Real-Time Ultrasound-Guided Versus Ultrasound-Assisted Spinal Anesthesia in Elderly Patients With Hip Fractures: A Randomized Controlled Trial.

BACKGROUND: Traditional landmark-guided spinal anesthesia can be challenging in elderly patients with hip fractures. Ultrasound assistance (USAS) and real-time ultrasound guidance (USRTG) techniques can facilitate lumbar neuraxial blocks. However, it remains undetermined which method is optimal for use in elderly patients. This study aimed to evaluate which technique was associated with a higher success rate of spinal anesthesia in elderly patients with hip fractures: USAS or USRTG technique. METHODS: A total of 114 elderly patients (≥70 years of age) with hip fractures were randomly assigned to receive spinal anesthesia using either the USAS or USRTG technique. The primary outcome was the first-attempt success rate, analyzed using the χ2 test. Secondary outcomes included first-pass success rate, the number of needle attempts and passes, locating time, procedure time, total time, adverse reactions and complications, patient satisfaction, and procedural difficulty score. RESULTS: The first-attempt success rate (80.7% vs 52.6%; 95% confidence interval [CI], for the difference, 11.6-44.6) and first-pass success rate (63.2% vs 31.6%; 95% CI for the difference, 14.2-49) were both significantly higher in the USAS compared with the USRTG group (both P = .001). The number of attempts (1 [1-1] vs 1 [1-3]; P = .001) and median passes (1 vs 3; P < .001) were both significantly lower in the USAS group than in the USRTG group. The USRTG group had a shorter locating time (175 seconds [129-234 seconds] vs 315 seconds [250-390 seconds]; P < .001) but a longer procedure time (488 seconds [260-972 seconds] vs 200 seconds [127-328 seconds]; P < .001) and total time (694 seconds [421-1133 seconds] vs 540 seconds [432-641 seconds]; P = .036). There were no significant differences between the 2 groups with regard to the adverse reactions and complications. More patients in the USAS group had a high satisfaction score of 3 to 5 (P = .008). Overall, anesthesiologists rated the USRTG group procedure as "more difficult" (P = .008). CONCLUSIONS: In elderly patients with hip fractures, spinal anesthesia with the USRTG technique is not superior to the USAS technique since it has a lower success rate, longer procedure time, lower satisfaction score, and is more difficult to perform. So USAS technique may be more suitable for elderly patients.

Raspberry Pi-Based Data Archival System for Electroencephalogram Signals From the SedLine Root Device.

BACKGROUND: The retrospective analysis of electroencephalogram (EEG) signals acquired from patients under general anesthesia is crucial in understanding the patient's unconscious brain's state. However, the creation of such database is often tedious and cumbersome and involves human labor. Hence, we developed a Raspberry Pi-based system for archiving EEG signals recorded from patients under anesthesia in operating rooms (ORs) with minimal human involvement. METHODS: Using this system, we archived patient EEG signals from over 500 unique surgeries at the Emory University Orthopaedics and Spine Hospital, Atlanta, for about 18 months. For this, we developed a software package that runs on a Raspberry Pi and archives patient EEG signals from a SedLine Root EEG Monitor (Masimo) to a secure Health Insurance Portability and Accountability Act (HIPAA) compliant cloud storage. The OR number corresponding to each surgery was archived along with the EEG signal to facilitate retrospective EEG analysis. We retrospectively processed the archived EEG signals and performed signal quality checks. We also proposed a formula to compute the proportion of true EEG signal and calculated the corresponding statistics. Further, we curated and interleaved patient medical record information with the corresponding EEG signals. RESULTS: We retrospectively processed the EEG signals to demonstrate a statistically significant negative correlation between the relative alpha power (8-12 Hz) of the EEG signal captured under anesthesia and the patient's age. CONCLUSIONS: Our system is a standalone EEG archiver developed using low cost and readily available hardware. We demonstrated that one could create a large-scale EEG database with minimal human involvement. Moreover, we showed that the captured EEG signal is of good quality for retrospective analysis and combined the EEG signal with the patient medical records. This project's software has been released under an open-source license to enable others to use and contribute.

Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial.

BACKGROUND: Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes. METHODS: We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test. RESULTS: Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024). CONCLUSIONS: Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.

The Evaluation of a Noninvasive Respiratory Volume Monitor in Mechanically Ventilated Neonates and Infants.

BACKGROUND: The respiratory volume monitor (RVM) (ExSpiron, Respiratory Motion Inc, Watertown, MA) uses thoracic impedance technology to noninvasively and continuously measure tidal volume (TV), respiratory rate (RR), and minute ventilation (MV). We aimed to validate the accuracy of the RVM to assess ventilation in neonates and infants by comparing it to spirometry. METHODS: We used the RVM and Respironics NM3 spirometer (Respironics NM3 Respiratory Profile Monitor, Philips Healthcare, Amsterdam, the Netherlands) to record simultaneous and continuous measurements of MV, TV, and RR. The RVM measurements, with and without external calibration, were compared to the Respironics NM3 spirometer using Bland-Altman analysis. The relative errors (Bland-Altman) between RVM and Respironics NM3 were calculated and used to compute individual patient bias, precision, and accuracy as the mean error, the standard deviation (SD) of the error, and the root mean square error. Bland-Altman limits of agreement (LoA) were computed, and equivalence tests were performed. RESULTS: Forty patients were studied to compare the RVM and Respironics NM3 measurements. The mean difference (ie, bias) for MV was 1.8% with 95% LoA, defined as mean ± 1.96 SD, in the range of -12.1% to 15.7%. Similarly, the mean difference (ie, bias) for TV and RR was 1.2% (95% LoA, -11.0% to 13.5%) and 0.6% (95% LoA, -3.7% to 5.0%), respectively. The mean measurement precision of the RVM relative to the Respironics NM3 for MV, TV, and RR was 10.8%, 8.9%, and 8.4%, respectively. The mean measurement accuracy for MV, TV, and RR across patients was 11.0%, 9.7%, and 7.1%, respectively. CONCLUSIONS: The data demonstrate that the RVM measures TV and MV in this cohort with an average relative error of 11% when using patient calibration and 16.9% without patient calibration. The average relative error of RR was 7.1%. The RVM provides accurate measurement of RR, TV, and MV in mechanically ventilated neonates and infants.

Comparison of a Handheld Device vs Endotracheal Tube-Based Neuromonitoring for Recurrent Laryngeal Nerve Stimulation.

OBJECTIVE: To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube-based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty. STUDY DESIGN: Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020. SETTING: Single-surgeon series at a tertiary care hospital. METHODS: Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility. RESULTS: Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty (R2 = 0.97). CONCLUSION: ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands. EVIDENCE LEVEL: 2.

Comparison of the resonance sonorheometry based Quantra® system with rotational thromboelastometry ROTEM® sigma in cardiac surgery - a prospective observational study.

BACKGROUND: Measures of the sonorheometry based Quantra® viscoelastic hemostatic analyzer (HemoSonics, LCC, Charlottesville, VA, USA) were compared with corresponding results of the ROTEM® sigma device (Instrumentation Laboratory, Bedford, MA, USA). METHODS: In thirty-eight patients scheduled for elective cardiac surgery between December 2018 and October 2019, blood samples were taken after induction of anesthesia (sample 1) and after heparin neutralization (sample 2) and measured on Quantra (QPlus® Cartridge) and ROTEM sigma (ROTEM® sigma complete + hep Cartridge). Clot times and clot stiffness values were recorded. Clot stiffness values of ROTEM amplitudes (A in mm) were converted to shear modulus (G) in hectoPascal (hPa): G (hPa) = (5 x A)/(100-A). Additionally, time-to-results was recorded. Spearman rank test correlation and Bland Altman analysis were performed. RESULTS: Clot stiffness parameters of the Quantra correlated strongly with corresponding measurements of the ROTEM with r = 0.93 and 0.94 for EXTEM A10 vs CS and r = 0.94 and 0.96 for FIBTEM A10 vs FCS for sample 1 and 2, respectively. Quantra clot time correlated strongly with ROTEM INTEM CT with r = 0.71 for sample 1 and r = 0.75 for sample 2. However, Bland Altman analysis showed no agreement in all compared assays of both methods. The median time to delivery of first and complete results was significantly shorter for Quantra (412 and 658 s) compared to ROTEM sigma (839 and 1290 s). CONCLUSIONS: The Quantra showed a strong correlation with the ROTEM sigma for determining clot times and clot stiffness and the parameters assess similar aspects of clot development. However, these parameters are not directly interchangeable and implicate that separate cut-off values need to be established for users of the Quantra device. Word count: 278. TRIAL REGISTRATION: The study was retrospectively registered with ClinicalTrials.gov (ID: NCT04210830 ) at December 20th 2019.

The World Federation of Societies of Anaesthesiologists Minimum Capnometer Specifications 2021-A Guide for Health Care Decision Makers.

Capnometry, the measurement of respiratory carbon dioxide, is regarded as a highly recommended safety technology in intubated and nonintubated sedated and/or anesthetized patients. Its utility includes confirmation of initial and ongoing placement of an airway device as well as in detecting gas exchange, bronchospasm, airway obstruction, reduced cardiac output, and metabolic changes. The utility applies prehospital and throughout all phases of inhospital care. Unfortunately, capnometry devices are not readily available in many countries, especially those that are resource-limited. Constraining factors include cost, durability of devices, availability of consumables, lack of dependable power supply, difficulty with cleaning, and maintenance. There is, thus, an urgent need for all stakeholders to come together to develop, market, and distribute appropriate devices that address costs and other requirements. To foster this process, the World Federation of Societies of Anaesthesiologists (WFSA) has developed the "WFSA-Minimum Capnometer Specifications 2021." The intent of the specifications is to set the minimum that would be acceptable from industry in their attempts to reduce costs while meeting other needs in resource-constrained regions. The document also includes very desirable and preferred options. The intent is to stimulate interest and engagement among industry, clinical providers, professional associations, and ministries of health to address this important patient safety need. The WFSA-Minimum Capnometer Specifications 2021 is based on the International Organization for Standardization (ISO) capnometer specifications. While industry is familiar with such specifications and their presentation format, most clinicians are not; therefore, this article serves to more clearly explain the requirements. In addition, the specifications as described can be used as a purchasing guide by clinicians.

Comparison of Monopolar and Bipolar Stimulator Probes for Intraoperative Nerve Mapping During Thyroidectomy: A Prospective Study.

OBJECTIVES/HYPOTHESIS: During intraoperative neuromonitoring in thyroid surgery, two different kinds of stimulator probes, monopolar and bipolar, are commonly used to stimulate the laryngeal nerves. We explore the unique characteristics of both of these probes as they relate to intraoperative laryngeal nerve mapping. METHODS: Twenty-one patients undergoing neuromonitored thyroidectomy by a single surgeon were enrolled. Electromyography (EMG) amplitude and latency measurements were prospectively recorded concurrently from 1 mA stimulation of vagus nerve (VN) and inferior/superior recurrent laryngeal nerve before (with and without fascia) and after thyroid resection using bipolar and monopolar stimulator probes. RESULTS: Significantly higher amplitudes were obtained with monopolar stimulator probes as compared to bipolar probes, in several stimulation scenarios such as at right VN pre-resection (carotid sheath intact), right VN pre-resection (carotid sheath dissected), right VN post-resection and left VN (carotid sheath dissected). No significant differences were found between amplitudes and latency values in all other stimulation scenarios. CONCLUSIONS: According to this study, both probes are reliable and safe for neural mapping. The kind of probe used during neural monitoring is based on surgical situations and surgeon preference. LEVEL OF EVIDENCE: 3 (According to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence) Laryngoscope, 131:E2718-E2726, 2021.

Comparison of accuracy of two uncalibrated pulse contour cardiac output monitors in off-pump coronary artery bypass surgery patients using pulmonary artery catheter-thermodilution as a reference.

BACKGROUND: Cardiac output (CO) is a key measure of adequacy of organ and tissue perfusion, especially in critically ill or complex surgical patients. CO monitoring technology continues to evolve. Recently developed CO monitors rely on unique algorithms based on pulse contour analysis of an arterial blood pressure (ABP) waveform. The objective of this investigation was to compare the accuracy of two monitors using different methods of pulse contour analysis - the Retia Argos device and the Edwards Vigileo-FloTrac device - with pulmonary artery catheter (PAC)-thermodilution as a reference. METHODS: Fifty-eight patients undergoing off-pump coronary artery bypass surgery formed the study cohort. A total of 572 triplets of CO measurements from each device - Argos, Vigileo-FloTrac (third generation), and thermodilution - were available before and after interventions (e.g., vasopressors, fluids, and inotropes). Bland-Altman analysis accounting for repeated measurements per subject and concordance analysis were applied to assess the accuracy of the CO values and intervention-induced CO changes of each pulse contour device against thermodilution. Cluster bootstrapping was employed to statistically compare the root-mean-squared-errors (RMSE = √(µ2 + σ2), where µ and σ are the Bland-Altman bias and precision errors) and concordance rates of the two devices. RESULTS: The RMSE (mean (95% confidence intervals)) for CO values was 1.16 (1.00-1.32) L/min for the Argos device and 1.54 (1.33-1.77) L/min for the Vigileo-FloTrac device; the concordance rate for intervention-induced CO changes was 87 (82-92)% for the Argos device and 72 (65-78)% for the Vigileo-FloTrac device; and the RMSE for the CO changes was 17 (15-19)% for the Argos device and 21 (19-23)% for the Vigileo-FloTrac device (p < 0.0167 for all comparisons). CONCLUSIONS: In comparison with CO measured by the PAC, the Argos device proved to be more accurate than the Vigileo-FloTrac device in CO trending and absolute CO measurement in patients undergoing off-pump coronary artery bypass surgery.

Perioperative Continuous Noninvasive Arterial Pressure Monitoring for Neuroendovascular Interventions: Prospective Study for Evaluation of the Vascular Unloading Technique.

BACKGROUND: Blood pressure monitoring is crucial during neuroendovascular procedures. Intraoperative hemodynamic instability is associated with complications, which underscores the importance of continuous monitoring. Although direct measurement with an intra-arterial catheter is the gold standard for determining arterial pressure, it is costly, time-consuming, and associated with complications. The novel ClearSight system offers a noninvasive technique for monitoring arterial pressure via a finger cuff. This study compared noninvasive arterial pressure measurements with the gold standard method. METHODS: Simultaneous recording of noninvasive and invasive arterial pressure was performed in patients undergoing neuroendovascular interventions. Both techniques were compared employing linear regression, Lin's correlation coefficient, Bland-Altman, and error grid analysis. RESULTS: The study enrolled 24 consecutive patients. The concordance correlation coefficient between both methods was 0.3526 (95% confidence interval [0.3134, 0.3906]) for mean arterial pressure and 0.4680 (95% confidence interval [0.4353, 0.4995]) and for systolic arterial pressure. The mean (SD) of the differences was 0.81 (17.86) mm Hg (95% limits of agreement [-52.52, 54.14]) for mean arterial pressure and 5.38 (14.64) mm Hg (95% limits of agreement [-45.12, 56.08]) for systolic arterial pressure. Error grid analysis demonstrated that the majority of measurements lie in regions with no or low risk for patients (mean arterial pressure, 71.0% and 24.4%; systolic arterial pressure, 59.2% and 25.8%). CONCLUSIONS: The ClearSight system provided accurate measurements of arterial blood pressure compared with invasive methods and within safe clinical parameters. This method may serve as a safe and reliable alternative for invasive blood pressure monitoring during neuroendovascular procedures.

ClearSight™ finger cuff versus invasive arterial pressure measurement in patients with body mass index above 45 kg/m2.

BACKGROUND: Measuring blood pressure in patients with obesity is challenging. The ClearSight™ finger cuff (FC) uses the vascular unloading technique to provide continuous non-invasive blood pressure measurements. We aimed to test the agreement of the FC with invasive radial arterial monitoring (INV) in patients with obesity. METHODS: Participants had a body mass index (BMI) ≥45 kg/m2 and underwent laparoscopic bariatric surgery. FC and INV measurements were obtained simultaneously every 5 min on each patient, following induction of anesthesia. Agreement over time was assessed using modified Bland-Altman plots and error grid analysis permitted clinical interpretation of the results. Four-quadrant plots allowed assessment of concordance in blood pressure changes. RESULTS: The 30 participants had a median (IQR) BMI of 50.2 kg/m2 (IQR 48.3-55.3). The observed bias (SD, 95% limits of agreement) for systolic blood pressure (SBP) was 14.3 mmHg (14.1, -13.4 - 42.0), 5.2 mmHg (10.9, -16.0 - 26.5) for mean arterial pressure (MAP) and 2.6 mmHg (10.8, -18.6 - 23.8) for diastolic blood pressure (DBP). Error grid analysis showed that the proportion of readings in risk zones A-E were 90.8, 6.5, 2.7, 0 and 0% for SBP and 91.4, 4.3, 4.3, 0 and 0% for MAP, respectively. Discordance occurred in ≤8% of pairs for consecutive change in SBP, MAP and DBP. CONCLUSIONS: The vascular unloading technique was not adequately in agreement with radial arterial monitoring. Evaluation in a larger sample is required before recommending this technique for intraoperative monitoring of patients with BMI ≥45 kg/m2.

Fast and robust localization of surgical array using Kalman filter.

PROBLEM: Intraoperative tracking of surgical instruments is an inevitable task of computer-assisted surgery. An optical tracking system often fails to precisely reconstruct the dynamic location and pose of a surgical tool due to the acquisition noise and measurement variance. Embedding a Kalman filter (KF) or any of its extensions such as extended and unscented Kalman filters (EKF and UKF) with the optical tracker resolves this issue by reducing the estimation variance and regularizing the temporal behavior. However, the current KF implementations are computationally burdensome and hence takes long execution time which hinders real-time surgical tracking. AIM: This paper introduces a fast and computationally efficient implementation of linear KF to improve the measurement accuracy of an optical tracking system with high temporal resolution. METHODS: Instead of the surgical tool as a whole, our KF framework tracks each individual fiducial mounted on it using a Newtonian model. In addition to simulated dataset, we validate our technique against real data obtained from a high frame-rate commercial optical tracking system. We also perform experiments wherein a diffusive material (such as a drop of blood) blocks one of the fiducials and show that KF can substantially reduce the tracking error. RESULTS: The proposed KF framework substantially stabilizes the tracking behavior in all of our experiments and reduces the mean-squared error (MSE) by a factor of 26.84, from the order of [Formula: see text] to [Formula: see text] mm[Formula: see text]. In addition, it exhibits a similar performance to UKF, but with a much smaller computational complexity.

Optimizing Location of Subdermal Recording Electrodes for Intraoperative Facial Nerve Monitoring.

OBJECTIVE: The purpose of this study is to determine if different facial muscle groups demonstrate different responses to facial nerve stimulation, the results of which could potentially improve intraoperative facial nerve monitoring (IOFNM). METHODS: IOFNM data were prospectively collected from patients undergoing cochlear implantation. At different stages of nerve exposure, three sites were stimulated using a monopolar pulse. Peak electromyography (EMG) amplitude (µV) in four muscle groups innervated by four different branches of the facial nerve (frontalis-temporal, inferior orbicularis oculi-zygomatic, superior oribularis oris-buccal, and mentalis-marginal mandibular) were recorded. RESULTS: A total of 279 peak EMG amplitudes were recorded in 93 patients. At all three stimulating sites, the zygomatic branch mean peak EMG amplitudes were statistically greater than those of the temporal, buccal, and marginal mandibular branches (P < .05). At stimulating Site C, the marginal mandibular branch mean peak EMG was stronger than the temporal or buccal branches (P < .05). Of the 279 stimulations, the zygomatic branch demonstrated the highest amplitude in 128 (45.9%) trials, followed by the marginal mandibular branch (22.2%). CONCLUSIONS: When utilized, IOFNM should be performed with at least two electrodes, one of which is placed in the orbicularis oculi muscles and the other in the mentalis muscle. However, there is wide variability between patients. As such, in cases of suspected variant nerve anatomy or increased risk of injury (intradural procedures), surgeons should consider using more than two recording electrodes, with at least one in the orbicularis oculi muscle. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2329-E2334, 2021.

Best Practices in Facial Nerve Monitoring.

OBJECTIVES/HYPOTHESIS: Facial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high-level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications. STUDY DESIGN: Literature review and expert opinion. METHODS: Given the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM. RESULTS: Over the years, two models of monitoring have become well-established: 1) monitoring by the surgeon using a stand-alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set-up and provide a basis for context-appropriate interpretation and troubleshooting of recorded signals. CONCLUSIONS: We trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:S1-S42, 2021.

Comparison of Sugammadex Dose for Intraoperative Neuromonitoring in Thyroid Surgery: A Randomized Controlled Trial.

OBJECTIVES/HYPOTHESIS: To compare effect of 1 and 2 mg/kg of sugammadex on the incidence of intraoperative bucking and intraoperative neuromonitoring (IONM) quality in thyroid surgery. STUDY DESIGN: Randomized controlled trial. METHODS: Patients qualified for thyroid surgery with IONM were eligible for this double-blind, randomized, controlled trial. After tracheal intubation with 0.6 mg/kg rocuronium, 1 or 2 mg/kg of sugammadex was administered to patients in group I or II, respectively. The quality of the IONM for the external branch of the superior laryngeal nerve (EBSLN) was evaluated (strong/intermediate/weak). The initial amplitude of electromyography for the vagus nerve (V1) and the recurrent laryngeal nerve (R1) were recorded. Intraoperative bucking movements was recorded. RESULTS: A total of 102 patients (51 in each group) completed the study. Time from sugammadex administration to initial checking for the EBSLN was not different between group I and II (25.0 ± 7.9 vs. 25.5 ± 9.0 minutes, P = .788). There was no difference in the neuromonitoring quality for the EBSLN between group I and II (strong/intermediate/weak: 46/5/0 vs. 50/1/0, P = .205). The amplitudes of V1 (1,086.3 ± 673.3 µV vs. 1,161.8 ± 727.5 µV, P = .588) and R1 (1,328.2 ± 934.1 µV vs. 1,410.5 ± 919.6 µV, P = .655) were comparable between the groups. Patients who experienced bucking were significantly fewer in the group I than the group II (13.7% vs. 35.3%, P = .020). CONCLUSION: A dose of 1 mg/kg sugammadex induced less bucking than 2 m/kg while providing comparable IONM quality during thyroid surgery. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:2154-2159, 2021.

Accuracy of noninvasive continuous arterial pressure monitoring using ClearSight during one-lung ventilation.

ABSTRACT: Noninvasive continuous arterial pressure monitoring may be clinically useful in patients who require continuous blood pressure monitoring in situations where arterial catheter placement is limited. Many previous studies on the accuracy of the noninvasive continuous blood pressure monitoring method reported various results. However, there is no research on the effectiveness of noninvasive arterial pressure monitoring during one-lung ventilation. The purpose of this study was to compare arterial blood pressure obtained through invasive method and noninvasive method by using ClearSight during one-lung ventilation.In this retrospective observational study, a total of 26 patients undergoing one-lung ventilation for thoracic surgery at a single institution between March and July 2019 were recruited. All patients in this study were cannulated on their radial artery to measure continuously invasive blood pressures and applied ClearSight on the ipsilateral side of the cannulated arm. We compared and analyzed the agreement and trendability of blood pressure recorded with invasive and noninvasive methods during one-lung ventilation.Blood pressure and pulse rate showed a narrower limit of agreement with a percentage error value of around 30%. In addition, the tracking ability of each measurement could be determined by the concordance rate, all of which were below acceptable limits (92%).In noninvasive arterial blood pressure monitoring using ClearSight, mean blood pressure and pulse rate show acceptable agreement with the invasive method.

Offline comparison of processed electroencephalogram monitors for anaesthetic-induced electroencephalogram changes in older adults.

BACKGROUND: Several devices record and interpret patient brain activity via electroencephalogram (EEG) to aid physician assessment of anaesthetic effect. Few studies have compared EEG monitors on data from the same patient. Here, we describe a set-up to simultaneously compare the performance of three processed EEG monitors using pre-recorded EEG signals from older surgical patients. METHODS: A playback system was designed to replay EEG signals into three different commercially available EEG monitors. We could then simultaneously calculate indices from the SedLine® Root (Masimo Inc., Irvine, CA, USA; patient state index [PSI]), bilateral BIS VISTA™ (Medtronic Inc., Minneapolis, MN, USA; bispectral index [BIS]), and Datex Ohmeda S/5 monitor with the Entropy™ Module (GE Healthcare, Chicago, IL, USA; E-entropy index [Entropy]). We tested the ability of each system to distinguish activity before anaesthesia administration (pre-med) and before/after loss of responsiveness (LOR), and to detect suppression incidences in EEG recorded from older surgical patients receiving beta-adrenergic blockers. We show examples of processed EEG monitor output tested on 29 EEG recordings from older surgical patients. RESULTS: All monitors showed significantly different indices and high effect sizes between comparisons pre-med to after LOR and before/after LOR. Both PSI and BIS showed the highest percentage of deeply anaesthetised indices during periods with suppression ratios (SRs) > 25%. We observed significant negative correlations between percentage of suppression and indices for all monitors (at SR >5%). CONCLUSIONS: All monitors distinguished EEG changes occurring before anaesthesia administration and during LOR. The PSI and BIS best detected suppressed periods. Our results suggest that the PSI and BIS monitors might be preferable for older patients with risk factors for intraoperative awareness or increased sensitivity to anaesthesia.