Saline versus Lactated Ringer's Solution: The Saline or Lactated Ringer's (SOLAR) Trial.

BACKGROUND: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline. METHODS: The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. RESULTS: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. CONCLUSIONS: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively.

[A day in the busy obstetric unit from the anesthesiologist point of view, experience at the Cleveland clinic; Cleveland, Ohio].

Cleveland Clinic Labor and Delivery Unit is a syntactical delivery facility and comprised of 16 delivery rooms, 3 operating rooms, 3 triage rooms, and 1 recovery room that has a capacity of 6 beds, 43 postpartum rooms, 2 nurseries, and 1 neonatal intensive care unit (NICU). Cleveland Clinic Labor and Delivery Unit (LDU) had 3,691 delivery cases in 2007. The ratio of neuraxial analgesia (NA) during labor is 84.2% (2,348/ 2,787), using epidural anesthesia or combined spinalepidural anesthesia (CSEA). This article introduces the obstetrical (OB) anesthesia practice at the Cleveland Clinic and our novel anesthetic regime as typical of one typical busy day.

[Obstetric anesthesia training in the USA, experience of the Cleveland Clinic; Cleveland, Ohio].

In Japan, the re-organization of obstetrical medical system is needed and this project is ongoing under Japanese government initiative. However the ratio of using neuraxial analgesia (NA) during labor in Japan has been low and, increased demand for NA during labor is anticipated in near future. To prepare for these demands, the adequate number of obstetrical (OB) anesthesia specialists in the advanced OB hospital is necessary. However, there is no official training program for OB anesthesiologists in Japan. This article reports the clinical practice of the OB anesthesia in one of the biggest hospitals in the United State, the Cleveland Clinic, from the view of an OB anesthesia clinical fellow.

Caesarean delivery complicated by unintentional subdural block and conversion disorder.

Combined spinal epidural (CSE) can provide excellent labor analgesia. Subdural block is also a potential but rare complication of attempted epidural placement during a CSE procedure, which may present as a block that is usually patchy in nature, with a component of sensory and/or motor deficit and a variable duration of action. In addition, a conversion disorder or a functional neurological disorder has been described with epidural and spinal anesthesia in obstetric patients. In this clinical report, we describe a 33-year-old G4P3 at 40 weeks gestation that received an unintentional subdural block as part of her labor analgesia and after an uneventful caesarean delivery presented with a conversion disorder. The rarity of the association between a subdural block and a conversion disorder complicated by the fact that the neurological deficit produced by the subdural block and that produced by a conversion disorder are similar in distribution made the clinical presentation and diagnosis a challenge for the obstetric anesthesia team. A functional neurological disorder of this nature complicating a subdural block in an obstetric anesthesia clinical practice has not been described so far.

A case series discussing the anaesthetic management of pregnant patients with brain tumours.

Pregnancy may aggravate the natural history of an intracranial tumour, and may even unmask a previously unknown diagnosis. Here we present a series of seven patients who had brain tumours during pregnancy. The aim of this case series is to characterize the current perioperative management and to suggest evidence based guidelines for the anaesthetic management of pregnant females with brain tumours. This is a retrospective study. Information on pregnant patients diagnosed with brain tumours that underwent caesarean section (CS) and/or brain tumour resection from May 2003 through June 2008 was obtained from the Department of General Anaesthesia and the Rose Ella Burkhardt Brain Tumour & Neuro-Oncology Centre (BBTC) at the Cleveland Clinic, OH, USA. The mean age was 34.5 years (range 29-40 years old). Six patients had glioma, two of whom had concomitant craniotomy and CS. Six cases had the tumour in the frontal lobe. Four cases were operated on under general anaesthesia and three underwent awake craniotomy. The neonatal outcomes of the six patients with elective or emergent delivery were six viable infants with normal Apgar scores. Pregnancy was terminated in the 7th patient. In conclusion, good knowledge of the variable anesthetic agents and their effects on the fetus is very important in managing those patients.