Lactate concentration at the end of liver transplant: Early predictor of graft function or just one piece of the puzzle?

BACKGROUND: The post-operative course after Liver Transplantation (LT) can be complicated by early allograft dysfunction (EAD), primary nonfunction (PNF) and death. A lactate concentration at the end of transplant of ≥5 mmol/L was recently proposed as a predictive marker of PNF, EAD, and mortality; this study aimed to validate these previous reports in a large single center cohort. METHODS: This retrospective cohort study included adult liver transplant recipients who received grafts from deceased donors at our center between June 2012 and May 2021. Receiver operating characteristic (ROC) curves for the lactate concentration at the end of transplantation were computed to determine the AUC for PNF, EAD and mortality at 90 days. RESULTS: In our cohort of 1137 cases, the AUCs for lactate to predict EAD, PNF and mortality were respectively .56 (95% confidence interval [CI]: .53-.60), .69 (95% CI: .52-.85), and .74 (95% CI: .63-.84). CONCLUSION: The clinical value of lactate concentration at the end of transplantation to predict PNF, EAD and mortality at 90 days was, at best, modest, as shown by the relatively low AUCs. Our findings cannot validate previous reports that the lactate level alone is a good predictor of poor outcomes after liver transplantation.

Perioperative mortality in liver transplantation before and after the implementation of the organ allocation policy Share 35.

INTRODUCTION: In 2013, a new liver transplant allocation policy (Share 35) aimed to reduce waitlist-mortality was introduced in the United States. Regional organ sharing for recipients with a MELD score of ≥35 was prioritized over local allocation to those with lower MELD scores. Our aim was to assess the changes in perioperative mortality following the introduction of Share 35 as well as changes in patients' short-term 7-day survival, patients discharged alive and 1-year survival. Analyses were also carried out for the subgroups of patients with MELD scores ≥ and < 35. METHODS: We used data from the Scientific Registry of Transplant Recipients and included liver transplants between March 2002 and December 2018 in this retrospective cohort study. Perioperative mortality was defined as death during and within two days of liver transplant. We used robust interrupted time series analyses to evaluate the impact of Share 35 on mortality. RESULTS: We included 90 002 liver transplants in our analysis and observed a decreasing trend in perioperative mortality over time (-.061 deaths per 1000 cases per month, 95% CI -.084 to -.037, p < .001). Share 35 was not associated with a change in perioperative mortality (p = .33), short-term 7-day survival (p = .48), survival to discharge (p = .56), or 1-year survival (p = .27). CONCLUSIONS: Prioritizing sicker recipients with a MELD score ≥35 for liver transplantation was not associated with a change in postoperative mortality.

Wildfire Smoke Exposure Is Associated with Adverse Respiratory Events under General Anesthesia in At-risk Pediatric Patients.

BACKGROUND: Increasing wildfire activity worldwide has led to exposure to poor air quality and numerous detrimental health impacts. This study hypothesized an association between exposure to poor air quality from wildfire smoke and adverse respiratory events under general anesthesia in pediatric patients. METHODS: This was a single-center retrospective double-cohort study examining two significant wildfire events in Northern California. Pediatric patients presenting for elective surgery during periods of unhealthy air quality were compared with those during periods of healthy air quality. The primary exposure, unhealthy air, was determined using local air quality sensors. The primary outcome was the occurrence of an adverse respiratory event under anesthesia. Secondary analysis included association with other known risk factors for adverse respiratory events. RESULTS: A total of 625 patients were included in the analysis. The overall risk of a respiratory complication was 42.4% (265 of 625). In children without a history of reactive airway disease, the risk of adverse respiratory events did not change during unhealthy air periods (102 of 253, 40.3%) compared with healthy air periods (95 of 226, 42.0%; relative risk 0.96 [0.77 to 1.19], P = 0.703). In children with a history of reactive airway disease, the risk of adverse respiratory events increased from 36.8% (25 of 68) during healthy air periods to 55.1% (43 of 78) during periods with unhealthy air (1.50 [1.04 to 2.17], P = 0.032). The effect of air quality on adverse respiratory events was significantly modified by reactive airways disease status (1.56 [1.02 to 2.40], P = 0.041). CONCLUSIONS: Pediatric patients with underlying risk factors for respiratory complications under general anesthesia had a greater incidence of adverse respiratory events during periods of unhealthy air quality caused by wildfire smoke. In this vulnerable patient population, postponing elective anesthetics should be considered when air quality is poor.

Perioperative outcomes for patients on chronic buprenorphine undergoing spine surgery: A case series.

OBJECTIVE: Pain management following spine surgery can be challenging as patients routinely suffer from chronic pain and opioid tolerance. The increasing popularity of buprenorphine use for pain management in this population may further complicate perioperative pain management due to the limited efficacy of other opioids in the presence of buprenorphine. This study describes perioperative management and outcomes in patients on chronic buprenorphine who underwent elective inpatient spine surgery. DESIGN: The authors performed a retrospective chart review of all patients >18 years of age taking chronic buprenorphine for any indication who had elective inpatient spine surgery at a single institution. Perioperative pain management data were analyzed for all patients who underwent spine surgery and were maintained on buprenorphine during their hospital stay. SETTING: The study was performed at a single tertiary academic medical center. MAIN OUTCOME MEASURES: The primary outcome measures were post-operative pain scores and analgesic medication requirements. RESULTS: Twelve patients on buprenorphine underwent inpatient spine surgery. Acceptable pain control was achieved in all cases. Management included preoperative dose limitation of buprenorphine when indicated and the extensive use of multimodal analgesia. CONCLUSION: The question whether patients presenting for painful, elective surgery should continue using buprenorphine perioperatively is an area of controversy, and the present manuscript provides more evidence for the concept of therapy continuation with buprenorphine.

Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study.

BACKGROUND: Perioperative normal saline administration remains common practice during kidney transplantation. The authors hypothesized that the proportion of balanced crystalloids versus normal saline administered during the perioperative period would be associated with the likelihood of delayed graft function. METHODS: The authors linked outcome data from a national transplant registry with institutional anesthesia records from 2005 to 2015. The cohort included adult living and deceased donor transplants, and recipients with or without need for dialysis before transplant. The primary exposure was the percent normal saline of the total amount of crystalloids administered perioperatively, categorized into a low (less than or equal to 30%), intermediate (greater than 30% but less than 80%), and high normal saline group (greater than or equal to 80%). The primary outcome was the incidence of delayed graft function, defined as the need for dialysis within 1 week of transplant. The authors adjusted for the following potential confounders and covariates: transplant year, total crystalloid volume, surgical duration, vasopressor infusions, and erythrocyte transfusions; recipient sex, age, body mass index, race, number of human leukocyte antigen mismatches, and dialysis vintage; and donor type, age, and sex. RESULTS: The authors analyzed 2,515 records. The incidence of delayed graft function in the low, intermediate, and high normal saline group was 15.8% (61/385), 17.5% (113/646), and 21% (311/1,484), respectively. The adjusted odds ratio (95% CI) for delayed graft function was 1.24 (0.85 to 1.81) for the intermediate and 1.55 (1.09 to 2.19) for the high normal saline group compared with the low normal saline group. For deceased donor transplants, delayed graft function in the low, intermediate, and high normal saline group was 24% (54/225 [reference]), 28.6% (99/346; adjusted odds ratio, 1.28 [0.85 to 1.93]), and 30.8% (277/901; adjusted odds ratio, 1.52 [1.05 to 2.21]); and for living donor transplants, 4.4% (7/160 [reference]), 4.7% (14/300; adjusted odds ratio, 1.15 [0.42 to 3.10]), and 5.8% (34/583; adjusted odds ratio, 1.66 [0.65 to 4.25]), respectively. CONCLUSIONS: High percent normal saline administration is associated with delayed graft function in kidney transplant recipients.

Continuous Lumbar Plexus Block vs Continuous Lumbar Erector Spinae Plane Block for Postoperative Pain Control After Revision Total Hip Arthroplasty.

BACKGROUND: Optimal pain management is key to successful recovery in revision total hip arthroplasty. Lumbar plexus blocks (LPBs) have traditionally been used for postoperative pain management. Recently, the lumbar erector spinae plane block (LESPB) has emerged as a promising regional anesthesia technique and is relatively simple to perform. Our study aimed to evaluate whether continuous LESPB provided better analgesia and clinical outcomes than continuous LPB in revision hip arthroplasty. MATERIAL AND METHODS: We compared 25 LPBs with 25 LESPBs performed from October 2017 to November 2018 for revision hip arthroplasty. The primary outcome of this study was difference in opioid consumption between the groups at 24 hours postoperatively. Secondary outcomes include pain scores, hospital lengths of stay, pain adjunct consumption, and incidence of postoperative nausea and vomiting. RESULTS: There was no significant difference in average opioid consumption between the LPB and LESPB groups during the first 24 hours postoperatively (73.8 ± 68.1 mg vs 85.1 ± 69.7 mg, respectively, P = .57). Similarly, there was no significant difference in average pain scores (3.3 ± 2.1 vs 3.7 ± 1.8, respectively, P = .42). CONCLUSIONS: There was no significant difference in opioid consumption and pain scores in patients with continuous LESPB compared with those with continuous LPB. While our study did not show a difference in these outcomes, the LESPB is a straightforward regional block that avoids many of the risks of LPBs and may be as effective for pain control.

Correction: Cross-cultural adaptation of the Fresno Test for Turkish language.

[This corrects the article DOI: 10.1371/journal.pone.0245195.].

Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial.

BACKGROUND: This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block. METHODS: 208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner's syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting. RESULTS: Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2-6] vs. 6 min [4-10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome. CONCLUSION: The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.

Cross-cultural adaptation of the Fresno Test for Turkish language.

OBJECTIVE: National and international medical organizations and boards have recognized the importance of Evidence Based Medicine (EBM) and emphasized that EBM training should be included in medical education programs. Although some Turkish medical schools have developed and implemented EBM training programs, no validated Turkish language assessment tool has been available to compare the effectiveness of these training programs to national or international standards. The aim of this study is to cross-culturally adapt the Fresno Test, which is a validated English language tool utilized worldwide in the assessment of EBM training. METHODS: This study is a cross-sectional validation study, which was performed in two stages: Cross-cultural adaptation of the Fresno Test into Turkish; and evaluation of the psychometric properties, validity, reliability and responsiveness, of the Turkish version of the Fresno Test. RESULTS: The content validity of the test was evaluated by experienced physicians in the field of Evidence-Based Medicine, and the content validity index was 1.00. The Cronbach α coefficient was 0.78 on the post-test results. The intraclass correlation (ICC) coefficient and the kappa analysis were calculated to evaluate inter-rater reliability. The ICC coefficients ranged from 0.66 to 0.97 for pre- and post-test results. The Kappa coefficients were 1.00 for all pre-test and post-test questions except one post-test question which was 0.89. The change score of the Fresno Test was used to evaluate responsiveness. The students' score of the Turkish Fresno Test was 49.9 ±18.2 pre-training and 118.9 ±26.3 post-training with a change of 69 points (95% CI, 63.9-74.2). The Cohen's effect size was 3.04 (95% CI, 2.6-3.5) indicating a very large change in scores. CONCLUSIONS: The Turkish adapted Fresno Test used to evaluate students' success and program effectiveness is a valid and reliable measurement tool. It will be of great benefit for the comparison of the effectiveness of Turkish education programs nationally and cross-culturally.

The effects of transmuscular quadratus lumborum blocks on postoperative pain in arthroscopic hip surgery: a cohort analysis.

PURPOSE: The Transmuscular Quadratus Lumborum block (TQLB) is one of the newest blocks and has been used as an effective analgesic option for various surgeries. However, it is still uncertain whether the TQLB provides beneficial analgesic outcomes for hip arthroscopic surgeries. Therefore, we aimed to investigate effects of the preoperative TQLB on postoperative pain levels and perioperative opioid consumption in patients who underwent outpatient arthroscopic hip surgery. METHODS: In this retrospective cohort study, patients who underwent arthroscopic hip surgery for femoroacetabular impingement (FAI) between June 1, 2017 and December 1, 2017 were included. All patients received general anesthesia for surgery. Two groups of patients were compared: (1) patients who received a preoperative TQLB, (2) patients who did not receive a TQLB. RESULTS: Seventy procedures (68 patients) were included in the study. Of these, 15 procedures (15 patients) received a preoperative TQLB (TQLB group) in addition to general anesthesia, whereas the other 55 procedures (54 patients) received general anesthesia only (control group). Highest pain scores in the PACU were similar in the TQLB (6.2) group versus the control group (5.6) (95% CI [Formula: see text] 2.08 to 0.99, p = 0.484). Pain scores decreased over time in both groups and there were no statistical differences in mean values or absolute risk differences between study groups (95% CI [Formula: see text] 0.19 to 0.33, P = 0.596). In addition, there were no significant differences in perioperative opioid consumption, length of PACU stay, or the need for a rescue block in the PACU between the two groups. CONCLUSION: The present study did not find the preoperative TQLB to be an effective analgesic technique for patients who underwent arthroscopic hip surgery for FAI. A randomized clinical trial may further validate these results.

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. METHODS: In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. RESULTS: The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: -0.2 (95% CI, -1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. CONCLUSIONS: Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery: A Multicenter Study by the Perioperative Research Network Investigators.

Importance: Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy. Objective: To prospectively study clinical and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population. Design, Setting, and Participants: We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables. Exposure: Noncardiothoracic surgery. Main Outcomes and Measures: Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables. Results: This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency [yes vs no]: odds ratio [OR], 4.47, 95% CI, 1.59-12.56; surgical site [abdominal/pelvic vs nonabdominal/pelvic]: OR, 2.54, 95% CI, 1.67-3.89; and age [in years]: OR, 1.03, 95% CI, 1.02-1.05) and potentially modifiable (colloid administration [yes vs no]: OR, 1.75, 95% CI, 1.03-2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80-0.93; blood loss [in milliliters]: OR, 1.17, 95% CI, 1.05-1.30; anesthesia duration [in minutes]: OR, 1.14, 95% CI, 1.05-1.24; and tidal volume [in milliliters per kilogram of predicted body weight]: OR, 1.12, 95% CI, 1.01-1.24) factors. Conclusions and Relevance: Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.

Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial.

STUDY OBJECTIVE: To compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. DESIGN: Prospective, randomized clinical trial. SETTING: Ambulatory surgery center affiliated with an academic medical center. PATIENTS: Sixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction. INTERVENTIONS: Subjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block. MEASUREMENTS: Our primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3. MAIN RESULTS: The highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P=.002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8mg intravenous morphine equivalents, P<.001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1minutes, P=.006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups. CONCLUSIONS: Preoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.

Anaesthetic techniques for risk of malignant tumour recurrence.

BACKGROUND: Surgery remains a mainstay of treatment for malignant tumours; however, surgical manipulation leads to a significant systemic release of tumour cells. Whether these cells lead to metastases is largely dependent on the balance between aggressiveness of the tumour cells and resilience of the body. Surgical stress per se, anaesthetic agents and administration of opioid analgesics perioperatively can compromise immune function and might shift the balance towards progression of minimal residual disease. Regional anaesthesia techniques provide perioperative pain relief; they therefore reduce the quantity of systemic opioids and of anaesthetic agents used. Additionally, regional anaesthesia techniques are known to prevent or attenuate the surgical stress response. In recent years, the potential benefit of regional anaesthesia techniques for tumour recurrence has received major attention and has been discussed many times in the literature. In preparing this review, we aimed to summarize the current evidence systematically and comprehensively. OBJECTIVES: To establish whether anaesthetic technique (general anaesthesia versus regional anaesthesia or a combination of the two techniques) influences the long-term prognosis for individuals with malignant tumours. SEARCH METHODS: We searched The Cochrane Library (2013, Issue 12), PubMed (1950 to 15 December 2013), EMBASE (1974 to 15 December 2013), BIOSIS (1926 to 15 December 2013) and Web of Science (1965 to 15 December 2013). We handsearched relevant websites and conference proceedings and reference lists of cited articles. We applied no language restrictions. SELECTION CRITERIA: We included all randomized controlled trials or controlled clinical trials that investigated the effects of general versus regional anaesthesia on the risk of malignant tumour recurrence in patients undergoing resection of primary malignant tumours. Comparisons of interventions consisted of (1) general anaesthesia alone versus general anaesthesia combined with one or more regional anaesthetic techniques; (2) general anaesthesia combined with one or more regional anaesthetic techniques versus one or more regional anaesthetic techniques; and (3) general anaesthesia alone versus one or more regional anaesthetic techniques. Primary outcomes included (1) overall survival, (2) progression-free survival and (3) time to tumour progression. DATA COLLECTION AND ANALYSIS: Two review authors independently scanned the titles and abstracts of identified reports and extracted study data.All primary outcome variables are time-to-event data. If the individual trial report provided summary statistics with odds ratios, relative risks or Kaplan-Meier curves, extracted data enabled us to calculate the hazard ratio using the hazard ratio calculating spreadsheet. To assess risk of bias, we used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included four studies with a total of 746 participants. All studies included adult patients undergoing surgery for primary tumour resection. Two studies enrolled male and female participants undergoing major abdominal surgery for cancer. One study enrolled male participants undergoing surgery for prostate cancer, and one study male participants undergoing surgery for colon cancer. Follow-up time ranged from nine to 17 years. All four studies compared general anaesthesia alone versus general anaesthesia combined with epidural anaesthesia and analgesia. All four studies are secondary data analyses of previously conducted prospective randomized controlled trials.Of the four included studies, only three contributed to the outcome of overall survival, and two each to the outcomes of progression-free survival and time to tumour progression. In our meta-analysis, we could not find an advantage for either study group for the outcomes of overall survival (hazard ratio (HR) 1.03, 95% confidence interval (CI) 0.86 to 1.24) and progression-free survival (HR 0.88, 95% CI 0.56 to 1.38). For progression-free survival, the level of inconsistency was high. Pooled data for time to tumour progression showed a slightly favourable outcome for the control group (general anaesthesia alone) compared with the intervention group (epidural and general anaesthesia) (HR 1.50, 95% CI 1.00 to 2.25).Quality of evidence was graded low for overall survival and very low for progression-free survival and time to tumour progression. The outcome of overall survival was downgraded for serious imprecision and serious indirectness. The outcomes of progression-free survival and time to tumour progression were also downgraded for serious inconsistency and serious risk of bias, respectively.Reporting of adverse events was sparse, and data could not be analysed. AUTHORS' CONCLUSIONS: Currently, evidence for the benefit of regional anaesthesia techniques on tumour recurrence is inadequate. An encouraging number of prospective randomized controlled trials are ongoing, and it is hoped that their results, when reported, will add evidence for this topic in the near future.

Anesthesia management of patients undergoing hyperthermic isolated limb perfusion with melphalan for melanoma treatment: an analysis of 17 cases.

BACKGROUND: Hyperthermic isolated limb perfusion (HILP) is used for patients with intractable or extensive in-transit metastatic melanoma of the limb to deliver high concentrations of cytotoxic agents to the affected limb and offers a treatment option in a disease stage with a poor prognosis when no treatment is given. METHODS: In a retrospective chart review of 17 cases, we studied the anesthetic and hemodynamic changes during HILP and its management. RESULTS: HILP was well tolerated except in one case that is described herein. We present summary data of all cases undergoing upper and lower limb perfusion, discuss our current clinical practice of preoperative, perioperative and intraoperative patient care including the management of HILP circuit. CONCLUSION: HILP is a challenging procedure, and requires a team effort including the surgical team, anesthesia care providers, perfusionists and nurses. Intraoperatively, invasive hemodynamic and metabolic monitoring is indispensable to manage significant hemodynamic and metabolic changes due to fluid shifts and release of cytokines.

Effects of theophylline on anesthetized malignant hyperthermia-susceptible pigs.

BACKGROUND: Theophylline was shown to induce contracture development in porcine malignant hyperthermia (MH) susceptible (MHS) skeletal muscles in vitro. The purpose of the current study was to investigate the in vivo effects of theophylline in MHS and MH normal (MHN) swine. METHODS: MH-trigger-free general anesthesia was performed in MHS and MHN swine. Theophylline was administered intravenously in cumulative doses up to 93.5 mg·kg⁻¹. The clinical occurrence of MH was defined by changes of central-venous pCO2, central-venous pH, and body core temperature. RESULTS: Theophylline induced comparable clinical alterations in the anesthetized MHS and MHN swine, especially in regard to hemodynamic data. No pig developed hypermetabolism and/or MH according to defined criteria. All animals died with tachycardia followed by ventricular fibrillation. CONCLUSIONS: The cumulative theophylline doses used in this study were much higher than doses used therapeutically in humans, as demonstrated by measured blood concentrations. Theophylline is thus not a trigger of MH in genetically determined swine.

Nausea and vomiting after office-based anesthesia.

PURPOSE OF THE REVIEW: Safety, quality, and patient satisfaction are not only defined by the incidences of serious adverse events but also include postoperative outcomes such as postdischarge nausea and vomiting (PDNV). PDNV has a high impact on patient recovery and may influence the cost-effectiveness of office-based surgical procedures. This article reviews the incidences and risk factors for PDNV as well as medications and concepts for prophylaxis and treatment. RECENT FINDINGS: Patients with PDNV require a longer recovery time to resume normal activities. PDNV can delay discharge from postanesthesia care units and is one of the leading causes of unexpected hospital admission after planned outpatient surgery. New data indicate that the incidence of PDNV is higher than expected and therefore we need a model that allows us to identify patients at risk for PDNV. A PDNV prediction model will help clinicians to better identify patients at risk who might benefit from long-acting antiemetics such as transdermal scopolamine, aprepitant, and/or palonosetron. SUMMARY: PDNV is an under-recognized problem after outpatient anesthesia. Valid data for the incidence and the best treatment of PDNV after office-based anesthesia are rare. For safety, quality, and patient satisfaction, further research is needed to develop a prediction model to better identify patients at risk for PDNV in order to direct antiemetic prophylaxis for ambulatory patients undergoing office-based anesthesia.

Cumulative and bolus in vitro contracture testing with 4-chloro-3-ethylphenol in malignant hyperthermia positive and negative human skeletal muscles.

In this study we evaluated the in vitro effects of 4-chloro-3-ethylphenol (CEP) using cumulative (12.5-200 micromol/L) or bolus (75 and 100 micromol/L) administrations, on muscle specimens from malignant hyperthermia (MH) susceptible and MH nonsusceptible patients, respectively. In the cumulative CEP in vitro contracture test, contractures were significantly greater in the MH susceptible compared with the MH nonsusceptible muscles in all concentrations between 25 and 100 micromol/L. There was no overlap between the diagnostic groups at 75 micromol/L of CEP, so this test appears to be feasible for diagnosis of MH susceptibility. The two bolus tests are not diagnostically useful, as overlaps between the diagnostic groups were observed.