoflurane consumption was also not influenced by the gender. The total cost of EUA correlated most strongly with duration of maintenance phase, followed by induction duration. [ABSTRACT FROM AUTHOR]

Background: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. Objectives: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. Patients and Methods: After taking parental consent, data were collected retrospectively for 33 patients who underwent 37 procedures (four patients had both anterior and posterior procedures) on 2 days of the week mainly from August 2008 to February 2010 at a tertiary care institution. Results: Children undergoing GR surgery were younger (8.1 ± 2.1 years) than patients undergoing AR (12.9 ± 1.7 years) or posterior fusion (14.2 ± 2.2 years). AR children had a significantly higher Cobb's angle and more rigid curves. (P = 0.057) Associated congenital abnormalities especially neurological were commoner in the GR children. Surgical duration and blood loss was significantly more for PF (2207.5 ± 1224.13 ml) than GR (456 ± 337.5 ml), or AR (642.85 ± 304.72 ml), (P = 0.0002). PF patients needed Intensive care unit (ICU) care mainly due to the blood loss and prolonged surgery (35%). AR performed via thoracotomy was associated with the need for mechanical ventilation in 28.6%. The GR patients had major intraoperative hemodynamic events and 20% needed ICU care. Conclusions: Post-operative ventilation may be required in 20-35% patients undergoing procedures for scoliosis correction. Despite GR insertion involving lesser blood loss; younger age, congenital abnormalities, positioning, and surgical manipulation resulted in life threatening events in these patients. [ABSTRACT FROM AUTHOR]

A letter to the editor and a reply are presented in response to the article "Are we infusing acids into our patients' blood?" in the previous issue of the journal.

To determine if the combinations of morphine, dexmedetomidine and maropitant enhance the analgesic effect and decrease the dose of individual drugs in rats subjected to noxious thermal stimulation with hot-plate and tail-flick tests. Randomized, blinded, prospective experimental study. A total of 96 male Sprague–Dawley rats. The rats were randomly assigned to the following groups: 1) morphine (3 mg kg–1; Mor); 2) dexmedetomidine (10 μg kg–1; Dex); 3) maropitant (20 mg kg–1; Maro); 4) morphine (1.5 mg kg–1) + dexmedetomidine (5 μg kg–1; Mor + Dex); 5) dexmedetomidine (5 μg kg–1) + maropitant (10 mg kg–1; Dex + Maro); 6) morphine (1.5 mg kg–1) + maropitant (10 mg kg–1; Mor + Maro); 7) morphine (1 mg kg–1) + dexmedetomidine (3.5 μg kg–1) + maropitant (6.5 mg kg–1; Mor + Dex + Maro); and 8) normal saline (0.5 mL; saline), all injected intravenously. The tail-flick and hot-plate tests were performed before and 5, 15, 30, 45, 60, 90 and 120 minutes after the injection of the drugs. These variables were analysed with the effect–time area under the curve (AUC) analysis and a mixed linear model. Data were analysed in 94 rats. The rank order of the total analgesic effects of the treatment groups shown by AUC analysis was found to be Mor > Maro + Mor > Dex + Mor > Dex > Maro > Dex + Maro + Mor > Dex + Maro > saline for the hot-plate test, and Maro + Mor > Mor > Dex + Mor > Dex + Maro + Mor > Maro > Dex > Dex + Maro > saline for the tail-flick test. The mixed model analysis showed a significant difference between latencies of the group morphine + maropitant versus all other treatment groups in the tail-flick test (p < 0.0001) and morphine versus saline in the hot-plate test (p < 0.05). Morphine and maropitant appeared to show a supra-additive effect for analgesia in the tail-flick test. Clinical trials should be conducted to establish its use in treating pain. [ABSTRACT FROM AUTHOR]

Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63–56.71), decreasing mortality (OR, 0.08; 95% CrI, 0–0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057–0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97–6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12–1.15). Fasudil (OR, 0.16; 95% CrI, 0.03–0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057–1.0) in preventing delayed ischemic neurologic deficits. Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings. [ABSTRACT FROM AUTHOR]