Postoperative pain management after abdominal transplantations.

PURPOSE OF REVIEW: The aim of this review article is to present current recommendations as well as knowledge gaps and controversies pertaining to commonly utilized postoperative pain management after solid organ transplantation in the abdominal cavity. RECENT FINDINGS: Postsurgical pain has been identified as one of the major challenges in recovery and treatment after solid organ transplants. Many perioperative interventions and management strategies are available for reducing and managing postoperative pain. Management should be tailored to the individual needs, taking an interdisciplinary and holistic approach and following enhanced recovery after surgery guidelines. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. SUMMARY: The optimal pain management regimen has not yet been definitively established, and current scientific evidence does not yet support the endorsement of a certain analgesic approach. This objective necessitates the need for high-quality randomized controlled trials.

Alternative sensor montage for Index based EEG monitoring. A systematic review.

The main objective of this systematic review is to assess the reliability of alternative positions of processed electroencephalogram sensors for depth of anesthesia monitoring and its applicability in clinical practice. A systematic search was conducted in PubMed, Embase, Cochrane Library, Clinical trial.gov in accordance with reporting guidelines of PRISMA statement together with the following sources: Google and Google Scholar. We considered eligible prospective studies, written in the English language. The last search was run on the August 2023. Risk of bias and quality assessment were performed. Data extraction was performed by two authors and results were synthesized narratively owing to the heterogeneity of the included studies. Thirteen prospective observational studies (438 patients) were included in the systematic review after the final assessment, with significant diversity in study design. Most studies had a low risk of bias but due to lack of information in one key domain of bias (Bias due to missing data) the overall judgement would be No Information. However, there is no clear indication that the studies are at serious or critical risk of bias. Bearing in mind, the heterogeneity and small sample size of the included studies, current evidence suggests that the alternative infraorbital sensor position is the most comparable for clinical use when the standard sensor position in the forehead is not possible.

After the Knife: A Detailed Roadmap for Vestibular Schwannoma Resection in the Semi-Sitting Position - How I do it.

BACKGROUND: Vestibular schwannoma surgery remains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for performing the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes. METHODS: In this study, we aimed to establish a standardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization. RESULTS: The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting position, with visual demonstration of the various parts of the procedure through surgical videos. Specific recommendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure of vestibular schwannoma resection in the semi-sitting position. CONCLUSIONS: This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.

Before the Knife: A Detailed Step-by-Step Description of an Optimized Semi-Sitting Position in Posterior Fossa Surgery.

BACKGROUND: In an ample armamentarium in neurosurgery, the semi-sitting position has produced debate regarding its benefits and risks. Although the position is apparently intuitive, many have abandoned its use since its initial inception, because of reported complexity and potential complications, leading to impracticality. However, through standardization, it has been shown not only to be safe but to carry with it many advantages, including less risk of secondary neurovascular injuries and better visualization of the surgical field. As with any surgical technical nuance, the semi-sitting position has advantages and disadvantages that must be weighed before the decision is made to adopt it or not, not only in a case-by-case scenario but also from a departmental standpoint. As we attempt to show, the advantages from a standardized approach for the semi-sitting position in experienced institutions may be more than sufficient to significantly outweigh the disadvantages, making it the preferable option for most, although not all, posterior fossa surgical interventions. METHODS: In the present study, we aim to elaborate a straightforward narrative of the steps before incision, in an attempt to simplify the complexity of the position, alleviating its disadvantages and exponentially concentrating on its benefits. In nearly 100 steps, we carefully describe the points that culminate with the skin incision, initiating the intraoperative part of the procedure. Each step, therefore, is detailed in full, not in an effort to create a strict manual of the semi-sitting position but rather to facilitate understanding and put the technique into effect in a real-life scenario, thus simplifying what some depict as complex and time consuming. CONCLUSIONS: Although several of the steps described are also relevant and integral parts of other surgical positioning, we intend to create a protocol, in a stepwise fashion, to allow facilitated following, to be easily implemented in departments with different levels of experience. The steps comprise nursing care through to electrophysiologic and anesthesiologic approaches, along with neurosurgical cooperation, making it a team approach, not only to avoid position-related complications but also to optimize preoperative standardization, constructing a safe, efficient, and patient-centered scenario, to set the best possible stage for the next step: the intraoperative part of the intervention.

Salted or sweet? Hypertonic saline or mannitol for treatment of intracranial hypertension.

PURPOSE OF REVIEW: The aim of this review article is to present current recommendations regarding the use of hypertonic saline and mannitol for the treatment of intracranial hypertension. RECENT FINDINGS: In recent years, a significant number of studies have been published comparing hypertonic saline with mannitol in patients with acute increased intracranial pressure, mostly caused by traumatic brain injury. Albeit several randomized controlled trials, systematic reviews and meta-analysis support hypertonic saline as more effective than mannitol in reducing intracranial pressure, no clear benefit in regards to the long-term neurologic outcome of these patients has been reported. SUMMARY: Identifying and treating increased intracranial pressure is imperative in neurocritical care settings and proper management is essential to improve long-term outcomes. Currently, there is insufficient evidence from comparative studies to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased intracranial pressure.

Air-embolism in the semi-sitting position for craniotomy: A narrative review with emphasis on a single centers experience.

Albeit the semi-sitting position in neurosurgery has been in use for several decades, its application remains controversial in the neurosurgical and neuro-anaesthesia communities. The imminent and most feared risk of the sitting position is air entry into the vascular system due to the negative intravascular pressure leading to potentially life-threatening air embolism with its consequences. Recent advents in neurosurgical (improvement of the operating microscope, employment of intra-operative neurophysiological monitoring) and neuro-anaesthesia care (new anaesthetics, advanced monitoring modalities) have significantly impacted the approach to these surgeries. Vigilant intra-operative observation by an experienced team and peri-operative patient management guided by institutional protocols improves the safety profile of these surgeries. This review outlines the workflow and protocols used in our institution for all cases of semi-sitting position for skull base neurosurgery.

Role of anaesthesia in neurosurgical enhanced recovery programmes.

The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.

Dynamic variation of the axillary veins due to intrathoracic pressure changes: A prospective sonographic study.

INTRODUCTION: The ultrasound-guided axillary vein is becoming a compulsory alternative vessel for central venous catheterization and the anatomical position offers several potential advantages over blind, subclavian vein techniques. OBJECTIVE: To determine the degree of dynamic variation of the axillary vein size measured by ultrasound prior to the induction of general anesthesia and after starting controlled mechanical ventilation. DESIGN: Prospective, observational study. METHODS: One hundred ten patients undergoing elective surgery were enrolled and classified according to sex, age, and body mass index. Two-dimensional cross-sectional vein diameter, area, and mean flow velocity were performed using ultrasound on both the left and right axillary veins of each subject before and after induction of anesthesia. RESULTS: There was statistically significant evidence showing that the axillary vein area increases when patients are mechanically ventilated. When considering venous flow velocity as a primary outcome, velocity decreased after patients moved from spontaneous to mechanical ventilation (coefficient = -0.267), but this relationship failed to achieve statistical significance (t = -1.355, p = 0.179). CONCLUSIONS: Anatomical variations in depth and diameter as well as the collapsibility due to intrathoracic pressures changes represent common challenges that face clinicians during central venous catheterization of the axillary vein. A noteworthy increase in vessel size as patients transition from spontaneous to mechanical ventilation may theoretically improve first-pass cannulation success with practitioners skilled in both ultrasound and procedure. As a result, placing a centrally inserted central catheter after the induction of anesthesia may be beneficial.

Management of complex spine surgery.

PURPOSE OF REVIEW: The main objective of this article is to present the updated data regarding the perioperative management of patients undergoing major spine surgery in an era where the surgical techniques are changing and there is a high demand for these surgeries in older and high-risk patients. RECENT FINDINGS: Preoperative assessment and stabilization is now more structured protocol and it is based on a multidisciplinary approach to the patient. The Enhanced Recovery After Surgery (ERAS) programs and the Perioperative Surgical Home on major spine surgery are not yet fully evidence based but it seems that the use of a perioperative optimization of patients and use of a drugs' bundle is more effective than using single drugs or interventions on the postoperative pain reduction and faster recovery from surgery. Fluid and pain-control protocols combined with an accurate blood management represent the key to success. SUMMARY: A tailored approach to patients undergoing major spine surgeries seems to be effective improving the outcome and quality of life of patients. Future studies should aim to understand which elements of the ERAS can be improved to allow the patient to have a long-term good outcome. VIDEO ABSTRACT.

Paying tuition and academic performance of students at Kragujevac University School of Medicine.

AIM: To assess whether the prospect of waiving tuition fees influenced the academic performance of students with the lowest admission test scores and consequent mandatory tuition. METHODS: We compared academic performance of 75 tuition-paying students with the students who did not have to pay tuition because they scored well on the 1996-1998 admission tests to the Kragujevac School of Medicine. We formed 3 control groups (high-, medium- and low-ranked students on the admission test), each with the similar number of students as the group of tuition-paying students. Students performance was assessed after the first two academic years on the basis of their average grades, number of tries to pass the same examination, the time needed to pass an examination after a course, and the number of repeated years. RESULTS: Of 75 tuition-paying students admitted to the School in the 1996-1998 period, 11 had their tuition permanently waived and were therefore excluded from the analysis after the first year. Tuition-paying students had the average grade of 6.8 +/- 3.2 (grade range 6-10), took each exam twice before passing it, needed more than four months of studying to pass an exam, and repeated 0.1 years per student. Their performance was statistically worse than the performance of the low-ranked group of control students in all parameters, except in the number of repeated years. The high-, medium-, and low-ranked student groups did not differ significantly in their performance, but all performed significantly better than the tuition-paying group in three following parameters: average grade (high-ranked group: 8.2 +/- 1.3), average number of tries to pass an exam (high-ranked group: 1.8 +/- 0.8), and average time of studying needed to pass an exam (high-ranked group: 119.6 +/- 65.9 days). CONCLUSION: The prospect of waiving tuition fees has no influence on students performance. The students rank on the admission test is a major predictor of their subsequent academic performance.