Effect of sugammadex on processed EEG parameters in patients undergoing robot-assisted radical prostatectomy.

BACKGROUND: Sugammadex has been associated with increases in the bispectral index (BIS). We evaluated the effects of sugammadex administration on quantitative electroencephalographic (EEG) and electromyographic (EMG) measures. METHODS: We performed a prospective observational study of adult male patients undergoing robot-assisted radical prostatectomy. All patients received a sevoflurane-based general anaesthetic and a continuous infusion of rocuronium, which was reversed with 2 mg kg-1 of sugammadex i.v. BIS, EEG, and EMG measures were captured with the BIS Vista™ monitor. RESULTS: Twenty-five patients were included in this study. Compared with baseline, BIS increased at 4-6 min (ß coefficient: 3.63; 95% confidence interval [CI]: 2.22-5.04; P<0.001), spectral edge frequency 95 (SEF95) increased at 2-4 min (ß coefficient: 0.29; 95% CI: 0.05-0.52; P=0.016) and 4-6 min (ß coefficient: 0.71; 95% CI: 0.47-0.94; P<0.001), and EMG increased at 4-6 min (ß coefficient: 1.91; 95% CI: 1.00-2.81; P<0.001) after sugammadex administration. Compared with baseline, increased beta power was observed at 2-4 min (ß coefficient: 93; 95% CI: 1-185; P=0.046) and 4-6 min (ß coefficient: 208; 95% CI: 116-300; P<0.001), and decreased delta power was observed at 4-6 min (ß coefficient: -526.72; 95% CI: -778 to -276; P<0.001) after sugammadex administration. Neither SEF95 nor frequency band data analysis adjusted for EMG showed substantial differences. None of the patients showed clinical signs of awakening. CONCLUSIONS: After neuromuscular block reversal with 2 mg kg-1 sugammadex, BIS, SEF95, EMG, and beta power showed small but statistically significant increases over time, while delta power decreased.

Factors Associated with Headache and Nausea During Magnetic Resonance-Guided Focused Ultrasound for Tremor.

BACKGROUND: During magnetic resonance-guided focused ultrasound for essential or parkinsonian tremor, adverse events (headache, nausea/vomiting, or anxiety) may alter the outcome of the procedure despite being mostly transient and mild. OBJECTIVES: Our aim was to analyze the relationship between demographic, procedural, and anesthetic characteristics with magnetic resonance/ultrasound-related events. METHODS: This was a retrospective study at the Clinica Universidad de Navarra of patients undergoing thalamotomy with magnetic resonance-guided focused ultrasound between September 2018 and October 2019. The anesthesia protocol included headache and nausea/vomiting prophylaxis and rescue therapy. Dexmedetomidine was used for anxiolysis in some patients after thorough multidisciplinary assessment. RESULTS: A total of 123 patients were included. Headache was directly related to skull density ratio (P < 0.001) and skull thickness (P = 0.02). Patients with a skull density ratio less than 0.48 had 3 times the odds of experiencing moderate or severe headache (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.21-7.82) and had a higher odds of aborting sonication due to pain. Sex was associated with increased nausea (P = 0.007). Women had 4 times the odds of nausea than men (OR, 4.4; 95% CI, 1.61-12.11). Dexmedetomidine did not reduce headache or nausea incidence. Patients who received dexmedetomidine had a higher number (P = 0.01) and total minutes of sonication (P = 0.01). CONCLUSIONS: Patients with lower skull density ratios and higher skull thicknesses could benefit from an aggressive analgesic prophylaxis. Women are more likely to experience nausea. Dexmedetomidine did not reduce headache and nausea, but increased the number and duration of sonications. Its exact effect on tremor is still unclear.

Effects of dexmedetomidine on subthalamic local field potentials in Parkinson's disease.

BACKGROUND: Dexmedetomidine is frequently used for sedation during deep brain stimulator implantation in patients with Parkinson's disease, but its effect on subthalamic nucleus activity is not well known. The aim of this study was to quantify the effect of increasing doses of dexmedetomidine in this population. METHODS: Controlled clinical trial assessing changes in subthalamic activity with increasing doses of dexmedetomidine (from 0.2 to 0.6 µg kg-1 h-1) in a non-operating theatre setting. We recorded local field potentials in 12 patients with Parkinson's disease with bilateral deep brain stimulators (24 nuclei) and compared basal activity in the nuclei of each patient and activity recorded with different doses. Plasma levels of dexmedetomidine were obtained and correlated with the dose administered. RESULTS: With dexmedetomidine infusion, patients became clinically sedated, and at higher doses (0.5-0.6 µg kg-1 h-1) a significant decrease in the characteristic Parkinsonian subthalamic activity was observed (P<0.05 in beta activity). All subjects awoke to external stimulus over a median of 1 (range: 0-9) min, showing full restoration of subthalamic activity. Dexmedetomidine dose administered and plasma levels showed a positive correlation (repeated measures correlation coefficient=0.504; P<0.001). CONCLUSIONS: Patients needing some degree of sedation throughout subthalamic deep brain stimulator implantation for Parkinson's disease can probably receive dexmedetomidine up to 0.6 µg kg-1 h-1 without significant alteration of their characteristic subthalamic activity. If patients achieve a 'sedated' state, subthalamic activity decreases, but they can be easily awakened with a non-pharmacological external stimulus and recover baseline subthalamic activity patterns in less than 10 min. CLINICAL TRIAL REGISTRATION: EudraCT 2016-002680-34; NCT-02982512.

Influence of Chemotherapy Within 30 Days Before ICU Admission on Mortality in Critically Ill Medical Patients With Cancer.

BACKGROUND: The main objective was to determine whether the administration of chemotherapy (CT) during the month before intensive care unit (ICU) admission of medical patients with cancer influences the survival rate. The design was a single-institution observational cohort study in an ICU of a tertiary university hospital. METHODS: Our cohort included 248 oncology patients admitted to the ICU from 2005 to 2014 due to nonsurgical problems. Seventy-six (30.6%) patients had received CT in the month before admission (CT group) and 172 did not receive CT (control group). The main outcome measures were ICU, hospital, 30-day, 90-day, and 1-year mortalities. We performed survival analysis using the Kaplan-Meier estimator, comparing both groups using the log-rank test, and multivariate analysis using Cox regression adjusted for gender, age, maximum Sequential Organ Failure Assessment (SOFA), and delta maximum SOFA to calculate the hazard ratios (HRs) and their respective 95% confidence intervals. This association was also evaluated by a graphic representation of survival. RESULTS: The CT group presented an ICU mortality rate of 27.6% versus 25.5% in the control group. The multivariate analysis adjusted for age, sex, and delta maximum SOFA showed significant differences between the groups (HR: 2.12; P = .009). The hospital mortality rate was 55.3% in the CT group compared to 45.4% in the control group (adjusted HR: 1.81; P = .003). At 30 days, the mortality rate was 56.6% in the CT group compared to 46.5% in the control group (adjusted HR: 1.69; P = .008). Mortality at 90 days was 65.8% in the CT group versus 59.9% in the control group (adjusted HR: 1.47; P = .03). One-year mortality was also higher in the CT group (79% vs 72.7%, adjusted HR: 1.44; P = .02). CONCLUSION: The administration of CT in the month before ICU admission in patients with cancer was associated with higher mortality in the ICU, in the hospital, and 30 and 90 days after admission when adjusted for the increase in organ failure measured by delta maximum SOFA. We provide useful new information for decision-making about ICU management of patients with cancer.

Recovery time after oral and maxillofacial ambulatory surgery with dexmedetomidine: an observational study.

OBJECTIVES: To evaluate the relationship between pharmacokinetic descriptors of dexmedetomidine (predicted area under the curve during the procedure, predicted plasma level at the end of the procedure, and duration of procedure) and sedation depth (proportion of time with bispectral index < 85 during the procedure) with recovery time after ambulatory procedures. MATERIALS AND METHODS: Clinical observational study of patients undergoing oral and maxillofacial ambulatory surgery with dexmedetomidine as sole sedative agent. Patients received a loading dose of dexmedetomidine (0.25-1 µg kg-1) followed by a maintenance infusion (0.2-1.4 µg kg-1 h-1) to keep a bispectral index < 85 until 5 min before the end of the procedure, and were transferred to a post-anesthesia care unit until criteria for discharge were met. RESULTS: Data from 75 patients was analyzed. Sedation depth was directly associated with recovery time (Pearson correlation coefficient [r] = 0.26; p = 0.024). Around 7% of the variation in recovery time was explained by the proportion of time with bispectral index < 85. No association with procedure duration (r = 0.01; p = 0.9), predicted area under the curve (r = 0.1; p = 0.4), or predicted plasma level of dexmedetomidine at the end of the procedure (r = 0.12; p = 0.3) with recovery time was observed. CONCLUSIONS: Sedation depth with dexmedetomidine could play a role in increasing recovery time after oral and maxillofacial ambulatory surgery. In our study, the pharmacokinetic descriptors of dexmedetomidine did not seem to influence recovery time. CLINICAL RELEVANCE: Sedation depth with dexmedetomidine could play a role in increasing recovery time after ambulatory procedures.

Preoperative predictive model for acute kidney injury after elective cardiac surgery: a prospective multicenter cohort study.

BACKGROUND: Predictive models of acute kidney injury after cardiac surgery (CS-AKI) include emergency surgery and patients with hemodynamic instability. Our objective was to evaluate the performance of validated predictive models (Thakar and Demirjian) in elective cardiac surgery and to propose a better score in the case of poor performance. METHODS: A prospective, multicenter, observational study was designed. Data were collected from 942 patients undergoing cardiac surgery, after excluding emergency surgery and patients with an intra-aortic balloon pump. The main outcome measure was CS-AKI defined by the composite of requiring dialysis or doubling baseline creatinine values. RESULTS: Both models showed poor discrimination in elective surgery (Thakar's model, AUC=0.57, 95% CI: 0.50-0.64 and Demirjian's model, AUC=0.64, 95% CI: 0.58-0.71). We generated a new model whose significant independent predictors were: anemia, age, hypertension, obesity, congestive heart failure, previous cardiac surgery and type of surgery. It classifies patients with scores 0-3 as at low risk (<5%), patients with scores 4-7 as at medium risk (up to 15%), and patients with scores >8 as at high risk (>30%) of developing CS-AKI with a statistically significant correlation (P<0.001). Our model reflects acceptable discriminatory ability (AUC=0.72, 95% CI: 0.66-0.78) which is significantly better than Thakar and Demirjian's models (P<0.01). CONCLUSIONS: We developed a new simple predictive model of CS-AKI in elective surgery based on available preoperative information. Our new model is easy to calculate and can be an effective tool for communicating risk to patients and guiding decision-making in the perioperative period. The study requires external validation.

Factors Associated with Tremor Changes during Sedation with Dexmedetomidine in Parkinson's Disease Surgery.

INTRODUCTION: Dexmedetomidine is an α2-agonist recently proposed as a potentially ideal drug for sedation during the surgical treatment of Parkinson's disease (PD). This report documents the incidence of changes in motor symptoms (especially tremor) in PD patients sedated with dexmedetomidine for deep brain stimulation or ablation procedures. METHODS: We reviewed a retrospective cohort of 22 patients who underwent surgery for PD with dexmedetomidine sedation at a single institution from 2010 to 2014. A logistic regression analysis was performed to analyze possible confounding factors. RESULTS: 14 cases of tremor reduction or suppression were recorded (cumulative incidence: 63.6%; 95% CI: 40.7-82.8). No association could be identified between loading dose, ß-blocker use and preoperative total Unified Parkinson's Disease Rating Scale III, with tremor changes. The maintenance dose of dexmedetomidine was higher in patients who did not experience changes [median and range for patients with and without tremor alteration 0.75 (0.2-1.0) and 1.0 µg × kg(-1) × h(-1) (0.7-1.4), respectively; p = 0.021]. CONCLUSION: Dexmedetomidine provides adequate sedation during surgery for PD, but it might affect motor signs making intraoperative testing difficult or even impossible. Dosage appears not to be the determining factor in motor changes, whose cause remains unclear.