External Validation of the Revised Cardiac Risk Index and the Geriatric-Sensitive Perioperative Cardiac Risk Index in Oldest Old Patients Following Surgery Under Spinal Anaesthesia; a Retrospective Cross-Sectional Cohort Study.

Background: The Revised Cardiac Risk Index (RCRI) and the Geriatric Sensitive Cardiac Risk Index (GSCRI) estimate the risk of postoperative major adverse cardiac events (MACE) regardless of the type of anesthesia and without specifying the oldest old patients. Since spinal anesthesia (SA) is a preferred technique in geriatrics, we aimed to test the external validity of these indices in patients ≥ 80 years old who underwent surgery under SA and tried to identify other potential risk factors for postoperative MACE. Methods: The performance of both indices to estimate postoperative in-hospital MACE risk was tested through discrimination, calibration, and clinical utility. We also investigated the correlation between both indices and postoperative ICU admission and length of hospital stay (LOS). Results: The MACE incidence was 7.5%. Both indices had limited discriminative (AUC for RCRI and GSCRI were 0.69 and 0.68, respectively) and predictive abilities. The regression analysis showed that patients with atrial fibrillation (AF) were 3.77 and those with trauma surgery were 2.03 times more likely to exhibit MACE, and the odds of MACE increased by 9% for each additional year above 80. Introducing these factors into both indices (multivariable models) increased the discriminative ability (AUC reached 0.798 and 0.777 for RCRI and GSCRI, respectively). Bootstrap analysis showed that the predictive ability of the multivariate GSCRI but not the multivariate RCRI improved. Decision curve analysis (DCA) showed that multivariate GSCRI had superior clinical utility when compared with multivariate RCRI. Both indices correlated poorly with postoperative ICU admission and LOS. Conclusion: Both indices had limited predictive and discriminative ability to estimate postoperative in-hospital MACE risk and correlated poorly with postoperative ICU admission and LOS, following surgery under SA in the oldest-old patients. Updated versions by introducing age, AF, and trauma surgery improved the GSCRI performance but not the RCRI.

Preoperative cerebral oxygenation in high-risk noncardiac surgical patients: an observational study on postoperative mortality and complications.

Near Infrared Spectroscopy (NIRS) has become widely accepted to evaluate regional cerebral oxygen saturation (rScO2), potentially acting as a surrogate parameter of reduced cerebral oxygen delivery or increased consumption. Low preoperative rScO2 is associated with increased postoperative complications after cardiac surgery. However, its universal potential in pre-anesthesia risk assessment remains unclear. Therefore, we investigated whether low preoperative rScO2 is indicative of postoperative complications and associated with poor outcomes in noncardiac surgical patients. We prospectively enrolled 130 patients undergoing high-risk noncardiac surgery. During pre-anesthesia evaluation, baseline rScO2 was recorded with and without oxygen supplementation. The primary endpoint was 30-day mortality, while secondary endpoints were postoperative myocardial injury, respiratory complications, and renal failure. We further evaluated the impact of body position and preoperative hemoglobin (Hb) concentration on rScO2. Of the initially enrolled 130 patients, 126 remained for final analysis. Six (4.76%) patients died within 30 postoperative days. 95 (75.4%) patients were admitted to the ICU. 32 (25.4%) patients suffered from major postoperative complications. There was no significant association between rScO2 and 30-day mortality or secondary endpoints. Oxygen supplementation induced a significant increase of rScO2. Furthermore, Hb concentration correlated with rScO2 values and body position affected rScO2. No significant association between rScO2 values and NYHA, LVEF, or MET classes were observed. Preoperative rScO2 is not associated with postoperative complications in patients undergoing high-risk noncardiac surgery. We speculate that the discriminatory power of NIRS is insufficient due to individual variability of rScO2 values and confounding factors.

Effect of Intraoperative Handovers of Anesthesia Care on Mortality, Readmission, or Postoperative Complications Among Adults: The HandiCAP Randomized Clinical Trial.

Importance: Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. Objective: To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. Design, Setting, and Participants: This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. Interventions: A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. Main Outcomes and Measures: The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. Results: Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. Conclusions and Relevance: Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04016454.

Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation.

BACKGROUND: Severe COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients. METHODS: 673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival. RESULTS: Most patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58-99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41-0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28-1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events. CONCLUSIONS: Structural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival. TRIAL REGISTRATION: Registered in the German Clinical Trials Register (study ID: DRKS00022964, retrospectively registered, September 7th 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022964 .

Emergence delirium in children: a Brazilian survey.

BACKGROUND: Pediatric emergence delirium is characterized by a disturbance of a child's awareness during the early postoperative period that manifests as disorientation, altered attention and perception. The incidence of emergence delirium varies between 18% and 80% depending on risk factors and how it is measured. Reports from Canada, Germany, Italy, United Kingdom, and France demonstrated a wide range of preventive measures and definitions, indicating that there is a lack of clarity regarding emergence delirium. We aimed to assess the practices and beliefs among Brazilian anesthesiologists regarding emergence delirium. METHODS: A web-based survey was developed using REDCap®. A link and QR Code were sent by email to all Brazilian anesthesiologists associated with the Brazilian Society of Anesthesiology (SBA). RESULTS: We collected 671 completed questionnaires. The majority of respondents (97%) considered emergence delirium a relevant adverse event. Thirty-two percent of respondents reported routinely administrating medication to prevent emergence delirium, with clonidine (16%) and propofol (15%) being the most commonly prescribed medications. More than 70% of respondents reported a high level of patient and parent anxiety, a previous history of emergence delirium, and untreated pain as risk factors for emergence delirium. Regarding treatment, thirty-five percent of respondents reported using propofol, followed by midazolam (26%). CONCLUSION: Although most respondents considered emergence delirium a relevant adverse event, only one-third of them routinely applied preventive measures. Clonidine and propofol were the first choices for pharmacological prevention. For treatment, propofol and midazolam were the most commonly prescribed medications.

From bench to bar side: Evaluating the red wine storage lesion.

Vitally essential red fluids like packed cells and red wine are seriously influenced in quality when stored over prolonged periods. In the case of red cell concentrates, the resulting storage lesion has particular significance in perioperative medicine. We hypothesized that, in contrast, aging rather improves the properties of red wine in several ways. A translational approach, including (I) in vitro experiments, (II) a randomized, blinded crossover trial of acute clinical effects, and (III) a standardized red wine blind tasting was used. Three monovarietal wines (Cabernet Sauvignon, Chianti, Shiraz) in three different vintages (range 2004-2016), each 5 years different, were assessed. Assessments were performed at a German university hospital (I, II) and on a garden terrace during a mild summer evening (III). Young wines induced cell stress and damage while significantly reducing cytoprotective proteins in HepG2 hepatoma cells. Sympathetic activity and multitasking skills were altered depending on wines' ages. Hangovers tended to be aggravated by young red wine. Aged variants performed better in terms of aroma and overall quality but worse in optical appearance. We found no evidence for a red wine storage lesion. However, we plead for consensus-based guidelines for proper storage, as it is common in clinical medicine.

Pediatric emergence delirium is linked to increased early postoperative negative behavior within two weeks after adenoidectomy: an observational study.

BACKGROUND: The aim of this prospective multicenter observational study was to measure the incidence of postoperative pediatric emergence delirium and to investigate the occurrence of early postoperative negative behavior within two weeks after outpatient adenoidectomy in preschool children. METHODS: The study comprised 222 patients (1-7 years of age). All children received a multimodal anesthesia based on total intravenous anesthesia with propofol and remifentanil in combination with piritramid (0.1 mg.kg-1), ibuprofen (10 mg.kg-1), dexamethason (0.15 mg.kg-1), and ketanest S (0.1 mg.kg-1). We evaluated emergence delirium using the Pediatric Anesthesia Emergence Delirium Scale (PAED) at different predefined time points during the recovery period. Emergence delirium was defined as a PAED score ≥ 9 for the first three criteria. Additionally, we defined early postoperative negative behavior to be present when at least 5 of 27 criteria of the post hospitalization behavior questionnaire were positive. RESULTS: The incidence of emergence delirium following our anesthetic regime was 23%. The incidence of early postoperative negative behavior was significantly higher among patients with emergence delirium (24% vs. 11%, p = 0.04). The two categories, "sleep disturbance" and "separation anxiety", tested within the questionnaire for early postoperative negative behavior, were identified as the most common postoperative negative behavioral changes. CONCLUSION: Emergence delirium not only plays a role immediately after surgery but is also linked to early postoperative negative behavior within two weeks after outpatient adenoidectomy. Parents should be informed that early postoperative negative behavior may occur in 1 out of 4 patients if emergence delirium was present postoperatively. TRIAL REGISTRATION: DRKS - German Clinical Trial Register ID: DRKS00013121.

Hidden danger in the neck-a problem of differential diagnostics: benign chronic lymphadenitis following carotid endarterectomy and patch angioplasty (CEAP) or a metastasis due to a squamous cell cancer of the tongue.

INTRODUCTION: Oncological head and neck operations as well as carotid endarterectomy are common surgical procedures. In some occasions, both procedures have occurred in the past, leading to possible diagnostic and therapeutic challenges when follow-up operations seem indicated. CASE REPORT: We report of a patient presenting with carotid endarterectomy including patch operation 8 years ago and neck dissection due to a squamous cell cancer of the tongue 3 months ago, now showing up with a suspected metastatic tumor of the neck during routine follow-up. Intraoperatively, nearly fatal bleeding occurs due to a partial release of the carotid patch and needs to be managed immediately. DISCUSSION: The primarily pre-operated neck remains challenging for the radiologist in terms of differentiating between chronic lymphadenitis and metastasis. Furthermore, it remains challenging for the oncological surgeon in case these entities are in the near proximity of the previously operated carotid artery. The operative treatment according to the guidelines can lead to major bleeding during the second surgery. During the diagnostic process, metastases and chronic lymphadenitis after alloplastic carotid operations must be differentiated remaining however difficult, due to only scarce data in the literature. CONCLUSION: In the case of previous neck surgery, the decision to operate must be chosen individually regarding the specific conditions and their sometimes vital risks. In case an operation is indicated, the team must be trained to treat life-threatening intraoperative bleeding. In reviewing the literature, we were unable to find published recommendations on how to tackle these challenges.

Relative cerebral hyperperfusion during cardiopulmonary bypass is associated with risk for postoperative delirium: a cross-sectional cohort study.

BACKGROUND: Our objective was to evaluate if changes in on-pump cerebral blood flow, relative to the pre-bypass baseline, are associated with the risk for postoperative delirium (POD) following cardiac surgery. METHODS: In 47 consecutive adult patients, right middle cerebral artery blood flow velocity (MCAV) was assessed using transcranial Doppler sonography. Individual values, measured during cardiopulmonary bypass (CPB), were normalized to the pre-bypass baseline value and termed MCAVrel. An MCAVrel > 100% was defined as cerebral hyperperfusion. Prevalence of POD was assessed using the Confusion Assessment Method for the Intensive Care Unit. RESULTS: Overall prevalence of POD was 27%. In the subgroup without POD, 32% of patients had experienced relative cerebral hyperperfusion during CPB, compared to 67% in the subgroup with POD (p < 0.05). The mean averaged MCAVrel was 90 (±21) % in the no-POD group vs. 112 (±32) % in the POD group (p < 0.05), and patients developing delirium experienced cerebral hyperperfusion during CPB for about 39 (±35) min, compared to 6 (±11) min in the group without POD (p < 0.001). In a subcohort with pre-bypass baseline MCAV (MCAVbas) below the median MCAVbas of the whole cohort, prevalence of POD was 17% when MCAVrel during CPB was kept below 100%, but increased to 53% when these patients actually experienced relative cerebral hyperperfusion. CONCLUSIONS: Our results suggest a critical role for cerebral hyperperfusion in the pathogenesis of POD following on-pump open-heart surgery, recommending a more individualized hemodynamic management, especially in the population at risk.

[Drama in the Recovery Unit: Paediatric Emergence Delirium]. / Drama im Aufwachraum: pädiatrisches Emergence-Delir.

The upcoming and ongoing debate on neurotoxicity of anesthetics at a young age put a new spotlight on the emergence delirium of children (paedED). The European Society for Anesthesiology published a consensus guideline on prevention and therapy in 2017 which can be a useful guidance in daily clinical practice. Patient data management systems with their clear documentation concerning pain/therapy of pain and paedED will be valuable tools in order to assess the real incidence of paedED. Differentiating between pain/agitation and paedED migth not always be easy. Age-adapted scores should always be applied. Main focus in the prevention of paedED is the reduction of anxiety. The way this is achieved by the dedicated pediatric anesthesia teams caring for children, e.g. by oral midazolam, clowns, music, smartphone induction, does not matter. Using α2-agonists in the perioperative phase and applying propofol seems to be effective. A quiet supportive environment for recovery adds to a relaxed, stress-free awakening. For the future detecting paedED on normal wards becomes an important issue. This may be achieved by structured interviews or questionnaires assessing postoperative negative behavioural changes at the same time.

Oxycodone is safe and effective for general anesthesia.

PURPOSE: In clinical practice, using different opioid analgesics is common during the induction and maintenance of general anesthesia and for postoperative analgesia. However, if the opioid analgesic could be limited to a single drug, we hypothesized that the risk of adverse drug interactions could be reduced, with fewer adverse effects. We examined the use of oxycodone as a single opioid in a well-defined cohort of orthopedic patients undergoing general anesthesia. METHODS: In this retrolective, monocentric investigation, we reviewed data from 83 patients who underwent general anesthesia and received intravenous oxycodone as the sole analgesic (0.075 mg/kg during induction and 0.05 mg/kg during maintenance). The use of oxycodone during general anesthesia and the postoperative pain scores were recorded. Safety was evaluated by the measurement of hemodynamic changes (blood pressure, heart rate), the detection of pathologic changes in the electrocardiogram, changes of the peripheral oxygen saturation, and by the assessment of adverse effects. RESULTS: There was no significant change in peripheral oxygen saturation or the electrocardiogram during or while recovering from general anesthesia. Heart rate changed only slightly from reversal to recovery (73.3/min versus 78.3/min, p < 0.05) and from prior intubation to recovery (72.5/min versus 78.3/min, p < 0.05). Systolic and diastolic blood pressure did not change significantly from the time points "after intubation" to "after incision," and "during recovery." Fifty-nine percent (n = 49) of patients' records revealed pain scores with a maximum of 3 on a numeric rating scale (NRS) of 0 to10 during the postoperative period. In 45 percent of patients (n = 37), further analgesics such as acetaminophen, dipyrone, or additional doses of oxycodone were used. No severe adverse events were recorded. According to data from 93 percent of patients (n = 77), nausea scores were less than 3 on a NRS of 0 to 10. CONCLUSION: Oxycodone can be used as the sole opioid in orthopedic surgery with good intra- and postoperative efficacy and safety; ie, without clinically relevant changes in hemodynamic and respiratory parameters.

Cerebral Function and Perfusion during Cardiopulmonary Bypass: A Plea for a Multimodal Monitoring Approach.

BACKGROUND: Postoperative neurological injury still represents a major cause of morbidity after cardiac surgery. Our objective was to compare the limits as well as advantages of routine monitoring tools for the detection of cerebral function and perfusion deficits during cardiopulmonary bypass in a daily clinical setting. METHODS: Adult patients undergoing elective cardiac surgery with use of cardiopulmonary bypass were included. Patients received monitoring comprising Bispectral Index (BIS), Near Infrared Spectroscopy (NIRS) and assessment of middle cerebral artery flow velocity (MCAV) using transcranial Doppler (TCD) sonography. Measurements were taken after anesthesia induction (at baseline) and every 10 minutes during aortic cross-clamping. Relative deviation from baseline values was calculated. Values were compared with predefined, generally accepted threshold values identifying patients at risk for cerebral functional and perfusion deficits. RESULTS: 30 consecutive patients were included into data analysis. Compared to NIRS as well as BIS monitoring, there was a wide interindividual variability in relative MCAV values for the whole cohort (median 0.9, range 0.39-2.19). Out of 229 measurements in total, 82 BIS but only 30 NIRS and 12 TCD values were lying outside predefined limits. TCD monitoring identified two patients with disturbed cerebral autoregulation, while NIRS remained unremarkable. The latter was significantly associated with systemic hemoglobin levels. Finally, patients with relative MCAV values >1.0 had a higher risk of developing postoperative delirium. CONCLUSION: Our findings reveal inherent technical limitations of each individual monitoring component, such as high interindividual variability (TCD), low spatial resolution (NIRS), or interaction with anesthetics (BIS). We therefore argue for a multimodal neuromonitoring that combines several qualities. Such approach would help reducing these limitations while individual components complement each other, thus providing more patient safety during cardiac surgery. Furthermore, such an approach would be easily applicable in a routine clinical setting.

Propofol Pharmacodynamics and Bispectral Index During Key Moments of Awake Craniotomy.

BACKGROUND: During awake craniotomy, the patient's language centers are identified by neurological testing requiring a fully awake and cooperative patient. Hence, anesthesia aims for an unconscious patient at the beginning and end of surgery but an awake and responsive patient in between. We investigated the plasma (Cplasma) and effect-site (Ceffect-site) propofol concentration as well as the related Bispectral Index (BIS) required for intraoperative return of consciousness and begin of neurological testing. MATERIALS AND METHODS: In 13 patients, arterial Cplasma were measured by high-pressure liquid chromatography and Ceffect-site was estimated based on the Marsh and Schnider pharmacokinetic/dynamic (pk/pd) models. The BIS, Cplasma and Ceffect-site were compared during the intraoperative awakening period at designated time points such as return of consciousness and start of the Boston Naming Test (neurological test). RESULTS: Return of consciousness occurred at a BIS of 77±7 (mean±SD) and a measured Cplasma of 1.2±0.4 µg/mL. The Marsh model predicted a significantly (P<0.001) higher Cplasma of 1.9±0.4 µg/mL as compared with the Schnider model (Cplasma=1.4±0.4 µg/mL) at return of consciousness. Neurological testing was possible as soon as the BIS had increased to 92±6 and measured Cplasma had decreased to 0.8±0.3 µg/mL. This translated into a time delay of 23±12 minutes between return of consciousness and begin of neurological testing. At begin of neurological testing, Cplasma according to Marsh (Cplasma=1.3±0.5 µg/mL) was significantly (P=0.002) higher as compared with the Schnider model (Cplasma=1.0±0.4 µg/mL). CONCLUSIONS: To perform intraoperative neurological testing, patients are required to be fully awake with plasma propofol concentrations as low as 0.8 µg/mL. Following our clinical setup, the Schnider pk/pd model estimates propofol concentrations significantly more accurate as compared with the Marsh model at this neurologically crucial time point.

The provision of pediatric cardiac anesthesia services in Germany: current status of structural and personnel organization.

BACKGROUND: Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. AIM: The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. METHODS: All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. RESULTS: An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. CONCLUSION: The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers.

Anesthesia in adults with congenital heart disease.

PURPOSE OF REVIEW: The current review focuses on patients with congenital heart disease (CHD) with regard to recent trends in global demographics, healthcare provision for noncardiac surgery, as well as anesthetic and perioperative care for these patients. RECENT FINDINGS: About 40 years after milestones of surgical innovation in CHD, the number of adults with CHD (ACHD) now surpasses those of children with CHD. This development leads to the fact that even patients with complex CHD managed for noncardiac surgery are not restricted to highly specialized centers. However, preoperative risk assessment for anesthesia in these patients is complex due to underlying cardiac morbidity and substantial CHD-associated noncardiac morbidity. In addition to clinical assessment and echocardiography, biomarker measurement may be a clinically useful tool to estimate severity of heart failure in CHD patients. The high negative predictive value of NT-proBNP makes it particularly valuable as a screening tool. Further, morbidity and mortality in ACHD patients are mainly caused by arrhythmias and therefore are also relevant for perioperative management. Adverse events and perioperative death in ACHD patients in cardiac and noncardiac surgery are frequently related to intraoperative anesthetic care. SUMMARY: Medical progress in treatment of CHD has shifted morbidity and mortality of these patients largely to adulthood. Future investigations including risk stratification of ACHD patients are necessary to further improve perioperative management, especially for low-risk and high-risk noncardiac management.

Prevention and Therapy of Pediatric Emergence Delirium: A National Survey.

INTRODUCTION: Although pediatric emergence delirium (ED) is common, preventive and therapeutic pharmacological treatment is the matter of an international controversial discussion and evidence on different options is partially vague. OBJECTIVE: We therefore examined clinical routine in prevention strategies and postoperative therapy of ED with respect to clinical experience in pediatric anesthesia. METHODS: A web-based survey was developed investigating routine management (prevention and treatment) of ED, facility structure, and patient population. The link was sent to all enlisted members of the German Society of Anesthesiology. RESULTS: We analyzed 1229 questionnaires. Overall, 88% reported ED as a relevant clinical problem; however, only 5% applied assessment scores to define ED. Oral midazolam was reported as standard premedication by 84% of respondents, the second largest group was 'no premedication' (5%). The first choice prevention strategy was to perform total intravenous (propofol) anesthesia (63%). The first choice therapeutic pharmacological treatment depended on clinical experience. Therapeutic propofol was preferentially chosen by more experienced anesthesiologists (5 to >20 patients per week, n = 538), while lesser experienced colleagues (<5 patients per week, n = 676) preferentially applied opioids. Dexmedetomidine (1%) and non-pharmacological (2%) therapy were rarely stated. The highest satisfaction levels for pharmacological therapy of ED were attributed to propofol. CONCLUSIONS: Propofol is the preferred choice for pharmacological prevention and treatment of ED among German anesthesiologists. Further therapy options as well as alternatives to a midazolam-centered premedication procedure are underrepresented.

[Emergence delirium in children - prophylaxis and treatment]. / Emergence Delir - Prophylaxe und Therapie.

Emergence Delirium in children after general anesthesia is a common and self limitating event. Although it might be seen as being harmless it can cause other serious complications and might leave both parents and other caregivers with a negative impression behind. Although the cause may still not be clear, potential predictors can be named: preschool age, the use of fast acting volatile anesthestics, higher preoperative anxiety levels and postoperative pain.A child-focused approach to reduce preoperative anxiety focusing on distraction methods rather than pharmacological sedation may be the key as well as sufficient postoperative pain control and the use of total intravenous anesthesia. Parenteal presence during induction of anaesthesia (PPIA) may be beneficial to reduce preoperative anxiety levels, but has failed to prove a better outcome regarding ED.The use of age adopted scores/scales to diagnose ED and Pain are mandatory.In the case of an ED event it is most important to protect the child from self injury and the loss of the iv-line. Postoperative pian needs to be ruled out before treating ED. Most cases can be treated by interrupting the situation and putting the child "back to sleep". Short acting drugs as Propofol have been used successfully due to its pharmacodynamics and short acting profile. Alternatively alpha-agonists or ketamin may be preferred by other authors. If potential predictors and a positive history are present, prophylactic treatment should be considered. A TIVA or the use of alpha-2-agonists have proven to be successful in reducing the risk of an ED. Midazolam may reduce preoperative anxiety but not the incidence of ED and should therefore be used carefully and is not a good choice in PACU for the treatment of ED.Parents who witnessed ED in their children should be guided and followed up. Explaining this phenomenon to parents beforehand should be part of the pre anaesthesia clinic talk and written consent.Standard protocols should be in place for treatment in the postoperative period.

Common carotid artery diameter responds to intravenous volume expansion: an ultrasound observation.

BACKGROUND: In case of intravascular fluid depletion, large veins react to volume expansion with dilation. Little is known about the reaction of arterial vessels. We herein report on the effect of a standardized fluid bolus on the diameter of the common carotid artery (CCA) and its association with hemodynamic parameters, assessed in 20 mechanically ventilated patients after cardiac surgery. CCA was visualized using ultrasound, and the percentage increase in diastolic diameter was calculated by measuring before and after administration of crystalloid infusion solution. Invasive arterial blood pressure and pulse pressure variation (PPV) were assessed in parallel. RESULTS: Median diastolic CCA diameter was 6.2 (Q1-Q3: 5.4-7.1) mm, and it significantly increased to 6.7 (5.8-7.3) mm upon fluid administration [5.0 (1.9-10.5) % increase]. Mean arterial blood (MAP) pressure likewise increased from 68 (70-73) to 85 (71-100) mmHg, whereas PPV was significantly reduced from 17.6 (16.8-23.9) to 13.2 (6.7-18.1) %. There was a significant association between the change in CCA diameter and the hemodynamic response (delta-MAP: r = 0.53, delta-PPV: r = 0.56; p < 0.05). Furthermore, carotid diameter measured before volume expansion significantly correlated with the delta-PPV upon fluid administration (r = -0.5; p = 0.02). CONCLUSIONS: Diameter of the CCA increases in response to intravascular volume expansion. Additional studies on the interplay between carotid geometry and intravascular fluid status are necessary.

Human plasmacytoid dentritic cells elicit a Type I Interferon response by sensing DNA via the cGAS-STING signaling pathway.

Plasmacytoid dendritic cells (pDCs) are a major source of type I interferon (IFN) and are important for host defense by sensing microbial DNA via TLR9. pDCs also play a critical role in the pathogenesis of IFN-driven autoimmune diseases. Yet, this autoimmune reaction is caused by the recognition of self-DNA and has been linked to TLR9-independent pathways. Increasing evidence suggests that the cytosolic DNA receptor cyclic GMP-AMP (cGAMP) synthase (cGAS) is a critical component in the detection of pathogens and contributes to autoimmune diseases. It has been shown that binding of DNA to cGAS results in the synthesis of cGAMP and the subsequent activation of the stimulator of interferon genes (STING) adaptor to induce IFNs. Our results show that the cGAS-STING pathway is expressed and activated in human pDCs by cytosolic DNA leading to a robust type I IFN response. Direct activation of STING by cyclic dinucleotides including cGAMP also activated pDCs and knockdown of STING abolished this IFN response. These results suggest that pDCs sense cytosolic DNA and cyclic dinucleotides via the cGAS-STING pathway and that targeting this pathway could be of therapeutic interest.

The Use of Internal Jugular Vein Ultrasonography to Anticipate Low or High Central Venous Pressure During Mechanical Ventilation.

BACKGROUND: Critically low or high central venous pressure (CVP) values, together with systemic hypotension, can indicate hypovolemia or acute heart failure. However, measuring CVP requires the insertion of a central venous catheter, a time-consuming procedure that can be associated with severe complications. OBJECTIVE: We sought to evaluate the use of ultrasonography of the internal jugular vein (IJV) to estimate low or high CVP values in patients who were on ventilation. METHODS: Ultrasonography of IJV dimensions and the collection of hemodynamic data was performed in 47 patients, and the ratio between IJV diameter in the 30° and 0° position was calculated (ratio(30/0)). The predictive value of ratio(30/0) for estimating low and high CVP levels was analyzed using receiver operating characteristic curves. RESULTS: The median IJV diameter ratio(30/0) was 0.49. CVP ranged from 1 to 13 mm Hg (median 7 mm Hg). Seventeen patients had a CVP ≤ 5 mm Hg or lower (defined as "low"), and in 11 patients, values of ≥ 10 mm Hg were measured (defined as "high"). The corresponding IJV diameter ratios increased significantly from 0.34 (in the low CVP group) to 0.9 (in the high CVP group). Receiver operating characteristic analysis revealed a good predictive value of the ratio(30/0) for the prediction of low or high CVP values, respectively. A ratio(30/0) of < 0.45 optimally indicated a low CVP, while > 0.65 was the cutoff value to detect a CVP ≥ 10 mm Hg. CONCLUSION: The estimation of low or high CVP values by IJV ultrasonography in different patient positions can be a helpful instrument for the rapid hemodynamic assessment of the critically ill patient.