The added value of cardiac index and pulse pressure variation monitoring to mean arterial pressure-guided volume therapy in moderate-risk abdominal surgery (COGUIDE): a pragmatic multicentre randomised controlled trial.

There is disagreement regarding the benefits of goal-directed therapy in moderate-risk abdominal surgery. Therefore, we tested the hypothesis that the addition of non-invasive cardiac index and pulse pressure variation monitoring to mean arterial pressure-based goal-directed therapy would reduce the incidence of postoperative complications in patients having moderate-risk abdominal surgery. In this pragmatic multicentre randomised controlled trial, we randomly allocated 244 patients by envelope drawing in a 1:1 fashion, stratified per centre. All patients had mean arterial pressure, cardiac index and pulse pressure variation measured continuously. In one group, healthcare professionals were blinded to cardiac index and pulse pressure variation values and were asked to guide haemodynamic therapy only based on mean arterial pressure (control group). In the second group, cardiac index and pulse pressure variation values were displayed and kept within target ranges following a pre-defined algorithm (CI-PPV group). The primary endpoint was the incidence of postoperative complications within 30 days. One hundred and seventy-five patients were eligible for final analysis. Overall complication rates were similar (42/94 (44.7%) vs. 38/81 (46.9%) in the control and CI-PPV groups, respectively; p = 0.95). The CI-PPV group had lower mean (SD) pulse pressure variation values (9.5 (2.0)% vs. 11.9 (4.6)%; p = 0.003) and higher mean (SD) cardiac indices (2.76 (0.62) l min-1 .m-2 vs. 2.53 (0.66) l min-1 .m-2 ; p = 0.004) than the control group. In moderate-risk abdominal surgery, we observed no additional value of cardiac index and pulse pressure variation-guided haemodynamic therapy to mean arterial pressure-guided volume therapy with regard to postoperative complications.

Occurrence and determinants of poor response to short-term pre-operative erythropoietin treatment.

BACKGROUND: This study aimed to explore the occurrence and determinants of poor response to short-term pre-operative erythropoietin treatment and the effect of such poor response on transfusion in total hip arthroplasty patients. METHODS: We studied total hip arthroplasty patients who received erythropoietin before surgery. The primary outcome was the pre-operative increase in haemoglobin (delta haemoglobin) as response to erythropoietin therapy. Additionally, patients were classified in tertiles based on this delta haemoglobin: poor responders (cases), responders and good responders (controls) to erythropoietin. Patient characteristics, comedication and co-morbidity were collected as potential determinants of erythropoietin response. Regression techniques were used to estimate the strength of the associations and to assess the effect of poor response on transfusion requirement. RESULTS: A total of 379 patients receiving erythropoietin were eligible to enter the study. Mean delta haemoglobin was 19.3 g/l (standard deviation 9.4). Factors significantly associated with delta haemoglobin were the use of angiotensin II antagonists [-3.1 g/l; 95% confidence interval (CI) -5.7 to -0.6] and vitamin K antagonists (-6.9 g/l; 95% CI -10.0 to -0.2), together with body mass index (BMI) (-0.3 g/l per unit>; 95% CI -0.5 to -0.2). The additional case-control analysis yielded comparable results. Poor response to erythropoietin was associated with an increased transfusion risk (odds ratio 4.6, 95% CI 2.0-11). CONCLUSION: Use of angiotensin II receptor antagonists and vitamin K antagonists, and having a high BMI were determinants of poor response to short-term pre-operative erythropoietin treatment in total hip arthroplasty patients. Poor responders had a higher risk for perioperative blood transfusion.

Neurologic injury after insertion of laminar hooks during Cotrel-Dubousset instrumentation.

BACKGROUND DATA: Although the use of Cotrel-Dubousset (CD) instrumentation has improved results of operative treatment of scoliotic deformities, this technique may be associated with increased risk of neurologic injury. CASE HISTORIES: Two cases of neurologic complications immediately after insertion of lumbar laminar hooks during CD instrumentation for correction of scoliosis are reported. METHODS: Between 1986 and 1992, the authors performed 220 CD instrumentations for various spinal deformities. All patients were monitored with posterior tibial nerve somatosensory cortical evoked potentials (PTN-SSEPs). CONCLUSION: These cases demonstrate that caution should be exercised during introduction of laminar hooks on the concave side during CD instrumentation for scoliotic deformities. Continuous neurophysiologic monitoring of spinal cord conduction may aid in early detection of local compression at the spinal cord or cauda equina level.

Electroencephalographic characteristics of emergence from propofol/sufentanil total intravenous anesthesia.

We recorded the electroencephalogram (EEG) in 16 patients during propofol/sufentanil total intravenous anesthesia to determine whether EEG changes might predict imminent awakening during emergence. Changes in absolute and relative power in four frequency bands, median frequency (MF), 95th percentile frequency (F95), and two frequency band power ratios (beta/alpha and (alpha+beta)/delta) were quantified. One minute before eye opening, absolute power in the delta and alpha bands had decreased to 49% (25%-73%) and 42% (25%-58%) of the value during the infusion (P > 0.005). MF, F95, and the two frequency band power ratios increased during emergence (P > 0.05). Of the individual spectral variables, only a 50% decrease in absolute alpha power was more than 90% sensitive and specific in predicting eye opening. We conclude that, although pronounced EEG changes occur during emergence from propofol/sufentanil anesthesia, the EEG does not reliably predict eye opening.