Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Depth of Anesthesia Monitoring.

The electroencephalogram (EEG) can be analyzed in its raw form for characteristic drug-induced patterns of change or summarized using mathematical parameters as a processed electroencephalogram (pEEG). In this article we aim to summarize the contemporary literature pertaining to the commonly available pEEG monitors including the effects of commonly used anesthetic drugs on the EEG and pEEG parameters, pEEG monitor pitfalls, and the clinical implications of pEEG monitoring for anesthesia, pediatrics, and intensive care.

Efficacy of axillary versus infraclavicular brachial plexus block in preventing tourniquet pain: A randomised trial.

BACKGROUND: Axillary and infraclavicular brachial plexus blocks are commonly used for upper limb surgery. Clinicians require information on the relative benefits of each to make a rational selection for specific patients and procedures. OBJECTIVES: The main objective of the study was to compare axillary and infraclavicular brachial plexus block in terms of the incidence and severity of tourniquet pain. DESIGN: Single blinded, randomised trial. SETTING: University affiliated hospital, level-1 trauma centre. PATIENTS: Age more than 18 years, ASAI-III patients undergoing orthopaedic surgery distal to the elbow, with an anticipated tourniquet duration of more than 45 min were recruited. INTERVENTIONS: Patients underwent either ultrasound guided axillary brachial plexus block or infraclavicular block (ICB). MAIN OUTCOME MEASURES: Incidence of tourniquet pain (onset, severity, associated haemodynamic changes) and block characteristics (block performance/onset times, distribution, incidence of adverse events, patient satisfaction) were recorded. RESULTS: Eighty two patients (40 in the axillary block and 42 in the ICB group) were recruited. The incidence (5/36 and 3/35; P = 0.71), onset time (73.0 ±â€Š14.8 and 86.6 ±â€Š5.7 min; P = 0.18) and severity (mild/moderate; 4/1 and 1/2; P = 0.51) of tourniquet pain were similar in the two groups. The incidence of paraesthesia during block performance, and block performance time were greater in the axillary block group (P = 0.0054 and 0.012, respectively). The volume of local anaesthetic administered was greater in the ICB group (P < 0.01). ICB was associated with a greater degree of sensory block in the distributions of both the axillary nerve and the medial cutaneous brachial nerve (P < 0.01). Overall patient satisfaction and incidence of inadvertent vascular puncture were similar in the two groups. CONCLUSION: For surgical procedures which are of moderate duration, infraclavicular and axillary blocks are associated with similar incidences of tourniquet pain. Other factors appear to differentiate between these two blocks, namely block performance time, incidence of paraesthesia and dose of local anaesthetic. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02714738.

Outcomes of emergency neurosurgical intervention in neuro-critical care patients with traumatic brain injury at Cork University Hospital.

Traumatic Brain Injury (TBI) is a major cause of death and disability; the leading cause of mortality and morbidity in previously healthy people aged under 40 in the United Kingdom (UK). There are currently little official Irish statistics regarding TBI or outcome measures following TBI, although it is estimated that over 2000 people per year sustain TBI in Ireland. We performed a retrospective cohort study of TBI patients who were managed in the intensive care unit (ICU) at CUH between July 2012 and December 2015. Demographic data were compiled by patients' charts reviews. Using the validated Glasgow outcome scale extended (GOS-E) outcome measure tool, we interviewed patients and/or their carers to measure functional outcomes. Descriptive statistical analyses were performed. Spearman's correlation analysis was used to assess association between different variables using IBM's Statistical Package for the Social Sciences (SPSS) 20. In the 42-month period, 102 patients were identified, mainly males (81%). 49% had severe TBI and 56% were referred from other hospitals. The mean age was 44.7 and a most of the patients were previously healthy, with 65% of patients having ASA I or II. Falls accounted for the majority of the TBI, especially amongst those aged over 50. The 30-day mortality was 25.5% and the mean length of hospital stay (LOS-H) was 33 days. 9.8% of the study population had a good recovery (GOS-E 8), while 7.8% had a GOS-E score of 3 (lower sever disability). Patients with Extra-Dural haemorrhage had better outcomes compared with those with SDH or multi-compartmental haemorrhages (p = 0.007). Older patients had a higher mortality, with the highest mortality (37.5%) among those over 50 years old (p = 0.009). TBI is associated with significant morbidity and mortality. Despite the young mean age and low ASA the mortality, morbidity and average LOS-H were significant, highlighting the health and socioeconomic burden of TBI.

Correction to: Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review.

The following row on page 691 of Table 3, as highlighted in bold under Incidence of Retention (%) should read "0" instead of "N/A".

Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review.

PURPOSE: Urinary retention requiring catheterization carries the risk of infection. Neuraxial anesthesia causes transient impairment of bladder function ranging from delayed initiation of micturition to frank urinary retention. We undertook a review of the literature to determine the elements of neuraxial anesthesia and analgesia that prolong bladder dysfunction and increase the incidence of urinary retention. METHODS: We performed a systematic search of the PubMed, MEDLINE, and EMBASE databases (from January 1980 to January 2011) to identify studies where neuraxial anesthesia and/or analgesia were employed and at least one of the following outcomes was reported: urinary retention, time to micturition, or post void residual. We included randomized controlled trials and observational studies published in the English language and we excluded case reports. The randomized trials were graded according to the Jadad score. PRINCIPAL FINDINGS: Our search yielded 94 studies, and in 16 of these studies, the authors reported time to micturition after intrathecal anesthesia of varying local anesthetics and doses. Intrathecal injections were performed in 41 of these studies, epidural anesthesia/analgesia was used in 39 studies, and five studies involved both the intrathecal and epidural routes. Meta-analysis was not possible because of the heterogeneity of interventions and reported outcomes. The duration of detrusor dysfunction after intrathecal anesthesia is correlated with local anesthetic dose and potency. The incidence of urinary retention displays a similar trend and is further increased by the presence of neuraxial opioids, particularly long-acting variants. Urinary tract infection secondary to catheterization occurred rarely. CONCLUSIONS: Neuraxial anesthesia/analgesia results in transient detrusor dysfunction. The duration of dysfunction depends on the potency and dose of medication used; however, it does not appear to result in significant morbidity.

Spectral entropy as a monitor of depth of propofol induced sedation.

OBJECTIVE: The aim of this prospective, observational study was to evaluate State and Response entropy (Entropy(TM) Monitor, GE Healthcare, Finland), indices as measures of moderate ("conscious") sedation in healthy adult patients receiving a low dose propofol infusion. Sedation was evaluated using: (I) the responsiveness component of the OAA/S scale (Observer's Assessment of Alertness/Sedation scale) and (II) multi-channel electroencephalogram (EEG) interpretation by a clinical expert. METHODS: 12 ASA I patients were recruited. A target-controlled infusion of propofol was administered (using Schnider's pharmacokinetic model) with an initial effect site concentration set to 0.5 microg ml(-1). A 4 minute equilibrium period was allowed. This concentration was increased at 4 minute intervals by 0.5 microg ml(-1) to a maximum of 2.0 microg ml(-1). State (SE) and Response (RE), entropy values were recorded for each 4 minute epoch together with clinical sedation scores (OAA/S) and continuous multi-channel EEG. The multi-channel EEG recorded during the final minute of each 4 minute epoch or "patient/time unit" was presented to a neurophysiologist who assigned a label "sedated/not sedated". SE/RE values were compared in patient/time units with clinical or EEG evidence of sedation versus those without. RESULTS: Mean SE and RE values were less in patient/time units when clinical evidence of sedation was present, [mean = 86.8 (95% CI, 84.0-88.3) and 94.3 (95%CI, 92-96.1)], P = 0.002 and P = 0.001, respectively. In patient/time units assigned the label "sedated" by the clinical neurophysiologist assessing the multi-channel EEG, SE and RE values were less [mean = 87.5 (95% CI, 86.3-88.4) and 95.0 (95% CI, 93.8-96.1)] P = 0.001 and P < 0.001, respectively. CONCLUSIONS: A statistically significant decrease in SE and RE values was demonstrated in patient/time units in which clinical or EEG evidence of sedation was present. We conclude that spectral entropy offers potential as a monitor of propofol induced sedation.

Perioperative acute renal failure.

PURPOSE OF REVIEW: Recent biochemical evidence increasingly implicates inflammatory mechanisms as precipitants of acute renal failure. In this review, we detail some of these pathways together with potential new therapeutic targets. RECENT FINDINGS: Neutrophil gelatinase-associated lipocalin appears to be a sensitive, specific and reliable biomarker of renal injury, which may be predictive of renal outcome in the perioperative setting. For estimation of glomerular filtration rate, cystatin C is superior to creatinine. No drug is definitively effective at preventing postoperative renal failure. Clinical trials of fenoldopam and atrial natriuretic peptide are, at best, equivocal. As with pharmacological preconditioning of the heart, volatile anaesthetic agents appear to offer a protective effect to the subsequently ischaemic kidney. SUMMARY: Although a greatly improved understanding of the pathophysiology of acute renal failure has offered even more therapeutic targets, the maintenance of intravascular euvolaemia and perfusion pressure is most effective at preventing new postoperative acute renal failure. In the future, strategies targeting renal regeneration after injury will use bone marrow-derived stem cells and growth factors such as insulin-like growth factor-1.