Impact of anesthesia modalities on functional outcome of mechanical thrombectomy in patients with acute ischemic stroke: a subgroup analysis of DIRECT-MT trial.

BACKGROUND: This subgroup analysis of Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals Multicenter Randomized Clinical Trial (DIRECT-MT) aimed to investigate the influence of anesthesia modalities on the outcomes of endovascular treatment. METHODS: Patients were divided into two groups by receiving general anesthesia (GA) or non-general anesthesia (non-GA). The primary outcome was assessed by the between-group difference in the distribution of the modified Rankin Scale (mRS) at 90 days, estimated using the adjusted common odds ratio (acOR) by multivariable ordinal regression. Differences in workflow efficiency, procedural complication, and safety outcomes were analyzed. RESULTS: Totally 636 patients were enrolled (207 for GA and 429 for non-GA groups). There was no significant shift in the mRS distribution at 90 days between the two groups (acOR, 1.093). The median time from randomization to reperfusion was significantly longer in GA group (116 vs. 93 min, P < 0.0001). Patients in non-GA group were associated with a significantly lower NIHSS score at early stages (24 h, 11 vs 15; 5-7 days or discharge, 6.5 vs 10). The rate of severe manipulation-related complication did not differ significantly between GA and non-GA groups (0.97% vs 3.26%; P = 0.08). There are no differences in the rate of mortality and intracranial hemorrhage. CONCLUSIONS: In the subgroup analysis of DIRECT-MT, we found no significant difference in the functional outcome at 90 days between general anesthesia and non-general anesthesia, despite the workflow time being significantly delayed for patients with general anesthesia. Clinical trail registration clinicaltrials.gov Identifier: NCT03469206.

The Protective Effects of Geraniol Against Damage of Short Term Renal Ischemia-Reperfusion in Rats

Abstract Ischemia/reperfusion (I/R) injury is one of the main causes of acute kidney injury. The pathological mechanisms underlying renal I/R injury are complex and remain uncertain. The protective effects of antioxidant properties of geraniol against renal ischemia reperfusion (I/R) damage were investigated in our study. 28 Wistar albino male rats were randomly selected and 4 groups of n = 7 were created. A right kidney nephrectomy surgery was conducted to all groups under anesthesia. 2 ml SF was given to Groups I and II, 50 mg/kg and 100 mg/ kg geraniol were administered intraperitoneally an hour before ischemia to Groups III and IV, respectively. Except for Group I, 45 minutes of ischemia and 4 hours of reperfusion were applied to the groups. At the end of the experiment, parameters related to oxidative stress and inflammation were determined by comparing kidney function, antioxidant enzyme activities and histological changes. Following comparison of BUN and CRE values with CAT and SOD values in tissue samples of Group I and Group II, an increase in Group II was observed and as a result I/R damage formation occurred. Values of geraniol-treated Group III and Group IV approximated to that of Group I, and that the 50 mg/kg geraniol dose proved more effective than 100 mg/kg geraniol.

Monitoring the Depth of Anesthesia Through the Use of Cerebral Hemodynamic Measurements Based on Sample Entropy Algorithm.

OBJECTIVE: The aim of this study is to explore the relationship between the depth of anesthesia and the cerebral hemodynamic variables during the complete anesthesia process. METHODS: In this study, near-infrared spectroscopy signals were used to record eight kinds of cerebral hemodynamic variables, including left, right, proximal, distal deoxygenated (Hb) and oxygenated (HbO2) hemoglobin concentration changes. Then, by measuring the complexity information of cerebral hemodynamic variables, the sample entropy was calculated as a new index of monitoring the depth of anesthesia. RESULTS: By means of receiver operating characteristic curve analysis, the sample entropy approach was proved to effectively discriminate anesthesia maintenance and waking phases. The discriminatory ability of HbO2 signals was stronger than that of Hb signals and the distal signals had weaker discrimination capability when compared with the proximal signals. In addition, there was statistical consistency between the bispectral index and sample entropy of cerebral hemodynamic variables during the complete anesthesia process. Moreover, the cerebral hemodynamic signals could not be interfered by clinical electrical devices. CONCLUSION: The sample entropy of cerebral hemodynamic variables could be suitable as a new index for monitoring the depth of anesthesia. SIGNIFICANCE: This study is very meaningful for developing new modality and decoding methods in perspective of anesthesia surveillance and may result in the anesthesia monitoring system with high performance.

Safety and efficacy of ketamine xylazine along with atropine anesthesia in BALB/c mice

Anesthetics are an indispensable prerequisite for surgical intervention and pharmacological animal studies. The objective of present study was to optimize the dose of ketamine (K) and xylazine (X) along with atropine sulfate (A) in order to achieve surgical tolerance in BALB/c mice. Several doses of ketamine (100, 150, 200 mg/kg) and xylazine (10, 15, 20 mg/kg) were mixed and combination of nine doses (K/X: 100/10, 100/15, 100/20, 150/10, 150/15, 150/20, 200/10,200/15,200/20) were evaluated (n=9 per combination). A constant dose of atropine (0.05 mg/kg) was also used to counter side effect. Time-related parameters were evaluated on the basis of reflexes. KX at dose 200/20 mg/kg produced surgical tolerance in all nine mice with duration 55.00±6.87 minutes. The induction time 0.97±0.09 minutes, sleeping time 90.67±5.81 minutes and immobilization time (102.23±6.83 minutes) were significantly higher than all combination. However, this combination was considered unsafe due to 11 % mortality. While, KX at dose 200/15 mg/kg results in none of the mortality, so was considered as safe. Moreover, this combination produces surgical tolerance in 89 % mice with duration (30.00±7.45 minutes). It was concluded that KX at dose 200/15 mg/kg along with atropine 0.05 mg/kg is safe for performing surgical interventions in BALB/c mice.

Anesthetic complications in diabetic dogs subjected to phacoemulsification / Complicações anestésicas em cães diabéticos submetidos a facoemulsificação

The aim of this paper was to compare the incidence of anesthetic complications in diabetic and nondiabetic dogs subjected to phacoemulsification. In total, 30 male and female dogs of different breeds were used. The dogs were distributed into two groups: diabetic (DG) (n=15) and control (CG) (n=15). The animals were premedicated with acepromazine (0.03mg/kg) and meperidine (4mg/kg), intramuscularly. After 20 minutes, anesthesia was induced with propofol (2 to 5mg/kg) and maintained with isoflurane. The animals were monitored and the heart rate, respiratory rate, peripheral oxyhemoglobin saturation, end tidal carbon dioxide tension, inspired and expired isoflurane fraction, and invasive arterial pressure were recorded at 10 minute intervals during the surgical procedure. Arterial hemogasometry was performed after anesthetic induction (T0) and at the end of the surgical procedure. Diabetic patients (DG 10±2 years) were older than non-diabetic group (CG 6±2 years). The expired isoflurane fraction after induction was 30% higher in the control group (CG 1.3±0.3%, DG 1.0±0.2%) (p<0.01). The most common anesthetic complication was hypotension. In total, 80% of the diabetic animals (n=12) exhibited mean arterial pressure (MAP) lower than 60mmHg (54±9.6mmHg) after anesthetic induction, and 83% of the hypotensive dogs (n=10) required vasoactive drugs to treat hypotension. Regarding hemodynamic changes, diabetic patients subjected to general anesthesia were more likely to exhibit hypotension which may be due to the response of older animals to the drugs used; however, this change deserves further investigation.(AU)

O objetivo do presente estudo foi comparar a incidência de complicações anestésicas em cães diabéticos e não diabéticos submetidos a cirurgia de facoemulsificação. Foram utilizados 30 cães, machos ou fêmeas de diversas raças. Os cães foram distribuídos em dois grupos: diabético (GD) (n=15) e controle (GC) (n=15). Os animais foram pré-tratados com acepromazina (0,03mg/kg) e meperidina (4mg/kg), pela via intramuscular. Após 20 minutos, a indução foi realizada com propofol (2 a 5mg/kg) e a manutenção da anestesia com isofluorano. Os animais foram monitorados e as variáveis de frequência cardíaca, frequência respiratória, saturação oxihemoglobina periférica, concentração dióxido de carbono no final da expiração, fração inspirada e expirada de isofluorano e pressão arterial invasiva, foram registradas em intervalos de 10 minutos durante o procedimento cirúrgico. A hemogasometria arterial foi realizada após a indução (T0) e ao final do procedimento cirúrgico (T40). A idade dos animais do grupo diabético (10±2 anos) foi superior em relação aos animais do grupo controle (6±2 anos) (p<0,0001). A concentração expirada de isofluorano após a indução foi 30% superior nos animais do grupo controle (GC 1,3±0,3%, GD 1,0±0,2%) (p<0,01). A complicação anestésica mais comum foi a hipotensão arterial, 80% dos animais diabéticos (n=12) apresentaram pressão arterial média inferior a 60mmHg (54±9.6 mmHg) após indução anestésica; 83% dos cães hipotensos (n=10) necessitaram de fármacos vasoativos para tratamento da hipotensão. Com relação às alterações hemodinâmicas, os pacientes diabéticos submetidos à anestesia geral foram mais propensos à hipotensão arterial que pode ser decorrente da resposta dos animais mais velhos aos fármacos empregados; entretanto essa alteração merece maior investigação.(AU)

Classificação anestésica do estado físico e mortalidade anestésico-cirúrgica em cães / Anesthetic classification of the physical status and surgical-anesthetic mortality in dogs

A classificação de estado físico ASA (Sociedade Americana de Anestesiologistas) é uma ferramenta importante para a avaliação pré-anestésica do paciente. Assim, é utilizada em diversos estudos por possuir estreita relação com a morbidade e a mortalidade anestésica. Realizou-se tal classificação em 243 pacientes caninos submetidos a procedimentos cirúrgicos em um Hospital Veterinário Universitário. Os resultados obtidos foram os seguintes: ASA I (38; 15,64%), ASA II (53; 21,81%), ASA II emergencial (E) (2; 0,82%), ASA III (78; 32,10%), ASA III E (23; 9,46%), ASA IV (11; 4,53%), ASA IV E (36; 14,81%) e ASA V (2; 0,82%). Verificou-se que a maior parte dos pacientes foram classificados como ASA III (doença sistêmica moderada), o que demonstra que, no serviço analisado, a maioria dos animais submetidos à cirurgia são portadores de enfermidades. A mortalidade foi de 2,46%, com a maioria dos óbitos ocorridos no pós-operatório e em pacientes com emergências. Concluiu-se que, no serviço analisado, os maiores riscos estão relacionados aos pacientes com categorias ASA de maior gravidade, em cirurgias emergenciais e, especialmente, no período pós-operatório.(AU)

The classification ASA (American Society of Anesthesiologists) is an important tool for assessing a patient's pre anesthetic. Thus, it is used in many studies because it has close relation with anesthetic morbidity and mortality. This classification was performed on 243 canine patients undergoing surgical procedures at the Veterinary Teaching Hospital. The results obtained were as follows: ASA I (38, 15.64%), ASA II (53; 21.81%), ASA II Emergency (E) (2; 0.82%), ASA III (78; 32.10%), ASA III E (23; 9.46%), ASA IV (11; 4.53 %), ASA IV E (36; 14.81%), and ASA V (2; 0.82%). Most patients were ASA III (moderate systemic disease), demonstrating that in the analyzed service the most operated animals are carriers of disease. The mortality rate was 2.46%, with most deaths occurring postoperatively and in patients with an emergency. The greatest risks are related to patients with more severe categories of the classification ASA, in emergency surgery, and especially in the postoperative period.(AU)

Earliest English Definitions of Anaisthesia and Anaesthesia.

The earliest identified English definition of the word anaisthesia was discovered in the first edition (1684) of A Physical Dictionary, an English translation of Steven Blankaart's medical dictionary, Lexicon Medicum Graeco-Latinum. This definition was almost certainly the source of the definition of anaesthesia which appeared in Dictionarium Anglo-Britannicum (1708), a general-purpose English dictionary compiled by the lexicographer John Kersey. The words anaisthesia and anaesthesia have not been identified in English medical or surgical publications that antedate the earliest English dictionaries in which they are known to have been defined.

Estudio prospectivo aleatorizado sobre el impacto de las medidas fast track en la cirugía abierta de aneurismas de aorta abdominal / Randomised, prospective study on the impact of fast track measures in the open surgery of abdominal aortic aneurysms

INTRODUCCIÓN: La implantación de las medidas fast track (FT) en la reparación abierta (RA) de aneurismas de aorta abdominal (AAA) no está convenientemente evaluada en nuestro medio. OBJETIVO: Queremos valorar el impacto de la instauración de medidas FT en nuestros pacientes. MATERIAL Y MÉTODOS: Estudio prospectivo aleatorizado (grupo control, grupo FT) de pacientes consecutivos intervenidos de manera electiva de AAA >55 mm infrarrenal por vía retroperitoneal mediante injerto recto. En el grupo FT se instauran medidas de optimización perioperatorias: ausencia de preparación intestinal, reducción del ayuno preoperatorio, administración de bebida carbohidratada 2 h antes de la intervención, control del dolor con elastómero preperitoneal, movilización y dieta precoces. Hemos comparado las variables postoperatorias: síndrome de respuesta inflamatoria sistémica (SIRS) postoperatorio, necesidad de transfusión, estancia en reanimación, días de ingreso y reintervenciones. RESULTADOS: De julio de 2011 a enero de 2014 se ha incluido a 38 pacientes (edad 68 años DE = 6,28; 97,4% hombres), 24 pacientes en grupo control y 14 en el grupo FT. La media de días de ingreso (6,17 vs. 4,64 en grupo FT) y de transfusiones son menores en el grupo FT (p < 0,05). La estancia en reanimación y las reintervenciones son menores en el grupo FT, aunque sin significación estadística. La incidencia de SIRS tras 48 h desde la intervención en el grupo FT fue 21,4% y del 54,16% en el grupo control (RR = 0,38; IC 95%: 0,15-0,61). CONCLUSIONES: Las medidas de optimización tipo FT podrían disminuir la incidencia de SIRS y reducir la estancia hospitalaria de los pacientes intervenidos de AAA

INTRODUCTION: Implementation of fast track (FT) measures for abdominal aortic aneurysm (AAA) open repair (OR) has not been sufficiently evaluated in our area. OBJECTIVE: The impact of implementing FT measures in our patients. MATERIAL AND METHODS: A prospective, randomised study (control and FT groups) was designed and conducted on patients with an infrarenal AAA >55 mm between July 2011 and January 2014 undergoing elective OR by retroperitoneal approach using straight graft interposition were included. The following perioperative optimisation measures were established in the FT group: No bowel preparation, reduced pre-operative fasting, administration of carbohydrate drink up to 2 h before surgery, pain control with pre-peritoneal elastomer, early onset of mobilisation and diet. A comparison was made of the postoperative variables: Postoperative systematic immune response syndrome (SIRS), need for transfusion, stay in resuscitation, hospital stay, and further interventions. RESULTS: A total of 38 patients were included, with a mean age of 68 years (SD = 6.28), of which 97.4% were men. There were 24 patients in control group and 14 in FT group. No statistically significant differences (NSSD) were found in comorbidities of both groups. Mean hospital stay was 6.17 vs. 4.64 days in the FT group, and transfusions were lower in the FT group, with statistically significant differences. Stay in resuscitation unit and re-interventions were also lower in FT group, although NSSD. The incidence of SIRS 48 h after surgery in FT group was 21.4% compared to 54.16% in control group (RR = 0.38, 95% CI; 0.15 - 0.61). CONCLUSIONS: The FT optimisation measures may reduce the incidence of SIRS, and reduce hospital stay in patients undergoing open repair of AAA

Implementación de un programa de alternativas a la transfusión sanguínea en cirugía de escoliosis en pediatría / Implementation of a patient blood management program in pediatric scoliosis surgery

Objetivos. Determinar si la puesta en marcha de un programa de ahorro de sangre y la adopción y asociación progresiva de diferentes métodos reducen las necesidades transfusionales en pacientes pediátricos intervenidos de escoliosis de múltiples etiologías. Material y método. Estudio cuasiexperimental, no aleatorizado y descriptivo, aprobado por el Comité de Ética para la Investigación de nuestra institución. Se incluyeron 50 pacientes pediátricos (ASA I-III) de edades comprendidas entre los 5 y los 18 años, intervenidos de cirugía de escoliosis de cualquier etiología mediante un único tiempo posterior o doble abordaje, anterior y posterior. Se compararon un grupo histórico (recogida retrospectiva de datos), sin alternativas a la transfusión (Grupo No ahorro = 15 pacientes), y otros 3 grupos prospectivamente: Grupo HNA (hemodilución normovolémica aguda) = 9 pacientes, Grupo HNA + Rec (recuperación intraoperatoria) = 14 pacientes, Grupo EPO (HNA + Rec + eritropoyetina ± donación preoperatoria) = 12 pacientes, conforme se implementaron las diferentes alternativas a la transfusión en nuestra institución. Resultados. La tasa de transfusión en los diferentes grupos (No ahorro, HNA, HNA + Rec, EPO) fue del 100, 66, 57 y 0% de los pacientes, con una media ± DE de 3,40 ± 1,59; 1,33 ± 1,41; 1,43 ± 1,50; 0 ± 0 unidades de CH transfundidas por paciente, respectivamente, con diferencias estadísticamente significativas (p < 0,001) tanto en la tasa de transfusión como en el número de unidades. Conclusiones. La aplicación de un programa multimodal de alternativas a la transfusión sanguínea en cirugía de escoliosis pediátrica, individualizado para cada paciente, puede evitar la transfusión en la práctica totalidad de los casos (AU)

Objectives. To determine whether the implementation of a blood conservation program, and the adoption and progressive association of different methods, reduces transfusion requirements in pediatric patients undergoing scoliosis surgery of different origins. Material and method. Quasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 pediatric patients (ASA I-III) aged 5 to 18 years, undergoing scoliosis surgery of any etiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro = 15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution) = 9 patients; Group HNA + Rec (intraoperative blood salvage) = 14 patients, and Group EPO (HNA + Rec + erythropoietin ± preoperative donation) = 12 patients; according with the implementation schedule of the transfusion alternatives in our institution. Results. The rate of transfusion in different groups (No ahorro, HNA, HNA + Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean ± SD of 3.40 ± 1.59; 1.33 ± 1.41; 1.43 ± 1.50; 0 ± 0 RBC units transfused per patient, respectively. Statistically significant differences (P < .001) were found in both the transfusion rate and number of RBC units. Conclusions. The application of a multimodal blood transfusion alternatives program, individualized for each pediatric patient undergoing scoliosis surgery can avoid transfusion in all cases (AU)

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS) / Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)

La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos) (AU)

Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents) (AU)

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database.

AIM: Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States. METHOD: The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status. RESULTS: Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss. CONCLUSION: Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts.

From sedation to continuous sedation until death: how has the conceptual basis of sedation in end-of-life care changed over time?

CONTEXT: Numerous attempts have been made to describe and define sedation in end-of-life care over time. However, confusion and inconsistency in the use of terms and definitions persevere in the literature, making interpretation, comparison, and extrapolation of many studies and case analyses problematic. OBJECTIVES: This evidence review aims to address and account for the conceptual debate over the terminology and definitions ascribed to sedation at the end of life over time. METHODS: Six electronic databases (MEDLINE, PubMed, Embase, AMED, CINAHL, and PsycINFO) and two high-impact journals (New England Journal of Medicine and the British Medical Journal) were searched for indexed materials published between 1945 and 2011. This search resulted in bibliographic data of 328 published outputs. Terms and definitions were manually scanned, coded, and linguistically analyzed by means of term description criteria and discourse analysis. RESULTS: The review shows that terminology has evolved from simple to complex terms with definitions varying in length, comprising different aspects of sedation such as indications for use, pharmacology, patient symptomatology, target population, time of initiation, and ethical considerations, in combinations of a minimum of two or more of these aspects. CONCLUSION: There is a pressing need to resolve the conceptual confusion that currently exists in the literature to bring clarity to the dialogue and build a base of commonality on which to design research and enhance the practice of sedation in end-of-life care.

Consciousness and depth of anesthesia assessment based on Bayesian analysis of EEG signals.

This study applies Bayesian techniques to analyze EEG signals for the assessment of the consciousness and depth of anesthesia (DoA). This method takes the limiting large-sample normal distribution as posterior inferences to implement the Bayesian paradigm. The maximum a posterior (MAP) is applied to denoise the wavelet coefficients based on a shrinkage function. When the anesthesia states change from awake to light, moderate, and deep anesthesia, the MAP values increase gradually. Based on these changes, a new function B(DoA) is designed to assess the DoA. The new proposed method is evaluated using anesthetized EEG recordings and BIS data from 25 patients. The Bland-Alman plot is used to verify the agreement of B(DoA) and the popular BIS index. A correlation between B(DoA) and BIS was measured using prediction probability P(K). In order to estimate the accuracy of DoA, the effect of sample n and variance τ on the maximum posterior probability is studied. The results show that the new index accurately estimates the patient's hypnotic states. Compared with the BIS index in some cases, the B(DoA) index can estimate the patient's hypnotic state in the case of poor signal quality.

Herbal medicine: a survey of use in Nigerian presurgical patients booked for ambulatory anaesthesia.

BACKGROUND: Utilization of herbal medicines in the preoperative period by Nigerian patients booked for day case surgery has not been explored. METHODS: Cross-sectional survey of 60 patients presenting for day-case surgery at a tertiary healthcare institution over a 3-week period in August 2011 was conducted. Using a structured questionnaire, inquiries were made concerning use of herbal medicines in the immediate preoperative period. Socio-demographic characteristics, information on use of concurrent medical prescriptions, types of herbs used, reasons for use, perceived side effects and perceived efficacy were obtained. Data were evaluated using descriptive statistics and Chi-square. RESULTS: Fifty-two (86.7%) were American Society of Anesthesiologists (ASA) class 1 while 8 (13%) were ASA 2. Most patients (86.7%) had their procedures done under local infiltration with monitored anaesthesia care (MAC), while 5.0% and 8.3% had their procedures done under regional and general anaesthesia, respectively. About 48.3% of respondents were on concurrent medical prescriptions while 51.7% were not. Forty percent (40%) of patients admitted to use of herbal medicine, all by the oral route, in the immediate perioperative period; 87.5% did not inform their doctor of their herbal use. Types of herbs used included 'dogonyaro', 'agbo', 'nchanwu', and Tahitian noni. Treatment of malaria was commonest reason for use in 29.2% of patients, while cough and concurrent surgical condition were reasons given by 12.5% of patients, respectively. Seventy-nine percent (79.2%) of patients considered their herbal medications effective. Perceived side effects of herbal medication (16.6%) included fever, waist pain and intoxication. There were no variations in use between ASA 1 and ASA 2 patients and none between respondents on conventional medication against those that were not. Variables such as age less than 35 years, female gender, being married and being an urban dweller did not show any significant difference in use. CONCLUSION: This survey revealed many patients were on one or more herbal preparations in the immediate preoperative period. In consideration of possible untoward drug interactions between conventional medication, herbal preparations and anaesthesia, doctors (especially anaesthetists) should routinely assess all patients booked to be anaesthetized, especially those for day case surgery. The authors recommend surveys with larger respondent numbers to determine prevalence of use and possible interactions between indigenous Nigerian herbs and anaesthesia.

Validity of anaesthetic complication coding data as a clinical indicator.

Clinical indicators using routinely collected International Statistical Classification of Diseases, Australian Modification (ICD-10-AM) data offer promise as tools for improvement of quality. The ICD-10-AM is the coding system used by Australian administrators to summarise information from the clinical record to describe a patient's hospital encounter. The use of anaesthesia complications as coded by this system has been proposed by two jurisdictions as a monitor of the quality of anaesthetic services. We undertook a review of cases identified by such indicators in a large tertiary hospital. Our results indicate the anaesthesia indicator dataset proposed by the Victorian and Queensland Health departments appears to have little clinical or quality improvement relevance.

Perioperative blood glucose level and postoperative complications in pediatric cardiac surgery.

BACKGROUND: Anesthesia for pediatric cardiac surgery is systematically performed in severely ill patients under abnormal physiological conditions. In the intraoperative period, there are significant variations in blood volume, body temperature, plasma composition, and tissue blood flow, in addition to activation of inflammation, with important consequences. Serial measurements of blood glucose levels can indicate states of exacerbation of the neuroendocrine-metabolic response to trauma, serving as prognostic markers of morbidity in that population. OBJECTIVE: To correlate perioperative blood glucose levels of children undergoing cardiac surgery with the occurrence of postoperative complications, and to compare intraoperative blood glucose levels according to perioperative conditions. METHODS: Information regarding the surgical/anesthetic procedure and perioperative conditions of patients was collected from the medical records. The mean perioperative blood glucose levels in the groups of patients with and without postoperative complications and the frequencies of perioperative conditions were compared by use of odds ratio and non-parametric univariate analyses. RESULTS: Higher intraoperative blood glucose levels were observed in individuals who had postoperative complications. Prematurity, age group, type of anesthesia, and character of the procedure did not influence the mean intraoperative blood glucose level. The use of extracorporeal circulation (ECC) was associated with higher blood glucose levels during surgery. In procedures with ECC, higher blood glucose levels were observed in individuals who had infectious and cardiovascular complications. In surgeries without ECC, that association was observed with infectious and hematological complications. CONCLUSION: Higher intraoperative blood glucose levels are associated with higher morbidity in the postoperative period of pediatric cardiac surgery.

Glicemia perioperatória e complicações pós-operatórias em cirurgia cardíaca pediátrica / Perioperative blood glucose level and postoperative complications in pediatric cardiac surgery

FUNDAMENTO: Anestesia para cirurgia cardíaca pediátrica é sistematicamente realizada em pacientes graves sob condições fisiológicas anormais. No intraoperatório, existem variações significativas da volemia, temperatura corporal, composição plasmática e fluxo sanguíneo tecidual, além de ativação da inflamação, com consequências importantes. Medidas seriadas da glicemia podem indicar estados de exacerbação da resposta neuroendocrinometabólica ao trauma servindo como marcadores prognóstico de morbidade nessa população. OBJETIVO: Correlacionar os níveis de glicemia do período perioperatório de crianças submetidas a cirurgia cardíaca com a ocorrência de complicações no pós-operatório e comparar os níveis intraoperatórios de glicemia de acordo com as condições perioperatórias. MÉTODOS: Informações referentes ao procedimento anestésico-cirúrgico e condições perioperatórias dos pacientes foram coletadas em prontuário. Comparações das médias dos valores perioperatórios da glicemia nos grupos de pacientes que apresentaram, ou não, complicações pós-operatórias e as frequências referentes às condições perioperatórias foram estabelecidas conforme cálculo da razão de chances e em análises univariáveis não paramétricas. RESULTADOS: Valores mais elevados de glicemia intraoperatória foram observados nos indivíduos que apresentaram complicações pós-operatórias. Prematuridade, faixa etária, tipo de anestesia e caráter do procedimento não apresentaram influência na média glicêmica do intraoperatório. O emprego de Circulação Extracorpórea (CEC) esteve associado a maiores valores de glicemia durante a cirurgia. Nos procedimentos com CEC, maiores níveis glicêmicos foram observados nos indivíduos que evoluíram com infecção e complicações cardiovasculares, nas cirurgias sem CEC essa mesma associação ocorreu com complicações infecciosas e hematológicas. CONCLUSÃO: Níveis intraoperatórios mais elevados de glicemia estão associados com maior morbidade no pós-operatório de cirurgia cardíaca pediátrica.

BACKGROUND: Anesthesia for pediatric cardiac surgery is systematically performed in severely ill patients under abnormal physiological conditions. In the intraoperative period, there are significant variations in blood volume, body temperature, plasma composition, and tissue blood flow, in addition to activation of inflammation, with important consequences. Serial measurements of blood glucose levels can indicate states of exacerbation of the neuroendocrine-metabolic response to trauma, serving as prognostic markers of morbidity in that population. OBJECTIVE: To correlate perioperative blood glucose levels of children undergoing cardiac surgery with the occurrence of postoperative complications, and to compare intraoperative blood glucose levels according to perioperative conditions. METHODS: Information regarding the surgical/anesthetic procedure and perioperative conditions of patients was collected from the medical records. The mean perioperative blood glucose levels in the groups of patients with and without postoperative complications and the frequencies of perioperative conditions were compared by use of odds ratio and non-parametric univariate analyses. RESULTS: Higher intraoperative blood glucose levels were observed in individuals who had postoperative complications. Prematurity, age group, type of anesthesia, and character of the procedure did not influence the mean intraoperative blood glucose level. The use of extracorporeal circulation (ECC) was associated with higher blood glucose levels during surgery. In procedures with ECC, higher blood glucose levels were observed in individuals who had infectious and cardiovascular complications. In surgeries without ECC, that association was observed with infectious and hematological complications. CONCLUSION: Higher intraoperative blood glucose levels are associated with higher morbidity in the postoperative period of pediatric cardiac surgery.

Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal / Experience with the Proseal laryngeal mask in ventriculoperitoneal shunting

Objetivo: Transmitir la experiencia con el uso de la mascarilla laríngea Proseal (MLP) en el manejo de la vía aérea de los pacientes sometidos a cirugía de derivación ventrículo peritoneal, en cuanto a su utilidad, eficacia y seguridad. Pacientes y métodos: Revisamos retrospectivamente las historias de todos los pacientes sometidos a derivación ventrículo peritoneal y ventilados con MLP entre enero del 2006 y octubre del 2009. Registramos las características demográficas de los pacientes, valoración de la vía aérea, tipo de anestesia, calidad de ventilación y complicaciones perioperatorias. Resultados: Se incluyeron 43 pacientes, 8 (18,6%) cumplían algún criterio de vía aérea difícil (VAD). La inserción de la MLP fue posible en todos los pacientes. La ventilación fue óptima en 39 pacientes (91%), manteniendo valores entre 35-40 mmHg de CO2 telespiratorio y presiones de vía aérea por debajo de 25 cmH2O durante todo el procedimiento. Tres pacientes (7%) presentaron fugas en la vía aérea al ser colocados en la posición quirúrgica cervical lateral forzada y precisaron intubación orotraqueal para iniciar la cirugía. El tiempo quirúrgico promedio fue de 53 minutos. La educción ocurrió sin incidentes en todos los casos. Conclusiones: La MLP es útil en el manejo de la vía aérea de los pacientes intervenidos de derivación ventriculoperitoneal, aunque debido a la posición forzada del cuello, puede ser necesario ajustar la colocación de la mascarilla, y en algunos casos la intubación orotraqueal. Como en otros usos avanzados se requiere experiencia en su uso y tener disponible el material de VAD(AU)

Objective: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitoneal shunting. Patients and methods: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. Results: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateralcervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. Conclusions: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand(AU)