Intraoperative suggestions to prevent postoperative delirium in patients undergoing transaortic valvular replacement: a randomized placebo-controlled trial.

BACKGROUND: Postoperative delirium (POD) is a serious complication following anaesthesia and surgery and significantly influences postoperative outcome especially in the elderly population. Intraoperative music and positive suggestions influence postoperative outcomes by attenuating analgesic demand and increasing patient satisfaction. AIMS: Here, we examined the effect of intraoperative music and positive suggestions on the development of POD in aged patients undergoing transcatheter aortic valve replacement (TAVR) procedure under general anaesthesia. METHODS: For this randomized placebo-controlled study, eligible patients without cognitive deficit, indicated by a MMSE < 10 points, were anesthetized using remifentanil and sevoflurane. Anaesthetic depth was guide with bispectral index. An audiotape with positive suggestions was applied from a MP3 player via headphones. POD, pain and PONV was assessed. CAM-ICU and Nu-DESC were done twice daily for the first 5 days. RESULTS: Of 140 patients 118 patients could be analysed (57 male, 80.6 ± 5.1 years). POD was diagnosed in 16 patients (12.7%). POD was significantly more often observed in male (12, 21.1%) than in female (4, 6.6%, p = 0.02) and in patients with a low MMSE (23.6 ± 4.5 vs. 26.8 ± 2.8, p = 0.001). Anaesthetic depth did not influence the incidence of POD. Intraoperative music and suggestions did not affect the rate of POD, pain, analgesic requirement or PONV. DISCUSSION: In patients undergoing TAVR male sex and low MMSE scoring are associated with an increase in POD. CONCLUSIONS: Intraoperative music and positive suggestions do not influence the incidence of POD in this patient group. STUDY REGISTRATION: DRKS: 00024444, start of registration: 4.02.202, final registration: 17.09.2021.

Hypnosis measured with monitors of anesthetic depth - EEG changes during the test for Harvard Group Scale of Hypnotic Susceptibility.

Introduction: Hypnotic trance can be defined as a non-ordinary state of consciousness that is accompanied by a number of neurophysiological changes, including brain electrophysiology. In addition to subjective measures, corresponding objective parameters are needed in experimental and clinical hypnosis research but are complex, impractical, or unspecific. A similar challenge exists for the measurement and monitoring of drug-induced hypnosis, namely general anesthesia. The observation of changes in EEG induced by narcotics has led to the development of monitors for the depth of anesthesia based on EEG parameters. We investigated whether two such monitors react to the induction and maintenance of hypnosis during a highly standardized procedure. Methods: A total of 56 volunteers were monitored for the bispectral index (BIS) and cerebral state index (CSI) (range 0-100, >95 considered "awake") during the Harvard Group Scale of Hypnotic Susceptibility test. For this test, trance is induced by a taped text and followed by 12 tasks performed under hypnosis. In contrast to random forms of hypnosis, this represents a standardized, worldwide-established condition. According to the resulting score, participants were classified into suggestibility groups in order to evaluate whether the electrophysiological measurements of BIS and CIS indices differ between high and low suggestible persons. Furthermore, participants were asked to rate their hypnotic depth (HD, 1-10) at every task of the test. Results: Scores dropped significantly from a mean of 97.7 to 86.4 for BIS and from 94.6 to 77.7 for CSI with the induction of hypnosis to stay throughout hypnosis at levels of approximately 88.6 or 82.9, respectively. Results did not differ between high- and low-suggestible participants. The means of the subjective score of hypnotic depth and of the electrophysiological measurements showed a similar course. However, no correlation was found between BIS or CSI values and scores of hypnotic depths. Conclusion: Monitors for depth of anesthesia respond to changes in consciousness, including trance states of hypnosis. However, specificity is unclear. Practically, in hypnosis research with the exclusion of drug effects or sleep, these monitors might be helpful to test and compare the efficacy of induction texts and to detect disturbances of trance state.

[Anaesthesia and Perioperative Management for Patients with Parkinson's Disease]. / Anästhesie und perioperative Betreuung bei Patienten mit Morbus Parkinson.

Idiopathic Parkinson's syndrome is associated with the loss of dopaminergic cells. It is defined by the presence of akinesia together with one of the cardinal symptoms: rigor, tremor, or postural instability. As the perioperative management of these patients can be challenging and they have an increased perioperative risk, every anaesthesiologist should know some special features. If a patient with Parkinson's disease does not receive the required amount of dopa, akinetic crisis may occur. Moreover, the administration of dopamine-antagonistic drugs can trigger a malignant neuroleptic syndrome. These are life-threatening clinical pictures that require intensive medical treatment. Therefore, patients with Parkinson's disease should be enabled to keep the period without the intake of the specific medication as short as possible. General anaesthesia should be performed with short acting anaesthetics and a regional anaesthesia might be beneficial. Besides, all dopamine antagonists sometimes used for prophylaxis or therapy of delirium or PONV (haloperidol, metoclopramide) are contraindicated. Alternatives are short-acting benzodiazepines, atypical neuroleptics and domperidone.

Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients - A Post hoc Analysis of a Randomized Controlled Trial.

Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3-4) and distinguished early (first two postoperative hours) and delayed PONV (2-24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7-18.3 and 29.9-24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1-4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects. Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.

Avoidance of nocebo effects by coincident naming of treatment benefits during the medical interview for informed consent-Evidence from dynamometry.

Introduction: In the context of giving risk information for obtaining informed consent, it is not easy to comply with the ethical principle of "primum nihil nocere." Carelessness, ignorance of nocebo effects and a misunderstood striving for legal certainty can lead doctors to comprehensive and brutal risk information. It is known that talking about risks and side effects can even trigger those and result in distress and nonadherence to medication or therapy. Methods: Recently, we have reported on significant clinically relevant effects of verbal and non-verbal suggestions on maximal muscular arm strength in healthy volunteers and in patients at two time points before surgery. Maximal strength during arm abduction was measured by dynamometry of the deltoid muscle group. Suggestions from clinical everyday life were formulated as presumed negative and neutral versions. Results: Here, we report on the effects of two versions of risk information in 45 patients. After sole mentioning risks of a puncture for the placement of a pain catheter, the maximal arm muscle strength was significantly reduced to 83% of baseline several days (T1), and to 84% the evening before surgery (T2). Strength was not significantly decreased and close to baseline at T1 and T2 when risks and benefits of a pain catheter were combined in one sentence. The difference between both versions was significant. With persistent normal distribution of values, the effect was due to uniform reactions of many patients, not to strong reactions of a few. High suggestibility and increase of anxiety with approaching surgery were identified as influencing factors for the neutralizing effect of modified wording. Conclusion: We not only suggest an alternative formulation for risk information to avoid nocebo effects but present an objective method to quantify and compare effects of different wordings. Thereby, we provide evidence that concurrently given positive aspects can neutralize negative effects during medical interview.

Nocebo Effects of Clinical Communication and Placebo Effects of Positive Suggestions on Respiratory Muscle Strength.

Introduction: The effects of specific suggestions are usually studied by measuring parameters that are directly addressed by these suggestions. We recently proposed the use of a uniform, unrelated, and objective measure like maximal muscle strength that allows comparison of suggestions to avoid nocebo effects and thus to improve communication. Since reduced breathing strength might impair respiration and increase the risk of post-operative pulmonary complications, the aim of the present study was to evaluate the effects of the suggestions on respiratory muscle power. Both the identification and neutralization of negative suggestions in the clinical context and stimulating suggestions could improve breathing force, a predictor of physical fitness and convalescence. Methods: In 50 healthy, adult volunteers, respiratory muscle strength was measured by maximal inspiratory and expiratory pressures, as well as by maximal inspiratory and expiratory flows. Baseline was compared to values after application of eleven suggestions, five out of clinical context, including memory of negative or positive past, risk information for informed consent, and a non-verbal suggestion. Six stimulating suggestions included self-affirmation, empowering words, a heroic mirror image, and an imagination. Results: All suggestions showed an impact on respiratory muscle strength, indicating placebo and nocebo effects. No single parameter could represent the breathing force in its complexity, however, trends and different specific aspects of it were measured. The strongest reaction was observed with the recall of a previous negative situation resulting in a reduction in expiratory flow to 96.1% of baseline (p = 0.041). After risk information, a decrease was observed in three of the parameters, with the highest extend in expiratory pressure by 4.4%. This nocebo effect was neutralized by adding positive aspects to the risk information. Every intended strengthening suggestion resulted in statistically significant increases of at least one parameter, with changes of up to 10% (e.g., MEP 110.3%, p = 0.001), indicating placebo effects. Here, expiration was more affected than inspiration. Sex was the only influencing factor reaching statistical significance, with stronger reactions in women. Conclusion: Respiratory muscle strength proved to be sensitive to suggestions with clinical context, as well as suggestions intended for stimulation. With this objective measurement, evaluation, and comparison of different suggestions is possible to help avoid nocebo effects. The demonstrated effect of supporting suggestions can be followed up and used in clinical practice.

Neurocognitive Impairment After Propofol With Relevance for Neurosurgical Patients and Awake Craniotomies-A Prospective Observational Study.

Background: Short-acting anesthetics are used for rapid recovery, especially for neurological testing during awake craniotomy. Extent and duration of neurocognitive impairment are ambiguous. Methods: Prospective evaluation of patients undergoing craniotomy for tumor resection during general anesthesia with propofol (N of craniotomies = 35). Lexical word fluency, digit span and trail making were tested preoperatively and up to 24 h after extubation. Results were stratified for age, tumor localization and hemisphere of surgery. Results in digit span test were compared to 21 patients during awake craniotomies. Results: Word fluency was reduced to 30, 33, 47, and 87% of preoperative values 10, 30, 60 min and 24 h after extubation, respectively. Digit span was decreased to 41, 47, 55, and 86%. Performances were still significantly impaired 24 h after extubation, especially in elderly. Results of digit span test were not worse in patients with left hemisphere surgery. Significance of difference to baseline remained, when patients with left or frontal lesions, i.e., brain areas essential for these tests, were excluded from analysis. Time for trail making was increased by 87% at 1 h after extubation, and recovered within 24 h. In 21 patients undergoing awake craniotomies without pharmacological sedation, digit span was unaffected during intraoperative testing. Conclusion: Selected aspects of higher cognitive functions are compromised for up to 24 h after propofol anesthesia for craniotomy. Propofol and the direct effects of surgical resection on brain networks may be two major factors contributing (possibly jointly) to the observed deficits. Neurocognitive testing was unimpaired in patients undergoing awake craniotomies without sedation.

German Norms of the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A) and Proposal of a 5-Item Short-Version (HGSHS-5:G).

The Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A), is commonly used to test hypnotizability. There is still some controversy about what exactly hypnotizability is and whether and how it can be measured, especially by the HGSHS:A. Furthermore, a wider clinical use is limited, requiring a testing time of more than 1 hour. We analyzed the German HGSHS:A version for its factorial structure, item contribution, and item difficulty based on test data from six studies, including 1276 persons, to propose a shorter version of the HGSHS:A. We hereby present a 5-item version of the HGSHS:A (HGSHS-5:G), consisting of the challenge items, that was compared with an 11-item version (highly variable posthypnotic amnesia omitted). Age- and gender-specific norms was generated. The HGSHS-5: G showed high validity, reliability, and classification agreement. It reduces test time to 30 minutes thus facilitating wider use of hypnotizability testing.

Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: multicentre randomised controlled trial.

OBJECTIVE: To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. DESIGN: Blinded randomised controlled study. SETTING: Five tertiary care hospitals in Germany. PARTICIPANTS: 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. INTERVENTION: The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. MAIN OUTCOME MEASURES: The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). RESULTS: Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. CONCLUSIONS: Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. TRIAL REGISTRATION: German Clinical Trial Register DRKS00013800.

Time-Dependent Negative Effects of Verbal and Non-verbal Suggestions in Surgical Patients-A Study on Arm Muscle Strength.

INTRODUCTION: The medical environment is full of suggestions that affect patients and their healing. Most of them inadvertently are negative, thus evoking nocebo effects. Recently, we have reported on the effect of such verbal and non-verbal suggestions as well as alternative formulations on maximal muscular arm strength in healthy volunteers. In the present study, we tested the same suggestions in patients at two time points to evaluate nocebo effects in a clinical situation and the impact of the approaching surgery date. METHODS: In 45 patients, maximal muscular strength during arm abduction was measured by dynamometry of the deltoid muscle group. One test was several days before and the second on the evening before surgery. Baseline values were compared to the performance after exposure to 18 verbal and non-verbal suggestions. The sequence of presumably negative and positive suggestions was randomized for each patient in order to avoid cumulation effects of immediate succession of two negatives. State anxiety was evaluated at both time points, and suggestibility was measured after surgery. RESULTS: Strong and statistically significant weakening effects were observed with all presumed negative suggestions from daily clinical practice including words of encouragement (91.4% of baseline), evaluation of symptoms (89.0%), announcement of a medical intervention (82.8%), a negative memory (86.5%), expectation of an uncertain future (82.8%), and non-verbal signals (87.7-92.2%). In contrast, alternative formulations did not interfere with muscular performance in most cases. A more pronounced effect was observed in the test repeated closer to the date of surgery, accompanied by a 15% higher anxiety level. The increase in anxiety correlated slightly with stronger weakening effects of suggestions, as did suggestibility. CONCLUSIONS: Negative suggestions cause a decrease in arm muscle strength, i.e., a "weakening" of the patient. This effect is enhanced by an increase in anxiety as the time of treatment, like surgery, approaches. The reaction can be avoided by alternative formulations. These nocebo effects that are objectively measured and quantified by a decrease in arm muscle strength are more pronounced in patients, i.e., in a clinical situation, than in healthy volunteers.

Impact of bedside percutaneous dilational and open surgical tracheostomy on intracranial pressure, pulmonary gas exchange, and hemodynamics in neurocritical care patients.

Aim was to compare the impact of bedside percutaneous dilational tracheostomy (PDT) and open surgical technique (ST) on intracranial pressure (ICP), pulmonary gas exchange and hemodynamics.We retrospectively analyzed data of 92 neurocritical care patients with invasive ICP monitoring during either PDT (43 patients) or ST (49 patients).Peak ICP levels were higher during PDT (22 [17-38] mm Hg vs 19 [13-27] mm Hg, P = .029). Mean oxygen saturation (SpO2) and end-tidal carbon dioxide partial pressure (etCO2) did not differ. Episodes with relevant desaturation (SpO2 < 90%) or hypercapnia (etCO2 > 50 mm Hg) occurred rarely (5/49 during ST vs 3/43 during PDT for SpO2 < 90%; 2/49 during ST vs 5/43 during PDT for hypercapnia). Drops in mean arterial pressure (MAP) below 60 mm Hg were seen more often during PDT (8/43 vs 2/49, P = .026). Mean infusion rate of norepinephrine did not differ (0.52 mg/h during ST vs 0.45 mg/h during PDT). No fatal complications were observed.Tracheostomy can be performed as ST and PDT safely in neurocritical care patients. The impact on ICP, pulmonary gas exchange and hemodynamics remains within an unproblematic range.

Nocebo Effects and Negative Suggestions in Daily Clinical Practice - Forms, Impact and Approaches to Avoid Them.

Medical situations are hot spots in the life of a patient with potentially long lasting effects arising from the use of either negative expressions or encouraging statements, or the lack of empathy or a positive physician-patient relationship. Health care personnel should be aware of and evaluate what patients are exposed to, hear and see. Knowing more about the effects of nocebos and negative suggestions, combined with increased attention to these matters, provides the basis for better recognition of detrimental influences in their own clinical environment and to be able to avoid, stop or neutralize them. After anamnesis patients should not be left with a focus on a negative past, but shifted to positive experiences prior to their illness, or to positive expectations in the future following surgery and rehabilitation. For example, after examining an injured leg the doctor should not turn to the computer for documentation unless he has shifted the patient's focus on the other, unimpaired leg. "Is that painful too? No? Good! Can you feel that? Yes? Perfect! Can you bend that knee, move these toes? Great! That's good." This example draws attention to the fact that negative effects (discussed in the following) substantially are dependent on the focus of the patient and thus can be affected by focus shift and distraction. Patients, their symptoms and their healing are negatively affected by the omission of placebo effects, by nocebo effects and by negative suggestions.

Nocebo Effects on Muscular Performance - An Experimental Study About Clinical Situations.

Introduction: Nocebo effects are not only seen in studies of pharmacology and placebo/nocebo research but also in clinical everyday situations. For generation of objective and quantitative data on the impact of negative communication we have evaluated the immediate effects of common sentences, non-verbal signals and situations in the medical context on muscular performance. Methods: In an experimental study, 46 volunteers were tested by dynamometry of the deltoid muscle group to evaluate the maximal muscular strength during arm abduction. Baseline values were compared to performance after exposure to 18 verbal and non-verbal suggestions. Suggestions suspected to be negative were alternated with and compared to positively formulated alternatives. Results: Verbal and non-verbal communication produced significant effects on muscular performance, resulting mainly in weakening. The decrease in muscle strength after risk information for informed consent (91.4% of baseline) was absent, when benefits of the treatment were named coincidently. The weakening effect of asking about "pain" and "nausea" (89.4%), and of the announcement of medical interventions (91.7%) could be avoided with alternative wording. Impairment of muscular performance was also observed with the nocebo-inducers negative memory (89.5%) or uncertain future (93.3%), in contrast to a positive memory or the orientation into the presence. Non-verbal suggestions like overhead anesthesia induction (89.9%), a transport in strict flat supine position (89.1%), or a view from the window to a parking lot (94.1%) significantly reduced maximal muscle strength, whereas face-to face induction, half-sitting position and a view into the landscape did not. 8 out of 9 tested clinical situations reduced maximal arm muscle strength significantly, whereas alternative formulations did not. Conclusion: This study describes a quick, simple and uniform test using objective measurement of maximal muscle strength to allow for identification, quantification, and comparison of negative suggestions, regardless of their specific content and effect. Muscle strength is a clinically relevant parameter with regard to early mobilization, risk of falling and sufficient breathing. Furthermore, the observed impairment of muscular performance could reflect a general "weakening effect" of negative suggestions. In addition, the test facilitates development and verification of appropriate alternatives to prevent nocebo effects in patients, thereby improving patient communication.

Deep Brain Stimulation Surgery without Sedation.

BACKGROUND: Sedatives and opioids used during deep brain stimulation (DBS) surgery interfere with optimal target localization and add to side effects and risks, and thus should be minimized. OBJECTIVE: To retrospectively test the actual need for sedatives and opioids when cranial nerve blocks and specific therapeutic communication are applied. METHODS: In a case series, 64 consecutive patients treated with a strong rapport, constant contact, non-verbal communication and hypnotic suggestions, such as dissociation to a "safe place," reframing of disturbing noises and self-confirmation, were compared to 22 preceding patients under standard general anaesthesia or conscious sedation. RESULTS: With introduction of the protocol the need for sedation dropped from 100% in the control group to 5%, and from a mean dose of 444 mg to 40 mg in 3 patients. Remifentanil originally used in 100% of the patients in an average dose of 813 µg was reduced in the study group to 104 µg in 31% of patients. There were no haemodynamic reactions indicative of stress during incision, trepanation, electrode insertion and closure. CONCLUSION: With adequate therapeutic communication, patients do not require sedation and no or only low-dose opioid treatment during DBS surgery, leaving patients fully awake and competent during surgery and testing.

Complications after transcatheter aortic valve implantation using transfemoral and transapical approach in general anaesthesia.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat degenerative heart valve disease. The implantation requires a highly specific and interdisciplinary management approach. Currently, TAVI is performed with the patient under local or general anaesthesia. METHODS: This study was a retrospective analysis of all TAVI procedures performed at the University Hospital of Regensburg between January 2009 and July 2015. All pre-, intra and postoperative data focusing on perioperative complications were recorded. RESULTS: A total of 853 transfemoral- and transapical-TAVI patients were included in the study. All patients underwent general anaesthesia. The ASA classifications were primarily 3-4. The average logistic EuroScores for the transfemoral- and transapical-TAVI patients were 18 ± 12% and 21 ± 15% (p = 0.002), respectively. The anaesthesia coverage time was 170 ± 49 min., including 37 ± 12 minutes for anaesthetic management. Overall, 458 complications were recorded; with pneumonia, acute renal failure, indication for a permanent pacemaker and non-extubation in the operating theatre the most frequently recorded complications. CONCLUSION: In the present study, we showed that our patients' outcomes are comparable to those reported in the available literature. Compared to TF, TA patients show an overall worse physical condition as well as a higher perioperative morbidity and mortality. Consequently TA patients need additional care and should only be operated in appropriately experienced medical centres.

Platelet sequestration with a new-generation autotransfusion device.

BACKGROUND: Autologous platelet-rich plasma (PRP) can be used either to prevent platelets (PLTs) from lesions during extracorporeal circulation or for wound therapy, when processed into PLT gel. The aim of this study was to evaluate the PLT sequestration abilities of a new-generation autotransfusion device. STUDY DESIGN AND METHODS: In this experimental study the discontinuous, new-generation autotransfusion device XTRA was evaluated using fresh donor blood. The blood was processed in four different size bowls (X55, X125, X175, X225 [bowls' size in mL]) using the device's built-in "PLT sequestration program." PLT functionality was tested using aggregometry; for PLT activation, ß-thromboglobulin (ß-TG) and soluble P-selectin levels were determined. Cell damage was assessed by a morphology score and hypotonic shock response. Additionally, PLTs were tested after 6 hours to identify storage lesions. RESULTS: Platelet recovery in the PRP ranged from 39% to 64% and averaged 6.2-fold PLT enrichment as defined by the increase in PLT concentration. The preparation caused minimal cell damage and a decrease in cell function by only 10%, but a slight activation was observed amounting to 9% of the maximal ß-TG release. The efficiency of the preparation, represented by the PLT recovery rate, increased in a linear fashion with the increasing bowl sizes being tested. After 6 hours of storage the prepared PLTs showed an additional 9% loss in function, but only 4% decrease in viability. CONCLUSION: The autotransfusion device XTRA was capable of high-quality perioperative PRP preparation, and the bowl size was found to have an influence on the efficiency of the preparation.

Efficacy of therapeutic suggestions under general anesthesia: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: General anesthesia does not block central nervous processing of auditive information. Therefore, positive suggestions even given during surgery might have the potential to encourage well-being and recovery of patients. Aim of this review was to summarize the evidence on the efficacy of therapeutic suggestions under general anesthesia in adults undergoing surgery compared to an attention control (i.e. white noise). METHODS: We included randomized controlled trials that investigated therapeutic suggestions presented during general anesthesia to adult patients undergoing surgery or medical procedures. Outcomes on pain intensity, mental distress, recovery, use of medication, measured postoperatively within hospitalization were considered. Electronic searches were carried out in the following databases (last search February 23, 2015): MEDLINE, CENTRAL, Web of Science, PsycINFO, ProQuest Dissertations and Theses. RESULTS: Thirty-two eligible randomized controlled trials were included, comprising a total of 2102 patients. All studies used taped suggestions. Random effects meta-analyses revealed no effects on pain intensity (Hedges' g = 0.04, CI 95% [-0.04; 0.12], number needed to treat [NNT] = 44.3) and mental distress (g = 0.03, CI 95% [-0.11; 0.16], NNT = 68.2). In contrast, we found small but significant positive effects on use of medication (g = 0.19, CI 95% [0.09; 0.29], NNT = 9.2) and on recovery (g = 0.14, CI 95% [0.03; 0.25], NNT = 13.0). All effects were homogeneous and robust. CONCLUSIONS: Even though effects were small, our results provide indications that intraoperative suggestions can have the potential to reduce the need for medication and enhance recovery. Further high quality trials are needed to strengthen the promising evidence on the efficacy of therapeutic suggestions under general anesthesia for patients undergoing surgery.

Fat removal during cell salvage: an optimized program for a discontinuous autotransfusion device.

BACKGROUND: Fat in wound blood observed in orthopedic or cardiac surgery might pose a risk for fat embolism during blood salvage. Fat removal was optimized in the washing process. STUDY DESIGN AND METHODS: In an experimental study blood from fresh donations was adjusted to a hematocrit (Hct) of 25% and an admixture of 1.25% human tissue fat. This blood was processed with the cell salvage device XTRA in a modified program mode. Volumetric quantification of fat was performed after centrifugation of blood samples in Pasteur pipettes. From the volumes, the Hct levels and the concentrations of fat and other variables elimination rates and RBC recovery were calculated. RESULTS: Pretests showed wash volume, wash flow, and process interruptions affecting fat elimination. With the new optimized fat elimination program Pfat removal rate of fat increased to 98.5 ± 0.9% for the 225-mL bowl. The product had a mean Hct of 48.7 ± 1.2% and a RBC recovery rate of 93.5 ± 2.3%. The program conserved the high elimination rates for albumin, heparin, potassium, and free plasma hemoglobin (98.8, 99.3, 95.3, and 94.9%, respectively). Similar high fat removal was also observed with bowls of smaller size, namely, 98.1% for the 175-mL bowl and 98.2% for the 125- and the 55-mL bowls. With test blood of Hct 10% a mean fat elimination of 99.6 ± 01% was observed. CONCLUSIONS: A special program modification Pfat involving extra washing and RBC concentration steps significantly improves fat removal by the Latham bowl-based autotransfusion device XTRA, thus yielding results equivalent to the continuous cell salvage system.

[The premedication visit--suggestions for a patient-friendly design]. / Das Prämedikationsgespräch--Anregungen zu einer patientenfreundlichen Gestaltung.

The premedication visit is often a difficult situation for the anaesthetist. On the one hand the patient needs to be informed in detail, but on the other he must not be alienated unnecessarily. Furthermore, a hospital stay represents an exceptional situation for the patient in which he behaves differently than in everyday life and shows a limited ability to process information. Following certain communication strategies allows to convey information to the patient in a comprehensible manner and to describe his individual anaesthesiological risk without needlessly creating fear.