The long-term survival outcomes of gastric cancer patients with total intravenous anesthesia or inhalation anesthesia: a single-center retrospective cohort study.

BACKGROUND: The relationship between the type of anesthesia and the survival outcomes of gastric cancer patients is uncertain. This study compared the overall outcome of gastric cancer patients after surgery with total intravenous anesthesia (TIVA) or inhalation anesthesia (IHA). METHODS: Clinicopathological variables of gastric cancer patients were retrieved from the database of the Surgical Gastric Cancer Patient Registry in West China Hospital, Sichuan University. Patients were grouped according to whether they received TIVA or IHA during the operation. Propensity score (PS) matching was used to balance the baseline variables, and survival outcomes were compared between these two groups. In addition, studies comparing survival outcomes between TIVA and IHA used for gastric cancer surgery and published before April 20th, 2020, were identified, and their data were pooled. RESULTS: A total of 2827 patients who underwent surgical treatment from Jan 2009 to Dec 2016 were included. There were 323 patients in the TIVA group and 645 patients in the IHA group, with 1:2 PS matching. There was no significant difference in overall survival outcomes between the TIVA and IHA groups before matching the cohort (p = 0.566) or after matching the cohort (p = 0.679) by log-rank tests. In the Cox hazard regression model, there was no significant difference between the TIVA and IHA groups before (HR: 1.054, 95% CI: 0.881-1.262, p = 0.566) or after (HR: 0.957, 95% CI: 0.779-1.177, p = 0.679) PS matching. The meta-analysis of survival outcomes between the TIVA and IHA groups found critical statistical value in the before PS matching cohort (HR 0.74, 95% CI: 0.57-0.96 p < 0.01) and after PS matching cohort (HR: 0.65, 95% CI: 0.46-0.94, p < 0.01). CONCLUSIONS: Combined with the results of previous studies, total intravenous anesthesia has been shown to be superior to inhalation anesthesia in terms of overall survival for gastric cancer patients undergoing surgical treatment. The selection of intravenous or inhalation anesthesia for gastric cancer surgery should take into account the long-term prognosis of the patient.

Deep Sedation with Intravenous Anesthesia Is Associated with Outcome in Patients Undergoing Cryoablation for Paroxysmal Atrial Fibrillation.

Whether deep sedation with intravenous anesthesia will affect the recurrence after cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (AF) is yet to be examined. Thus, in this study, we hypothesize that there is difference in terms of the recurrence between local anesthesia and deep sedation with intravenous anesthesia after an index ablation procedure.In total, 109 patients were enrolled and received CBA, of which 68 (58.2 years) patients underwent pulmonary vein (PV) isolation with a local anesthesia (group 1) and 41 patients (63.2 years) underwent PV isolation with deep sedation using intravenous anesthesia (group 2).During the index procedure, isolation of all major PVs was achieved in 66 patients in group 1 and in 41 patients in group 2. There was no difference in non-PV triggers between the two groups. The periprocedural complication was found to be similar between the two groups (2.9% in group 1 and 4.9% in group 2). Further, 17 patients in group 1 and 4 patients in group 2 experienced recurrences after a follow-up of 19.3 months (P = 0.019). Repeat procedures revealed similar PV reconnection rates between the two groups. It has also been noted that the number of reconnected PV and incidence of atypical flutter seem to increase in group 1.Deep sedation with intravenous anesthesia during CBA for paroxysmal AF is safe and had a better long-term outcome than those with local anesthesia.

Anaesthetic management for robotic-assisted laparoscopic prostatectomy: the first UK national survey of current practice.

Robotic-assisted laparoscopic prostatectomy (RALP) is the most common robotic surgical procedure, but there are little published data to inform anaesthetic practice. We aimed to characterise the range of anaesthetic practice for RALP in the United Kingdom through a national survey. We conducted an online national survey to determine current anaesthetic practice for RALP. The survey was distributed to all NHS hospitals within the UK that perform RALP. Thirty-four (79%) of 43 hospitals responded to the survey. Fourteen (41%) centres routinely provide spinal anaesthesia and 79% of these use diamorphine as their intrathecal opioid of choice. Thirty-one (91%) centres administer intravenous strong opioids intraoperatively, and a wide range of non-opioid analgesic agents are also administered. Five (15%) centres reported that they discharge a minority of patients on the day of surgery. High-volume centres are more likely to have a formalised enhanced recovery after surgery (ERAS) pathway and to provide ambulatory surgery for selected patients. This represents the first UK national survey of anaesthetic practice for RALP. The results of the survey revealed significant variation in anaesthetic practice implying a lack of consensus on best perioperative management.

mu-Opioid Receptor Polymorphisms and Breast Cancer Recurrence in Adult Korean Women Undergoing Breast Cancer Surgery: A Retrospective Study.

Background: Genetic variations of mu-opioid receptors are well known to contribute to growth and progression of tumors. The most common single-nucleotide polymorphism (SNP) in the mu-opioid receptor 1 gene (OPRM1) is the A118G mutation. We examined the association between the recurrent breast cancer and genotypes of OPRM1 A118G SNP (AA vs. AG vs. GG) in Korean women population. Methods: We analysed medical records and genetic data of 200 patients aged more than 20 who underwent primary breast cancer surgery from June 2012 to June 2014 and diagnosed recurrent breast cancer from June 2012 to September 2019. Results: The incidence of recurrent breast cancer was 6.1%, 8.2%, and 4.8% in genotype AA, AG and GG, respectively (p=0.780). The incidence of recurrent breast cancer in volatile anaesthesia group was 7.0% and 7.1% in total intravenous anaesthesia (TIVA) group (RR = 0.984, 95% CI = 0.328 - 2.951; p = 0.978). Conclusion: OPRM1 A118G SNP had no influence on breast cancer recurrence in Korean women. Anaesthesia technique did not show significant effect on the incidence of recurrent breast cancer.

Anaesthetic technique and outcomes after colorectal cancer surgery.

INTRODUCTION: Previous studies have suggested that choice of anaesthesia can affect long-term outcome. In this study, the association between type of anaesthesia and outcomes in terms of survival, recurrence, post-operative complications and recovery after surgery for colorectal cancer was investigated in an Enhanced Recovery after Surgery (ERAS) setting. METHODS: This was a retrospective study including patients undergoing elective curative-intended surgery for colorectal cancer between April 2013 and May 2015 at Zealand University Hospital, Denmark. Patients were stratified by anaesthetic technique. The primary outcome was cancer recurrence. Cox regression analyses were used for time-to-event variables; recurrence, disease-free survival, mortality, length of hospitalisation and time to bowel movement. Odds ratios for post-operative complications and time to discharge were estimated using logistic regression. RESULTS: A total of 534 patients were included, 51 were exposed to inhalational anaesthesia and 483 had total intravenous anaesthesia. We found no statistically significant difference in recurrence (hazard ratio (HR) = 0.70; 95% confidence interval (CI): 0.21-1.68; p = 0.421). Patients in the inhalational aneasthesia group had a significantly lower chance of discharge per post-operative day (HR = 0.66; 95% CI: 0.48-0.91; p = 0.012). The same was seen for time to bowel movement (HR = 0.65; 95% CI: 0.46-0.90; p = 0.011). No statistically significant differences were seen for the other outcomes. CONCLUSION: Anaesthetic technique might influence time to discharge and bowel function in an ERAS setting. FUNDING: none TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (record number 2008-58-0020). Under Danish law, consent from participants is not required in observational studies.

Total intravenous versus inhalational anesthesia in endoscopic sinus surgery: A meta-analysis.

OBJECTIVE: Achieving optimal intraoperative surgical field visibility and minimizing blood loss are two important parameters in endoscopic sinus surgery (ESS). The aim of this meta-analysis was to compare two total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) to determine if either conferred superior outcomes of these and other parameters based on randomized control trials (RCTs) only. METHODS: The recommended Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed, and searches of electronic databases from inception to September 2018 identified 157 articles for screening. Data were extracted and analyzed using meta-analysis of proportions. RESULTS: In total, we identified 15 RCTs that satisfied our selection criteria. There were 828 ESS cases described, with 391 (47%) and 437 (53%) being managed by TIVA and IA, respectively. Pooled analysis demonstrated significantly superior visibility scores for TIVA compared to IA based on 10-point grading scores (P = 0.049, visual analog scale; P = 0.009, Wormald scale) and 5-point grading scores (P = 0.002, Boezaart scale). Blood loss was significantly less following TIVA (P = 0.003), with no significant difference in intraoperative heart rate (P = 0.70) or mean arterial pressure (P = 0.96). Additionally, duration of surgery (P = 0.16) and anesthesia (P = 0.39) were comparable between the two approaches. CONCLUSION: This meta-analysis indicates that TIVA has the potential to confer superior surgical field visibility and reduce intraoperative blood loss compared to IA in ESS. Currently, there are significant heterogeneity concerns in this meta-analysis, which temper any expectations that either approach is absolutely superior to the other. Caution should be exercised when interpreting these results until further validation can be achieved. LEVEL OF EVIDENCE: 1A Laryngoscope, 130:575-583, 2020.

Surgical Treatment of Distal Radius Fractures under the Ultrasound-Guided Brachial Plexus Block Performed by Surgeons.

Background: The upper limb surgery under the ultrasound-guided brachial plexus block is becoming popular due to its safety, effectiveness, and convenience. However, the uneven distribution of anesthesiologists become a social problem. Ultrasound-guided brachial plexus block by surgeons has been widespread especially in hand surgeons. We report the surgical treatment of distal radius fractures under the ultrasound-guided brachial plexus block performed by surgeons in our hospital. Methods: The subjects were 101 patients (41 males and 60 females, average age 61.6 years) who underwent surgery for distal radius fractures under ultrasound-guided brachial plexus block administered by orthopedists at our university or related facilities between January 2014 and June 2016. Brachial plexus block was administered through the supraclavicular approach. The time from initiation of anesthesia to initiation of surgery, mean operative time, the presence or absence of additional anesthesia (local infiltration anesthesia, intravenous anesthesia, and general anesthesia), and complications were evaluated. Results: The mean time from brachial plexus block to initiation of surgery was 35.7 (20-68) minutes, and the mean operative time was 90.5 (35-217) minutes. Surgery was completed with brachial plexus block alone in 62 patients (61.4%), and additional anesthesia was necessary in 39 patients (38.6%). Furthermore, general anesthesia was employed in 6 patients (5.9%). No serious complications occurred. Conclusions: According to our results, the operation could be completed with brachial plexus block alone and additional local infiltration anesthesia or intravenous anesthesia in 94.1% (95 cases). However, 6 cases (5.9%) shifted to general anesthesia. Although it needs training, we consider that hand surgery including distal radius fractures treatment under the ultrasound-guided brachial plexus block is possible. On the other hand, cooperation or a cooperative system with anesthesiologists is necessary for surgeons to administer this anesthesia.

A follow-up survey of total intravenous anesthesia usage in children in the U.K. and Ireland.

BACKGROUND: Total intravenous anesthesia usage in children remains relatively unpopular in the UK and Ireland. A postal survey by Hill et al in 2008 indicated that only 26% of Consultants used a propofol infusion at least once a month. AIMS: Following an increase in teaching and training opportunities in pediatric total intravenous anesthesia in the UK, we repeated the survey among Consultant members of Association of Paediatric Anaesthetists of Great Britain and Ireland and Society for Intravenous Anaesthesia, to see if this had affected total intravenous anesthesia usage in children and how practice may have changed. METHODS: We used an anonymous online survey sent to Association of Paediatric Anaesthetists of Great Britain and Ireland and Society for Intravenous Anaesthesia members. RESULTS: A total of 291 responses were analyzed. Total intravenous anesthesia was the default method of anesthesia in 8% of respondents and a further 46% used total intravenous anesthesia at least monthly. Overall total intravenous anesthesia usage had increased in the past year in 53%. The main indications were malignant hyperthermia susceptibility, and postoperative nausea and vomiting. Ear/nose/throat surgery was the most popular surgical specialty. The main reasons for not using total intravenous anesthesia were that it was too "fiddly" and lack of confidence in the user. Most respondents used propofol in combination with remifentanil. Over 80% used propofol target-controlled infusion. The potential for propofol-related infusion syndrome concerned many, with 74% limiting infusion duration as a result. Bispectral Index was not used routinely by the majority of anesthetists. Even though most anesthetists did not use total intravenous anesthesia routinely, 98% felt they would be confident to anesthetize an malignant hyperpyrexia-positive patient using the technique. CONCLUSION: This survey has shown that although total intravenous anesthesia is not the default anesthetic technique for most anesthetists, overall usage in children has more than doubled in the past 10 years, with many happy to use it in a wide variety of patients and procedures.

Total Intravenous Anesthesia versus Inhalation Anesthesia for Breast Cancer Surgery: A Retrospective Cohort Study.

BACKGROUND: The association between type of anesthesia used and recurrence of cancer remains controversial. This retrospective cohort study compared the influence of total IV anesthesia and inhalation anesthesia on the primary outcome of recurrence-free survival after breast cancer surgery. METHODS: The authors reviewed the electronic medical records of patients who had breast cancer surgery at a tertiary care teaching hospital between January 2005 and December 2013. The patients were grouped according to whether IV or inhalation anesthesia was used for surgery. Propensity score matching was used to account for differences in baseline characteristics. Kaplan-Meier survival curves were constructed to evaluate the influence of type of anesthesia on recurrence-free survival and overall survival. The risks of cancer recurrence and all-cause mortality were compared between each type of anesthesia. RESULTS: Of 7,678 patients who had breast cancer surgery during the study period, data for 5,331 patients were available for analysis (IV group, n = 3,085; inhalation group, n = 2,246). After propensity score matching, 1,766 patients remained in each group. Kaplan-Meier survival curves showed that there was no significant difference in recurrence-free survival or overall survival between the two groups, with 5-yr recurrence-free survival rates of 93.2% (95% CI, 91.9 to 94.5) in the IV group and 93.8% (95% CI, 92.6 to 95.1) in the inhalation group. Inhalation anesthesia had no significant impact on recurrence-free survival (hazard ratio, 0.96; 95% CI, 0.69 to 1.32; P = 0.782) or overall survival (hazard ratio, 0.96; 95% CI, 0.69 to 1.33, P = 0.805) when compared with total IV anesthesia. CONCLUSIONS: The authors found no association between type of anesthesia used and the long-term prognosis of breast cancer. The results of this retrospective cohort study do not suggest specific selection of IV or inhalation anesthesia for breast cancer surgery.

An international survey evaluating factors influencing the use of total intravenous anaesthesia.

The purpose of this study was to evaluate factors influencing the use of propofol-based total intravenous anaesthesia (TIVA)since despite TIVA being a well-established technique, it is used far less frequently than volatile anaesthesia. Questions were formulated after reviewing the literature for perceived disadvantages of TIVA and meeting with a focus group consisting of both senior and junior anaesthestists from our department. Once the survey had been formulated, specialist anaesthetists from professional colleges and societies from several countries were invited to complete the survey on an electronic web-based platform to allow evaluation of the respondent's rating of the importance of a range of factors in their decision not to use TIVA for a particular case. Basic descriptive statistics were determined using SPSS statistical software, while graphical depictions of data were handled using R for statistical analysis. A total of 763 survey responses were included in the final analysis and stratified according to the frequency of TIVA use. Among the infrequent users, issues such as additional effort, institutional preference, lack of real-time monitoring of propofol concentration, risk of missing drug delivery failure and increased turnaround time were among the top reasons mentioned. Interestingly, these issues were considered far less important among the frequent users when not choosing TIVA. We concluded that frequent and infrequent users respond quite differently to similar technical TIVA-related factors. Non-technical factors may play an important role in the infrequent user's decision not to use TIVA for a particular case.

Intellectual disability is a risk factor for delayed emergence from total intravenous anaesthesia.

BACKGROUND: Previous studies have suggested that ID influences the depth of general anaesthesia (GA) and delays emergence from GA. In this retrospective cohort study, we investigated whether ID affects the time taken to emerge from GA. METHODS: We selected dental patients who underwent GA at the Department of Dental Anaesthesiology, Okayama University Hospital, using predefined inclusion and exclusion criteria, before dividing the selected participants into ID and non-ID (control) groups. Relevant data were collected from electronic anaesthesia records. Emergence time, the time from the discontinuation of propofol and remifentanil to tracheal extubation, was recorded for each patient. We compared the data of the ID group and control group. The association between ID and the emergence time was tested for statistical significance. Multivariate linear regression analysis was used to control for confounders. RESULTS: A total of 97 cases (control = 50, ID = 47) were included in the study. The emergence time was significantly longer in the ID group (ID group: 15.8 ± 6.6 min, control group: 10.8 ± 3.6 min). The ID group included more men and lower propofol and remifentanil infusion rates. The treatment time was longer, and the mean bispectral index was lower in the ID group. Sevoflurane inhalation was used only for anaesthesia induction in the ID group. In the multivariate linear regression analysis, ID was found to be significantly associated with a longer emergence time. CONCLUSION: Our results suggest that ID is associated with a longer emergence time from GA.

A comparison of different synchronization measures in electroencephalogram during propofol anesthesia.

Electroencephalogram (EEG) synchronization is becoming an essential tool to describe neurophysiological mechanisms of communication between brain regions under general anesthesia. Different synchronization measures have their own properties to reflect the changes of EEG activities during different anesthetic states. However, the performance characteristics and the relations of different synchronization measures in evaluating synchronization changes during propofol-induced anesthesia are not fully elucidated. Two-channel EEG data from seven volunteers who had undergone a brief standardized propofol anesthesia were then adopted to calculate eight synchronization indexes. We computed the prediction probability (P K ) of synchronization indexes with Bispectral Index (BIS) and propofol effect-site concentration (C eff ) to quantify the ability of the indexes to predict BIS and C eff . Also, box plots and coefficient of variation were used to reflect the different synchronization changes and their robustness to noise in awake, unconscious and recovery states, and the Pearson correlation coefficient (R) was used for assessing the relationship among synchronization measures, BIS and C eff . Permutation cross mutual information (PCMI) and determinism (DET) could predict BIS and follow C eff better than nonlinear interdependence (NI), mutual information based on kernel estimation (KerMI) and cross correlation. Wavelet transform coherence (WTC) in α and ß frequency bands followed BIS and C eff better than that in other frequency bands. There was a significant decrease in unconscious state and a significant increase in recovery state for PCMI and NI, while the trends were opposite for KerMI, DET and WTC. Phase synchronization based on phase locking value (PSPLV) in δ, θ, α and γ1 frequency bands dropped significantly in unconscious state, whereas it had no significant synchronization in recovery state. Moreover, PCMI, NI, DET correlated closely with each other and they had a better robustness to noise and higher correlation with BIS and C eff than other synchronization indexes. Propofol caused EEG synchronization changes during the anesthetic period. Different synchronization measures had individual properties in evaluating synchronization changes in different anesthetic states, which might be related to various forms of neural activities and neurophysiological mechanisms under general anesthesia.

Long-term Survival for Patients Undergoing Volatile versus IV Anesthesia for Cancer Surgery: A Retrospective Analysis.

BACKGROUND: Surgical resection remains the best option for long-term survival in many solid tumors. Surgery can, however, lead to tumor cell release into the circulation. Data have suggested differential effects of anesthetic agents on cancer cell growth. This retrospective analysis investigated the association of anesthetic technique with long-term survival in patients presenting for elective surgery in a comprehensive cancer center over 3 yr. METHODS: All patients undergoing elective surgery between June 2010 and May 2013 were included. Patients were grouped according to whether they had received volatile inhalational (INHA) or total IV anesthesia (TIVA). After excluding those who received both forms of anesthesia during the study period, Kaplan-Meier survival curves were constructed from the date of surgery to death. After propensity matching, univariate and multivariable regression models were used to compare hazard ratios for death. RESULTS: A total of 11,395 anesthetics using INHA or TIVA were delivered in the study period. After exclusions, 3,316 patients (796 deaths, 24%) remained in the INHA group and 3,714 (504 deaths, 13.5%) in the TIVA group. After propensity matching, 2,607 patients remained in each group (597 deaths, 22.8%, in INHA group vs. 407, 15.6%, in TIVA group). Volatile inhalational anesthesia was associated with a hazard ratio of 1.59 (1.30 to 1.95) for death on univariate analysis and 1.46 (1.29 to 1.66) after multivariable analysis of known confounders in the matched group. CONCLUSIONS: This retrospective analysis demonstrates an association between type of anesthetic delivered and survival. This analysis alongside biological plausibility should lead to urgent prospective work exploring the effect of anesthetic technique on survival.

Use of volatile anaesthetic agents in anaesthesia: A survey of practice in France in 2012.

Volatile anaesthetic agents are used in the vast majority of general anaesthesias performed in France. We assessed the degree of understanding of French anaesthetists with regard to the general pharmacology of these products and their understanding of the factors that govern selection of the different agents available for use in adults. A validated 13-item questionnaire was sent electronically in 2012 using files from the Société française d'anesthésie et de réanimation (Sfar). It covered four categories: general characteristics of the respondent; practical aspects of anaesthesia with volatile agents; pharmacological properties and criteria for choosing a volatile agent; risk of intra-operative awareness. Among the 981 respondents, the anaesthetic technique used by 50% was that of an intravenous induction followed by maintenance with sevoflurane. The concepts relating to the practical use of these products are well known. A fresh gas flow of less than 2 L/min is used by 96% of the respondents. However, knowledge levels are often inadequate (rate of correct answers often<50%). This lack of knowledge pertains to current themes (climate pollution), those of debatable clinical significance, e.g. pre-conditioning, hypoxic vasoconstriction and those that concern scientific theory (medullary action). However, a lack of knowledge is also observed with regard to basic pharmacology (respiratory, vascular, neurological or pharmacokinetic effects). There is no significant difference in the mode of practice. The experience of the anaesthetist (measured by number of years post diploma) resulted in a number of differences in response to many aspects of the questionnaire but these were minor. These results suggest the need for an improvement both in the initial and continued training of anaesthetists with respect to volatile anaesthetic agents.

The effect of total intravenous anesthesia on the postoperative cognitive functions of young and elderly patients after lumbar disk surgery.

BACKGROUND/AIM: The negative effects of surgery and anesthesia on cognitive functions and their relationships with many factors are well known. In the present study we aimed to investigate the effect of the total intravenous anesthesia (TIVA) method on the postoperative cognitive functions between young and elderly patients scheduled to undergo lumbar disk surgery. MATERIALS AND METHODS: The TIVA method was applied to 40 patients less than 65 years old (young, Group Y) and ≥65 years old (old, Group O), whose Mini Mental State Examination (MMSE) results and serum S-100 beta protein levels were compared preoperatively and postoperatively at the 24th hour. RESULTS: Postoperative cognitive dysfunction was not observed in any of the groups in the early stage. MMSE results and mean S-100 beta protein levels determined before and after the operation did not have statistically significant differences between the groups over time. CONCLUSION: In the present study, the TIVA method did not affect postoperative early cognitive functions in either old or young patients who underwent lumbar disk surgery.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors.

We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ~1:8200 (1:7030-9700), and without, it was ~1:135,900 (1:78,600-299,000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ~1:670 (1:380-1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.

Influence of multi-lumen extensions on fluid flow through intravenous cannulae.

Multi-lumen extensions used to infuse multiple fluids via a single intravenous cannula might increase resistance and so limit the flow that can be achieved. We constructed low-pressure and high-pressure models and compared the effect of two different multi-lumen extensions on flow rate. Both multi-lumen extensions reduced flows by up to 76% (p < 0.001). The effect was greatest with large cannulae and in the high-pressure model, with the longer and narrower extension most impeding flow. Multi-lumen extensions can therefore significantly impede fluid flow, and should be avoided or removed when rapid infusion is required. These effects are less important in paediatric anaesthesia where smaller cannulae are used. Manufacturers should include internal diameter or flow effects on the packaging of these extensions to assist clinicians in making such decisions.

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population.

AIM: The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population. METHODS: A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated. RESULTS: The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need. CONCLUSIONS: The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.

[Questionnaire on the anaesthesiology treatment of patients subjected to posterior fossa neurosurgery]. / Encuesta sobre el tratamiento anestesiológico de los pacientes sometidos a neurocirugía de fosa posterior.

OBJECTIVES: To find out, by means of a questionnaire, the procedures used by Spanish anaesthetists in peri-operative management of patients subjected to neurosurgery of the posterior cranial fossa. MATERIAL AND METHODS: A closed-question type questionnaire was sent to Anaesthesiology Departments with a Neurosurgery Department on the participation of anaesthetists in the peri-operative treatment of patients subjected posterior fossa surgery. RESULTS: The questionnaire was completed by 42 (57.5%) of the 73 national public hospitals with a Neurosurgery Department. The posterior fossa surgery was performed in the sitting position in 36 hospitals, although it was less frequently used than the lateral decubitus or prone decubitus position. There was little specific neurological monitoring, as well as little use of precordial and/or transcranial Doppler for detecting vascular air embolism. Nitrous oxide was used in less than 10% of the centres, and 15% avoided neuromuscular block when neurophysiological monitoring was used during the surgery. Cardiovascular problems were mentioned as being the most frequent in 29% of the centres, while in the post-operative period the most common complications were, cranial nerve déficit, airway oedema (23%), and post-operative vomiting (47%). CONCLUSIONS: The results obtained from the questionnaire showed that the sitting position was less used than the prone position in posterior fossa surgery, and that neurophysiological monitoring is during surgery is hardly used.

Perioperative serum brain natriuretic peptide and cardiac troponin in elective intracranial surgery.

BACKGROUND: There are some intracranial insults which are associated with cardiac abnormalities. Studies of these abnormalities have never been carried out in elective intracranial neurosurgery for the removal of brain tumors. Our prospective study aims at quantifying serum cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) before and after elective intracranial neurosurgery for tumor resection in patients with no history of cardiac abnormality. METHODS: Pre- and postoperative serum cTnT and NT-proBNP were measured in 108 patients submitted to elective major intracranial surgery for the removal of neoplastic lesions. We tested potentially predictive models for these biomarker serum levels. RESULTS: cTnT was undetectable both before and after surgery. Median (IQR) basal NT-proBNP was 35 (18-69) pg/mL and 110 (51-191) pg/mL after surgery. In a multiple linear regression model, basal NT-proBNP was predicted by age, gender, BMI, and the presence of "mass effect" (midline shift or effaced perimesencephalic cisterns on preoperative CT scan) (whole model P < 0.0001; R (2) = 0.3502; and Adjusted R (2) = 0.3247). Postoperative NT-proBNP increase was predicted by baseline NT-proBNP level (whole model P < 0.0001; R (2) = 0.5106; and Adjusted R (2) = 0.5052). CONCLUSION: An intracranial mass effect is associated with higher NT-proBNP serum levels in patients with a brain neoplasm. Following elective intracranial surgery for brain tumor resection NT-proBNP values increase.