The Effects of Neuromonitoring and Cerebrolysin Administration on Outcomes in Patients with Traumatic Brain Injury-An Interventional Pilot Study.

INTRODUCTION: Traumatic brain injury (TBI) is one of the most common causes of death and an important burden to the worldwide healthcare system and society. There is a lack of guidelines for types of monitoring or neuroprotective therapy. The aim of this pilot study was to assess its feasibility and, furthermore, to evaluate the impact of Cerebrolysin on the following clinical outcomes: length of stay, Glasgow Outcome Scale (GOS) and mortality. METHODS: A cohort of 56 patients was included in this non-randomised, real-time, pre-post-interventional study. The patients were assessed with the Glasgow Coma Scale (GCS) and divided into two groups: severe (GCS < 8) and non-severe (GCS > 8). After the radiological examination (CT scan), the patients were qualified for an immediate neurosurgical procedure if needed. The patients were admitted to the intensive care unit, where a standardised protocol for TBI treatment was implemented. Additional neuromonitoring was applied. RESULTS: There were 56 patients (19 females; 33.9%), of which 41 were considered severe cases; the patients were allocated to the Cerebrolysin (n = 25) or control groups (n = 31). In a generalised linear model (GLM) approach, the use of Cerebrolysin was associated with a decrease in the probability of death in non-severe patients (by 0.333 (standard error (SE) = 0.157, p = 0.034)) but not in severe patients (estimate (Est.) = -0.115, SE = 0.127, p = 0.364). Patients who received Cerebrolysin and who were neuromonitored had favourable outcomes and better survival rates. CONCLUSIONS: A multimodal treatment approach with monitoring and Cerebrolysin may have a beneficial effect on patients with less severe TBIs; however, the present study has multiple limitations, and further research is needed.

Cerebrolysin in Patients with Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

Subarachnoid Hemorrhage (SAH) is one of the acute neurological conditions that is associated with high mortality and recovery failure rates. In recent years, due to the development of endovascular and classical techniques, the mortality rate after SAH has decreased. Currently, more research is focused on understanding the molecular mechanisms underlying SAH. Methods of treatment are investigated in order to obtain the best treatment result, not only survival. One of the drugs used in stroke, including SAH, is Cerebrolysin. It is a mixture of neuropeptides that has similar properties to neurotrophic factors. Its positive impact on strokes has been analyzed; however, there are no meta-analyses concerning only the subpopulation of patients diagnosed with SAH in the current literature. Therefore, we conducted a meta-analysis of available clinical trials to evaluate the effect of Cerebrolysin on the treatment outcome. The data suggest a positive effect of Cerebrolysin on the mortality of SAH patients. However, further randomized clinical trials with larger groups of patients are needed to draw final conclusions.

Novel Interdisciplinary Enhanced Recovery after Surgery Protocol Implementation in Paediatric Orthopaedics.

The enhanced recovery after surgery (ERAS) protocol is not routine management in paediatric orthopaedics. Cultural differences or assumptions about the financing of medical care in different countries encourage creative adaptation of general assumptions in local communities. The aim of this study was to compare the quality of the perioperative period before and after the introduction of an interdisciplinary protocol adopted to organisational conditions. A group of 4098 children were included in the "before-after" observational study. The data of 1553 patients (BEFORE group) were analysed in terms of compliance with the enhanced recovery after surgery protocol guidelines and the time and cost of hospitalisation over a 20-month period. A novel interdisciplinary protocol was developed, including an education and training app called BackOnFeet (BOF®), standardised hospital management, and the introduction of methods novel to Poland (intraoperative nerve cryoanalgesia in children). A further 2545 patients (AFTER group) were reassessed over a period of 20 months. It was found that the groups differed in hospitalisation time (p < 0.001), type of procedures, and percentage ratio of costs incurred to revenue generated. The usefulness of the BOF® app as an effective educational tool was demonstrated. The optimisation of perioperative management in paediatric orthopaedics based on novel tools and the interdisciplinary ERAS protocol is possible and brings tangible benefits in psychological, organisational, and financial terms.

Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes.

Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.

The Impact of Intraoperative Haemodynamic Monitoring, Prediction of Hypotension and Goal-Directed Therapy on the Outcomes of Patients Treated with Posterior Fusion Due to Adolescent Idiopathic Scoliosis.

A prospective, single-centre, non-randomised, case-control study aimed to evaluate the effectiveness of intraoperative haemodynamic monitoring, prediction of hypotension and goal-directed therapy on the outcomes of patients undergoing posterior fusion for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure control during surgery, while the intervention group (n = 24, mean age: 14 years) underwent minimally invasive haemodynamic monitoring and goal-directed therapy. The intervention group showed significantly shorter durations of hypotension (mean arterial pressure < 60 mmHg), reduced hospital stays and smaller decreases in post-surgery haemoglobin levels. Additionally, the intervention group experienced shorter times from the end of surgery to extubation. These findings suggest that incorporating targeted interventions during intraoperative care for AIS patients undergoing posterior fusion can lead to improved outcomes.

Cerebrolysin in Patients with TBI: Systematic Review and Meta-Analysis.

TBI (traumatic brain injury) is one of the most common causes of deaths and failure to return to society according to the latest statistics. Cerebrolysin is a drug approved for use in patients diagnosed with TBI. It is a mixture of neuropeptides derived from purified porcine brain proteins and multiple experimental studies have proven its neuroprotective and neurorestorative properties both in vitro and in vivo. In our meta-analysis, we analyze the latest clinical study reports on the use of Cerebrolysin in patients with TBI. The authors searched the databases: Pub Med, Cinahl, Web Of Science, and Embase from database inception until 11th July 2022. Ten clinical studies were eligible and included in the final analysis, including both retrospective and prospective studies of 8749 patients. Treatment with Cerebrolysin was associated with a statistically significant change in GCS and GOS. Mortality of any cause and the length of stay was not affected by the treatment. Our findings support and confirm the beneficial effects of Cerebrolysin treatment on the clinical outcome of patients after TBI. Further multi-center studies to optimize dosing and time of administration should be conducted.

Fascial plane blocks for breast surgery - current state of knowledge.

Breast surgeries belong to the most frequently performed procedures and are often associated with a high intensity of pain in the postoperative period. Regional anesthesia techniques, and paravertebral block, have been the gold standard of postoperative pain management for major breast cancer surgeries. In recent years, the development of new techniques of regional anesthesiology, which is due to the extensive implementation of ultrasound imaging, has enabled the use of a number of new blockades. The "new players" in regional anesthesiology include numerous fascial plane blocks. Fascial plane blocks are often technically easier and less invasive compared to, for example, paravertebral blockade. The core mechanism of action in fascial blocks consists in blocking the nerve structures that supply a certain area of the trunk after deposition of local anesthetic (LA) within the fascial and fasciomuscular compartments. In addition to direct nerve blockade, there are other potential mechanisms of analgesia such as systemic effects. This idea differs from the traditional concept of nerve and plexus blocks, but it should be remembered that the final effect of a fascial plane block and its extent can be extremely variable across individual cases. According to the current state of knowledge, an alternative to paravertebral blockade may be PECS blockade. The available options also include erector spinae plane block (ESPB) and serratus plane block (SPB), however their recommendation in breast surgery requires more extensive scientific evidence.

Intercostal nerve cryoanalgesia in the treatment of pain in patients operated on by the modified Nuss method with the BackOnFeet application-a new strategy to improve outcomes.

Introduction: The surgical Nuss correction of the funnel chest deformity is a painful procedure without an established consensus of pain relief methods. High doses and long duration of opioids requirements impedes the ERAS protocol introduction. The aim of this study was to evaluate the effectiveness of intraoperative intercostal nerve cryolysis in terms of pain management in relation to the routinely used multimodal analgesia in Poland. We also assessed the impact of using the proprietary "BackOnFeet" application on the quality of life of patients after surgery in relation to the ERAS protocol. Methods: The prospective, single-centre, non-randomised, before-after pilot study was conducted. Inclusion criteria were: funnel-shaped chest deformity, age range 11-18 years, first chest wall operation, agreement for the cryolysis and regional analgesia, no history of chronic painkillers use. The results of the "control group" (multimodal analgesia with regional analgesia commonly performed in Poland) were assessed. The interdisciplinary perioperative protocol with the "BackOnFeet" application and intraoperative intercostal nerve cryoanalgesia were introduced to the "intervention group". Results: Eighteen children were treated with standard protocol typical for Polish management and matched to eighteen patients who received cryoanalgesia and the "BackOnFeet" application access "intervention group". We noticed lower NRS points in first 24 h (p = 0.0048), shortening of time of opioid use (p = 0.0002), hospitalisation time (p = 0,01), improved quality of postoperative rehabilitation (p < 0.0001) and quality of life (p < 0.0001) among the "intervention group". Conclusions: Intraoperative intercostal nerves cryolysis performed during the minimally invasive Nuss correction of funnel deformation in combination with bilateral is more effective in terms of acute pain management in relation to the routinely used multimodal analgesia in Poland, allowing for the shortening of time of opioid use, hospitalisation time, improved quality of postoperative rehabilitation and enabled ERAS protocol introduction. The use of the proprietary "BackOnFeet" application has a positive effect on the quality of life of patients after surgery.

Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review.

Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU) in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk.