Showing papers in "Acta Anaesthesiologica Scandinavica in 2010"

Video-laryngoscopes in the adult airway management: a topical review of the literature

Abstract: The aim of the present paper is to review the literature regarding video-laryngoscopes (Storz V-Mac and C-Mac, Glidescope, McGrath, Pentax-Airway Scope, Airtraq and Bullard) and discuss their clinical role in airway management. Video-laryngoscopes are new intubation devices, which provide an indirect view of the upper airway. In difficult airway management, they improve Cormack-Lehane grade and achieve the same or a higher intubation success rate in less time, compared with direct laryngoscopes. Despite the very good visualization of the glottis, the insertion and advancement of the endotracheal tube with video-laryngoscopes may occasionally fail. Each particular device's features may offer advantages or disadvantages, depending on the situation the anaesthesiologist has to deal with. So far, there is inconclusive evidence indicating that video-laryngoscopy should replace direct laryngoscopy in patients with normal or difficult airways.

New insights into the pathophysiology of postoperative cognitive dysfunction

Abstract: There is evidence that postoperative cognitive dysfunction (POCD) is a significant problem after major surgery, but the pathophysiology has not been fully elucidated. The interpretation of available studies is difficult due to differences in neuropsychological test batteries as well as the lack of appropriate controls. Furthermore, there are no internationally accepted criteria for defining POCD. This article aims to provide an update of current knowledge of the pathogenesis of POCD with a focus on perioperative pathophysiology and possible benefits achieved from an enhanced postoperative recovery using a fast-track methodology. It is concluded that the pathogenesis of POCD is multifactorial and future studies should focus on evaluating the role of postoperative sleep disturbances, inflammatory stress responses, pain and environmental factors. Potential prophylactic intervention may include minimal invasive surgery, multi-modal non-opioid pain management and pharmacological manipulation of the inflammatory response and sleep architecture.

The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review.

Abstract: The transversus abdominis plane (TAP) block is a newly described peripheral block involving the nerves of the anterior abdominal wall. The block has been developed for post-operative pain control after gynaecologic and abdominal surgery. The initial technique described the lumbar triangle of Petit as the landmark used to access the TAP in order to facilitate the deposition of local anaesthetic solution in the neurovascular plane. Other techniques include ultrasound-guided access to the neurovascular plane via the mid-axillary line between the iliac crest and the costal margin, and a subcostal access termed the 'oblique subcostal' access. A systematic search of the literature identified a total of seven randomized clinical trials investigating the effect of TAP block on post-operative pain, including a total of 364 patients, of whom 180 received TAP blockade. The surgical procedures included large bowel resection with a midline abdominal incision, caesarean delivery via the Pfannenstiel incision, abdominal hysterectomy via a transverse lower abdominal wall incision, open appendectomy and laparoscopic cholecystectomy. Overall, the results are encouraging and most studies have demonstrated clinically significant reductions of post-operative opioid requirements and pain, as well as some effects on opioid-related side effects (sedation and post-operative nausea and vomiting). Further studies are warranted to support the findings of the primary published trials and to establish general recommendations for the use of a TAP block.

Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients

Abstract: Background: Spinal anaesthesia for caesarean section may cause hypotension, jeopardizing the foetus and its mother. We aimed to identify the spectrum of definitions of hypotension used in the scientific literature. In a second part, we applied these definitions to a prospective cohort in order to evaluate the effect of different definitions on the incidence of hypotension. Methods: A systematic literature search in PubMed was performed from 1999 to 2009 with the search terms ‘hypotension’ and ‘caesarean section’. Consecutive parturients undergoing caesarean section under spinal anaesthesia were included in a prospective study. Results: Sixty-three eligible publications (7120 patients) were retrieved, revealing 15 different definitions of hypotension. A decrease below 80% baseline and the combined definition of a blood pressure below 100 mmHg or a decrease below 80% baseline were the two most frequent definitions, found in 25.4% and 20.6% of the papers, respectively. When applying the spectrum of definitions to a prospective cohort, the incidences of hypotension varied between 7.4% and 74.1%. The incidence increased from 26.7% to 38.5% when using a value below 75% of baseline instead of below 70% of baseline. Conclusion: There is not one accepted definition of hypotension in the scientific literature. The incidence of hypotension varies depending on the chosen definition. Even minor changes of the definition cause major differences in the frequency of hypotension. This makes it difficult to compare studies on interventions to treat/prevent hypotension and probably hampers progress in this area of research.

Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review.

Abstract: Post-operative cognitive dysfunction (POCD) is a decline in cognitive function from pre-operative levels, which has been frequently described after cardiac surgery. The purpose of this study was to examine the variability in the measurement and definitions for POCD using the framework of a 1995 Consensus Statement on measurement of POCD. Electronic medical literature databases were searched for the intersection of the search terms 'thoracic surgery' and 'cognition, dementia, and neuropsychological test.' Abstracts were reviewed independently by two reviewers. English articles with >50 participants published since 1995 that performed pre-operative and post-operative psychometric testing in patients undergoing cardiac surgery were reviewed. Data relevant to the measurement and definition of POCD were abstracted and compared with the recommendations of the Consensus Statement. Sixty-two studies of POCD in patients undergoing cardiac surgery were identified. Of these studies, the recommended neuropsychological tests were carried out in less than half of the studies. The cognitive domains measured most frequently were attention (n=56; 93%) and memory (n=57; 95%); motor skills were measured less frequently (n=36; 60%). Additionally, less than half of the studies examined anxiety and depression, performed neurological exam, or accounted for learning. Four definitions of POCD emerged: per cent decline (n=15), standard deviation decline (n=14), factor analysis (n=13), and analysis of performance on individual tests (n=12). There is marked variability in the measurement and definition of POCD. This heterogeneity may impede progress by reducing the ability to compare studies on the causes and treatment of POCD.

Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study

Abstract: Background: There is an evident need for improved management of elderly patients with trauma in order to avoid common and troublesome complications such as delirium. The aim of this study was to investigate whether an implementation of a multi-factorial program including intensified pre-hospital and perioperative treatment and care could reduce the incidence of delirium in elderly patients with hip fracture, cognitively intact at admission to the hospital. In addition, we explored the factors that characterize patients who developed delirium. Methods: A prospective, quasi-experimental design was used. A total of 263 patients with hip fracture (>/=65 years), cognitively intact at admission, were consecutively included between April 2003 and April 2004. On 1 October 2003, a new program was introduced. All patients were screened for cognitive impairment within 30 min after admission to the emergency department using The Short Portable Mental Status Questionnaire (SPMSQ). To screen for delirium, patients were tested within 4 h of admission and thereafter daily, using the Organic Brain Syndrome scale. Results: The number of patients who developed delirium during hospitalization was 74 (28.1%), with a decrease from 34% (45 of 132) in the control group to 22% (29 of 131) in the intervention group (P=0.031). Patients who developed delirium were statistically older, more often had >4 prescribed drugs at admission and scored less well in the SPMSQ test. Conclusion: The use of a multi-factorial intervention program in elderly hip fracture patients, lucid at admission, reduced the incidence of delirium during hospitalization by 35%. (Less)

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Abstract: Background: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. Methods: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. Results: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts’ opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts’ opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. Conclusions: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations.

Abstract: Emergency patients need special considerations and the number and severity of complications from general anaesthesia can be higher than during scheduled procedures. Guidelines are therefore needed. The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine appointed a working group to develop guidelines based on literature searches to assess evidence, and a consensus meeting was held. Consensus opinion was used in the many topics where high-grade evidence was unavailable. The recommendations include the following: anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists. Problems with the airway and the circulation must be anticipated. The risk of aspiration must be judged for each patient. Pre-operative gastric emptying is rarely indicated. For pre-oxygenation, either tidal volume breathing for 3 min or eight deep breaths over 60 s and oxygen flow 10 l/min should be used. Pre-oxygenation in the obese patients should be performed in the head-up position. The use of cricoid pressure is not considered mandatory, but can be used on individual judgement. The hypnotic drug has a minor influence on intubation conditions, and should be chosen on other grounds. Ketamine should be considered in haemodynamically compromised patients. Opioids may be used to reduce the stress response following intubation. For optimal intubation conditions, succinylcholine 1-1.5 mg/kg is preferred. Outside the operation room, rapid sequence intubation is also considered the safest method. For all patients, precautions to avoid aspiration and other complications must also be considered at the end of anaesthesia.

Premedication with clonidine is superior to benzodiazepines. A meta analysis of published studies

Abstract: Background: Premedication is considered important in pediatric anesthesia. Benzodiazepines are the most commonly used premedication agents. Clonidine, ana2 adrenoceptor agonist, is gaining popularity among anesthesiologists. The goal of the present study was to perform a meta-analysis of studies comparing premedication with clonidine to Benzodiazepines. Methods: A comprehensive literature search was conducted to identify clinical trials focusing on the comparison of clonidine and Benzodiazepines for premedication in children. Six reviewers independently assessed each study to meet the inclusion criteria and extracted data. Original data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), 95% confidence intervals [95% CI] and statistical heterogeneity were accessed. Results: Ten publications fulfilling the inclusion criteria were found. Premedication with clonidine, in comparison with midazolam, exhibited a superior effect on sedation at induction (OR 5 0.49 [0.27, 0.89]), decreased the incidence of emergence agitation (OR 5 0.25 [0.11, 0.58]) and produced a more effective early post-operative analgesia (OR 5 0.33 [0.21, 0.58]). Compared with diazepam, clonidine was superior in preventing post-operative nausea and vomiting (PONV). Discussion: Premedication with clonidine is superior to midazolam in producing sedation, decreasing postoperative pain and emergence agitation. However, the superiority of clonidine for PONV prevention remains unclear while other factors such as nausea prevention might interfere with this result.

Management of major blood loss: An update

Abstract: Haemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution and consumption of clotting factors and platelets. Concepts of damage control surgery have evolved, prioritizing the early control of the cause of bleeding by non-definitive means, while haemostatic control resuscitation seeks early control of coagulopathy. Haemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells (RBCs) in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients. Transfusion of RBCs, plasma and platelets in a similar proportion as in whole blood prevents both hypovolaemia and coagulopathy. Although an early and effective reversal of coagulopathy is documented, the most effective means of preventing coagulopathy of massive transfusion remains debated and randomized controlled studies are lacking. Results from recent before-and-after studies in massively bleeding patients indicate that trauma exsanguination protocols involving the early administration of plasma and platelets are associated with improved survival. Furthermore, viscoelastic whole blood assays, such as thrombelastography (TEG)/rotation thromboelastometry (ROTEM), appear advantageous for identifying coagulopathy in patients with severe haemorrhage, as opposed to conventional coagulation assays. In our view, patients with uncontrolled bleeding, regardless of its cause, should be treated with goal-directed haemostatic control resuscitation involving the early administration of plasma and platelets and based on the results of the TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal haemostatic competence until surgical haemostasis is achieved, as this appears to be associated with reduced mortality.

Long-term effect of the ICU-diary concept on quality of life after critical illness.

Abstract: Background Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be ...

Impact of the CYP2D6 genotype on post-operative intravenous oxycodone analgesia.

Abstract: Background: Oxycodone is a semi-synthetic opioid with a μ-receptor agonist-mediated effect in several pain conditions, including post-operative pain. Oxycodone is metabolized to its active metabolite oxymorphone by O-demethylation via the polymorphic CYP2D6. The aim of this study was to investigate whether CYP2D6 poor metabolizers (PMs) yield the same analgesia post-operatively from intravenous oxycodone as extensive metabolizers (EMs). Methods: Two hundred and seventy patients undergoing primarily thyroid surgery or hysterectomy were included and followed for 24 h post-operatively. The CYP2D6 genotype was blinded until study procedures had been completed for all patients. All patients received intravenous oxycodone as pain treatment for 24 h post-operatively and morphine 5 mg was used as escape medication. A responder was characterized as a patient without the need for escape medication and a positive evaluation in a questionnaire 24 h post-operatively. Results: Twenty-four patients were PM (8.9%) and 246 were EM (91.1%). One PM (4.17%, CI=0.1–21.1) was a non-responder and 42 EM (17.07%, CI=12.6–22.4) were non-responders. The non-responder rate did not differ between the two genotypes (P=0.14). There was no difference in the total consumption of oxycodone between the two genotypes (EM=14.7 mg, CI=13.0–16.4 and PM=13.0 mg, CI=8.9–17.0, P=0.42). The mean oxymorphone/oxycodone ratios were 0.0031 and 0.00081 in the EMs and PMs, respectively (P<0.0001). Conclusion: This study showed for the first time in patients that the oxymorphone formation depends on CYP2D6, but we found no difference in the post-operative analgesic effect of intravenous oxycodone between the two CYP2D6 genotypes.

Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes.

Abstract: BACKGROUND: The operating room is a complex work environment with a high potential for adverse events. Protocols for perioperative verification processes have increasingly been recommended by profe ...

Early predictors of morbidity and mortality in trauma patients treated in the intensive care unit.

Abstract: Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, Stockholm, SwedenBackground: We investigated the incidence and severity ofpost-injury morbidity and mortality in intensive care unit(ICU)-treated trauma patients. We also identified riskfactors in the early phase afterinjurythatpredictedthelater development of complications.Methods: Aprospectiveobservationalcohortstudyde-sign was used. One hundred and sixty-four adult patientsadmitted to the ICU for more than 24h were includedduring a 21-month period. The incidence and severity ofmorbidity such as multiple organ failure (MOF), acutelung injury (ALI), severe sepsis and 30-day post-injurymortality were calculated and risk factors were analyzedwith uni- and multivariable logistic regression analysis.Results: The median age was 40 years, the injury severityscore was 24, the new injury severity score was 29, theacute physiology and chronic health evaluation II scorewas 15, sequential organ failure assessment maximum was7andICUlengthofstaywas3.1days.Theincidencesofpost-injury MOF were 40.2%, ALI 25.6%, severe sepsis31.1% and 30-day mortality 10.4%. The independent riskfactors differed to some extent between the outcome para-meters. Age, severity of injury, significant head injury andmassive transfusion were independent risk factors forseveral outcome parameters. Positive blood alcohol wasonly a predictor of MOF, whereas prolonged rescue timeonly predicted death. Unexpectedly, injury severity wasnot an independent risk factor for mortality.Conclusions: Although the incidence of morbidity wasconsiderable, mortality was relatively low. Early post-injury risk factors that predicted later development ofcomplications differed between morbidity and mortality.

Endotracheal tube size and sore throat following surgery : a randomized-controlled study

Abstract: Background: Sore throat following endotracheal intubation is a common problem following surgery and one of the factors that affects the quality of recovery. This study was carried out with the prim ...

Lidocaine vs. magnesium: effect on analgesia after a laparoscopic cholecystectomy

Abstract: Background: This double-blinded study aimed at evaluating and comparing the effects of magnesium and lidocaine on pain, analgesic requirements, bowel function, and quality of sleep in patients undergoing a laparoscopic cholecystectomy (LC). Methods: Patients were randomized into three groups (n=40 each). Group M received magnesium sulfate 50 mg/kg intravenously (i.v.), followed by 25 mg/kg/h i.v., group L received lidocaine 2 mg/kg i.v., followed by 2 mg/kg/h i.v., and group P received saline i.v. Bolus doses were given over 15 min before induction of anesthesia, followed by an i.v. infusion through the end of surgery. Intraoperative fentanyl consumption and averaged end-tidal sevoflurane concentration were recorded. Abdominal and shoulder pain were evaluated up to 24 h using a visual analog scale (VAS). Morphine consumption was recorded at 2 and 24 h, together with quality of sleep and time of first flatus. Results: Lidocaine or magnesium reduced anesthetic requirements (P<0.01), pain scores (P<0.05), and morphine consumption (P<0.001) relative to the control group. Lidocaine resulted in lower morphine consumption at 2 h [4.9 ± 2.3 vs. 6.8 ± 2.8 (P<0.05)] and lower abdominal VAS scores compared with magnesium (1.8 ± 0.8 vs. 3.2 ± 0.9, 2.2 ± 1 vs. 3.6 ± 1.6, and 2.1 ± 1.4 vs. 3.3 ± 1.9) at 2, 6, and 12 h, respectively (P<0.05). Lidocaine was associated with earlier return of bowel function and magnesium was associated with better sleep quality (P<0.05). Conclusion: I.v. lidocaine and magnesium improved post-operative analgesia and reduced intraoperative and post-operative opioid requirements in patients undergoing LC. The improvement of quality of recovery might facilitate rapid hospital discharge.

Cognitive dysfunction and health-related quality of life after a cardiac arrest and therapeutic hypothermia.

Abstract: Centre for Clinical Research, Haukeland University Hospital, Bergen, NorwayBackground: Evidence-based treatment protocols includ-ing therapeutic hypothermia have increased hospitalsurvival to over 50% in unconscious out-of-hospitalcardiac arrest survivors In this study we estimated theincidence of cognitive dysfunctions in a group of cardiacarrest survivors with a high functional outcome treatedwith therapeutic hypothermia Secondarily, we assessedthe cardiac arrest group’s level of cognitive performance ineach tested cognitive domain and investigated therelationship between cognitive function and age, timesince cardiac arrest and health-related quality of life(HRQOL)Methods: We included 26 patients 13–28 months after acardiac arrest All patients were scored using the CerebralPerformance Category scale (CPC) and Mini-Mental StateExamination (MMSE) Twenty-five of the patients weretested for cognitive function using the Cambridge Neu-ropsychological Test Automated Battery (CANTAB) Thesepatients were tested using four cognitive tests: MotorScreening Test, Delayed Matching to Sample, Stockings ofCambridge and Paired Associate Learning from CANTABAll patients filled in the Short Form-36 for the assessmentof HRQOLResults: Thirteen of 25 (52%) patients were classified ashaving a cognitive dysfunction Compared with the refer-ence population, there was no difference in the perfor-mance in motor function and delayed memory but therewere significant differences in executive function andepisodic memory We found no associations between cog-nitive function and age, time since cardiac arrest orHRQOLConclusion: Half of the patients had a cognitive dysfunc-tion with reduced performance on executive function andepisodic memory, indicating frontal and temporal lobeaffection, respectively Reduced performance did not affectHRQOL

Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study

Abstract: Background We conducted a prospective observational survey of pregnant women with cardiac disease. The aim was to analyse and present the mode of delivery, outcome, and haemodynamic changes during a caesarean section under regional anaesthesia in women with cardiac disease. Methods All pregnant women with a cardiovascular diagnosis, except hypertension, were included in the registry. Based on the cardiac diagnoses, and on the New York Heart Association classification, a multidisciplinary group made recommendations for each patient and decided on the mode of delivery. The data from continuous, invasive haemodynamic monitoring in intermediate- and high-risk patients under regional anaesthesia for a caesarean section were analysed and presented. Results The hospital had approximately 9000 deliveries in the period from November 2003 to April 2008. A total of 113 pregnancies in 107 women were included. Thirty-two (28.3%) pregnancies were classified into the high-risk category. Of 103 deliveries, caesarean sections were performed in 59 (52.2%) cases, with regional anaesthesia in 51 patients (18 emergencies), general anaesthesia in eight patients (five emergencies), and a planned vaginal delivery in 44 patients. There was no mortality among the mothers or the babies during the hospital stay or 6 months postpartum. Pre-operative cardiovascular stability during the caesarean section was maintained by volume and phenylephrine infusion guided by invasive monitoring of haemodynamic variables. Conclusion Our study suggests that pregnant women with cardiac disease may safely deliver the baby by a caesarean section under regional anaesthesia. According to our findings, haemodynamic stability can be obtained by titrated regional anaesthesia, intravenous (i.v.) volume, phenylephrine infusion, and small repeated doses of i.v. oxytocin guided by invasive monitoring.

Effect of epidural dexmedetomidine on intraoperative awareness and post-operative pain after one-lung ventilation.

Abstract: Background: During combined general and regional anaesthesia, it is difficult to use autonomic signs to assess whether wakefulness is suppressed adequately. We compared the effects of a dexmedetomidine–bupivacaine mixture with plain bupivacaine for thoracic epidural anaesthesia on intraoperative awareness and analgesic benefits, when combined with superficial isoflurane anaesthesia (<0.05 maximum alveolar concentration) in patients undergoing thoracic surgery with one-lung ventilation (OLV). Methods: Fifty adult male patients were randomly assigned to receive either epidural dexmedetomidine 1 μg/kg with bupivacaine 0.5% (group D) or bupivacaine 0.5% alone (group B) after induction of general anaesthesia. Gasometric, haemodynamic and bispectral index values were recorded. Post-operative verbal rating score for pain and observer's assessment of alertness/sedation scale were determined by a blinded observer. Results: Dexmedetomidine reduced the use of supplementary fentanyl during surgery. Patients in group B consumed more analgesics and had higher pain scores after operation than patients of group D. The level of sedation was similar between the two groups in the ICU. Two patients (8%) in group B reported possible intraoperative awareness. There was a limited decrease in PaO2 at OLV in group D compared with group B (P<0.05). Conclusion: In thoracic surgery with OLV, the use of epidural dexmedetomidine decreases the anaesthetic requirements significantly, prevents awareness during anaesthesia and improves intraoperative oxygenation and post-operative analgesia.

Neuroprotective effects of a combination of dexmedetomidine and hypothermia after incomplete cerebral ischemia in rats.

Abstract: BACKGROUND Dexmedetomidine and hypothermia are known to reduce neuronal injury following cerebral ischemia We examined whether a combination of dexmedetomidine and hypothermia reduces brain injury after transient forebrain ischemia in rats to a greater extent than either treatment alone METHODS Thirty-eight male Sprague-Dawley rats were anesthetized with fentanyl and nitrous oxide in oxygen Four groups were tested: group C (saline 1 ml/kg, temporal muscle temperature 375 degrees C); group H (saline 1 ml/kg, 350 degrees C); group D (dexmedetomidine 100 microg/kg, 375 degrees C); and group DH (dexmedetomidine 100 microg/kg, 350 degrees C) Dexmedetomidine or saline was administered intraperitoneally 30 min before ischemia Cerebral ischemia was produced by right carotid artery ligation with hemorrhagic hypotension (mean arterial pressure 40 mmHg) for 20 min Neurologic outcome was evaluated at 24, 48, and 72 h after ischemia Histopathology was evaluated in the caudate and hippocampus at 72 h after ischemia RESULTS Neurologic outcome was significantly better in the group DH than the group C (P<005), whereas it was similar between the group DH and the groups D or H Survival rate of the hippocampal CA1 neurons was significantly greater in groups D, H, and DH than group C (P<005) Histopathologic injury in the caudate section was significantly less in groups H and DH than group C (P<005) CONCLUSION The combination of dexmedetomidine and hypothermia improved short-term neurologic outcome compared with the control group, whereas the combination therapy provided comparable neuroprotection with either of the two therapies alone

Chronic pain after cardiac surgery: a prospective study

Abstract: Background: Chronic pain is a complication of several surgical procedures. The prevalence of chronic pain reported after cardiac surgery varies from 18% to 61%. However, most studies are retrospective, do not use validated instruments for pain measurement or include only pain at the sternum site. The aim of the present study was to assess chronic pain and health-related quality of life (HRQOL) after cardiac surgery. Methods: In a prospective, population-based study, we included 534 patients (413 males) and assessed chronic pain and HRQOL before, 6 months after, and 12 months after cardiac surgery. Pain was measured by the Brief Pain Inventory, while HRQOL was measured by the Short-Form 36 (SF-36). Results: Five hundred and twenty-one patients were alive 12 months after surgery; 462 (89%) and 465 (89%) responded after 6 and 12 months, respectively. Chronic pain was reported by 11% of the patients at both measurements. Younger age was associated with chronic pain [odds ratio 0.7 (95% confidence interval: 0.5–0.9)] at 12 months. Patients with chronic pain reported lower scores on seven of eight SF-36 subscales. Discussion: In conclusion, we observed a lower prevalence of chronic pain after cardiac surgery than in previous studies. Still, more than one out of 10 patients reported chronic pain after cardiac surgery. Chronic pain appears to affect HRQOL. Thus, given the large number of patients subjected to cardiac surgery, this study confirms that chronic pain after cardiac surgery is an important health care issue.

Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction

Abstract: Background/objective Our aim was to evaluate analgesia, motor block and pharmacokinetics of ropivacaine 0.2% and 0.75% in a femoral nerve block (FNB) in day case patients for anterior crucial ligament (ACL)-reconstruction compared with bupivacaine 0.25% and placebo. Methods Following ethics committee approval and informed consent, 280 patients were randomly allocated to four groups for single-shot FNB [30 ml ropivacaine 0.2% (group RO2.0), 0.75% (RO7.5), bupivacaine 0.25% (BU2.5) and NaCl 0.9% (NaCl)]. Analgesia (pain scores, primary outcome) and motor block were assessed at 4 h (dismissal) and up to 24 h. Plasma concentration was determined up to 240 min thereafter. Results Pain scores at 4 h were significantly higher for NaCl 4 (0-8) (median, range) (vs.) BU2.5 2 (0-8), RO2.0 3 (0-9) and RO7.5 2 (0-8) (NS within the LA groups). Patients of the NaCl group needed analgesics significantly more often (93%) within 4 h after surgery vs. 16% of group RO2.0, 19% of group RO7.5 and 19% of group BU2.5. Motor block was significantly increased with all local anesthetics without a significant difference within the LA groups 3 (0-5) in RO2.0, 3 (0-5) in RO7.5 and 3 (0-4) in BU2.5 vs. 0 (0-3) in group NaCl (median (range); scale from 0=full strength to 5=complete paralysis). Peak plasma concentrations differed significantly: RO7.5: 1.4 +/- 0.4 (0.73-2.6) [microg/ml, mean +/- SD (range)] after 33 +/- 14 (10-40) min, RO2.0: 0.6 +/- 0.3 (0.13-1.0) after 22+17 (10-60) and BU2.5: 0.3 +/- 0.16 (0.05-0.62) at 31 +/- 17 (10-60), respectively. Conclusion FNB for ACL reconstruction with ropivacaine or bupivacaine provided better post-operative analgesia than placebo without reaching toxic plasma concentrations. Significant motor block was observed after 4 h in all groups including the lowest concentration of ropivacaine but occurred even with placebo.

Anaesthesia for endoscopic sinus surgery.

Abstract: Endoscopic sinus surgery is commonly performed and has a low risk of major complications. Intraoperative bleeding impairs surgical conditions and increases the risk of complications. Remifentanil appears to produce better surgical conditions than other opioid analgesics, and total intravenous anaesthesia with propofol may provide superior conditions to a volatile-based technique. Moderate hypotension with intraoperative beta blockade is associated with better operating conditions than when vasodilating agents are used. Tight control of CO(2) does not affect the surgical view. The use of a laryngeal mask may be associated with improved surgical conditions and a smoother emergence. It provides airway protection equivalent to that provided by an endotracheal tube in well-selected patients, but offers less protection from gastric regurgitation. Post-operatively, multimodal oral analgesia provides good pain relief, while long-acting local anaesthetics have been shown not to improve analgesia.

Management of post-partum haemorrhage

Abstract: Management of post-partum haemorrhage (PPH) involves the treatment of uterine atony, evacuation of retained placenta or placental fragments, surgery due to uterine or birth canal trauma, balloon tamponade, effective volume replacement and transfusion therapy, and occasionally, selective arterial embolization. This article aims at introducing pregnancy- and haemorrhage-induced changes in coagulation and fibrinolysis and their relevant compensatory mechanisms, volume replacement therapy, optimal transfusion of blood products, and coagulation factor concentrates, and briefly cell salvage, management of uterine atony, surgical interventions, and selective arterial embolization. Special attention, respective management, and follow-up are required in women with bleeding disorders, such as von Willebrand disease, carriers of haemophilia A or B, and rare coagulation factor deficiencies. We also provide a proposal for practical instructions in the treatment of PPH.

Successful rotational thromboelastometry-guided treatment of traumatic haemorrhage, hyperfibrinolysis and coagulopathy.

Abstract: Transfusion of allogeneic blood products is associated with increased morbidity and mortality. Therefore, strategies for reducing transfusion of these products during trauma management are valuable. We report a case of severe blunt abdominal trauma, successfully treated with antifibrinolytic medication and fibrinogen concentrate. Rotational thromboelastometry (ROTEM) was used to identify hyperfibrinolysis and afibrinogenaemia. In order to achieve haemostasis, over a 3-h period, the patient received a total of 1 g of tranexamic acid, 7 U of packed red blood cells, 16 g of fibrinogen concentrate (Haemocomplettan P), 3500 ml of colloids and 5500 ml of lactated Ringer's solution. Together with surgical measures, this treatment stopped the bleeding and stabilised the patient. There was no transfusion of either fresh-frozen plasma or platelets. The limited need for allogeneic blood products is of particular interest, and clinical studies of the approach used here appear to be warranted.

Depth of anaesthesia and post-operative cognitive dysfunction.

Abstract: Background: A deep level of anaesthesia measured by the bispectral index has been found to improve processing speed as one aspect of cognitive function after surgery. The purpose of the present study was to assess the possible effect of the level of anaesthesia on post-operative cognitive dysfunction (POCD) 1 week after surgery, as assessed by a neuropsychological test battery. Methods: We included 70 patients >60 years of age scheduled for elective non-cardiac surgery with general anaesthesia. The depth of anaesthesia was monitored using the cerebral state monitor, which provided a cerebral state index (CSI) value. Cognitive function was assessed by the ISPOCD neuropsychological test battery before and at 1 week (or hospital discharge) after surgery and POCD was defined as a Z score above 1.96. Results: Five patients were not assessed after surgery. The mean CSI was 40 and 43 in patients with (N=9) and without POCD (N=56), respectively (P=0.41). The cumulated time of both deep anaesthesia (CSI 60) did not differ significantly, and no significant correlation was found between the mean CSI and the Z score. Conclusion: We were unable to detect a significant association between the depth of anaesthesia and the presence of POCD 1 week after the surgery.

New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners.

Abstract: Background: Cardiovascular status is a crucial determinant in the pre-operative assessment of patients for surgery as well as for the handling of patients with acute illness. We hypothesized that focus-assessed transthoracic echocardiography (FATE) could be performed with the subject in the semi-recumbent position. The aim was also to test whether the image quality of Vscan is interchangeable with a conventional high-quality portable echocardiography system. Furthermore, we evaluated the time needed to achieve an interpretable four-chamber view and to complete a full FATE examination. Methods: Sixty-one subjects were included. All subjects were examined in accordance with the FATE protocol in the semi-recumbent position on two different systems: the novel Vscan pocket device and the high-quality portable Vivid i system. Two evaluations were performed. In group A (n=30), the focus was on image quality. In group B (n=31), the focus was on the time consumed. Results: Group A: All patients (100%) had at least one image suitable for interpretation and no significant difference in image quality (P=0.32) was found between the two different systems. Group B: The mean value for the total time consumed for a full FATE was 69.3 s (59.8–78.8) on the Vscan and 63.7s (56.7–70.8) on the Vivid i, with no significant difference among the scanners (P=0.08). Conclusion: The Vscan displays image quality interchangeable with larger and more expensive systems. The apparatus is well suited for performing a FATE examination in a 1-day surgery setting and could very well also be applicable in almost any situation involving patients with acute illness.

A case of fatal caffeine poisoning.

Abstract: Caffeine is a natural alkaloid methylxanthine that is found in various plants such as coffee or tea. Symptoms of a severe overdose may present with hypokalemia, hyponatremia, ventricular arrhythmias, hypertension followed by hypotension, respiratory failure, seizures, rhabdomyolysis, ventricular fibrillation and finally circulatory collapse. A 21-year-old woman called for the ambulance herself soon after the ingestion of about 10,000 mg of caffeine. At the arrival of the ambulance, the patient went into cardiac arrest almost immediately. After a total resuscitation period of 34 min including seven counter-shocks and 2 mg epinephrine, the patient was stable enough to be transferred to the hospital. The patient soon went into VF again and received two more counter-shocks and 1 mg epinephrine and finally an intravenous bolus dose of 300 mg amiodarone. The initial arterial blood gas showed pH at 6.47, lactate at 33 mmol/l and potassium level at 2.3 mmol/l. Unfortunately, no blood samples for caffeine analysis were taken. Three days after hospital admission, the patient developed myoclonus, which did not respond to medical treatment. Excessive intake of caffeine may produce arrhythmias and pronounced hypokalemia and ensuing ventricular fibrillation. In case of counter-shock-resistant VF, it can be necessary to give an early loading dose of amiodarone. Furthermore, it may be beneficial to replace the potassium as early as possible. Epinephrine and buffer solutions used during resuscitation may further decrease blood potassium levels and should be administrated cautiously. Epinephrine can be replaced by other vasopressor drugs, such as vasopressin without effects on beta-receptors.

Time course of rocuronium-induced neuromuscular block after pre-treatment with magnesium sulphate: a randomised study.

Abstract: Background: A previously published study suggested that pre-treatment with magnesium sulphate (MgSO4) had no impact on the speed of onset of rocuronium-induced neuromuscular block. We set out to verify this assumption. Methods: Eighty patients (18–60 years) were randomly allocated to MgSO4 60 mg/kg or placebo (saline). Study drugs were given intravenously for 15 min before induction of anaesthesia with propofol, sufentanil and rocuronium 0.6 mg/kg. Anaesthesia was maintained with a target-controlled propofol infusion. Neuromuscular transmission was measured using train-of-four (TOF)-Watch SX® acceleromyography. Results: Onset was analysed in 37 MgSO4 and 38 saline patients, and recovery in 35 MgSO4 and 37 saline patients. Onset time (to 95% depression of T1) was on average 77 [SD=18] s with MgSO4 and 120 [48] s with saline (P<0.001). The total recovery time (DurTOF0.9) was on average 73.2 [22] min with MgSO4 and 57.8 [14.2] min with saline (P<0.003). The clinical duration (Dur25%) was on average 44.7 [14] min with MgSO4 and 33.2 [8.1] min with saline (P<0.0002). The recovery index (Dur25–75%) was on average 14.0 [6] min with MgSO4 and 11.2 [5.2] min with saline (P<0.02). The recovery time (Dur25%TOF0.9) was on average 28.5 [11.7] min with MgSO4 and 24.7 [8.4] min with saline (P=0.28). Conclusion: Magnesium sulphate given 15 min before propofol anaesthesia reduces the onset time of rocuronium by about 35% and prolongs the total recovery time by about 25%. Trial Registration: Clinicaltrials.gov identifier: NCT00405977.

Functional intravascular volume deficit in patients before surgery

Abstract: Background: Stroke volume (SV) maximization with a colloid infusion, referred to as individualized goal-directed therapy, improves outcome in high-risk surgery. The fraction of patients who need intravascular volume to establish a maximal SV has, however, not been evaluated, and there are only limited data on the volume required to establish a maximal SV before the start of surgery. Therefore, we estimated the occurrence and size of the potential functional intravascular volume deficit in surgical patients. Methods: Patients scheduled for mastectomy (n=20), open radical prostatectomy (n=20), or open major abdominal surgery (n=20) were anaesthetized, and before the start of surgery, a 200 ml colloid fluid challenge was provided and repeated if a ≥10% increment in SV estimated by oesophageal Doppler was established. The volume needed for SV maximization defined the intravascular volume deficit. Results: Forty-two (70%) of the patients needed volume to establish a maximal SV. For the patients needing volume, the required amount was median 200 ml (range 200–600 ml), with no significant difference between the three groups of patients. The required volume was ≥400 ml in nine patients (15%). Conclusion: The majority of anaesthetized patients present with a functional intravascular volume deficit before surgery. Although the deficit in general was minor, a fraction of patients presented with a deficit that may be of clinical relevance, emphasizing the importance of the individual approach of goal-directed fluid therapy.