The role of pre-operative α-blockade in patients with normotensive phaeochromocytoma or paraganglioma: A retrospective cohort study

No abstract available

https://ift.tt/2Oz1GSl

Comparison of a novel clinical score to estimate the risk of REsidual neuromuscular block Prediction Score and the last train-of-four count documented in the electronic anaesthesia record: A retrospective cohort study of electronic data on file

BACKGROUND Residual neuromuscular block (rNMB) after surgery is not difficult to identify if proper neuromuscular monitoring is used, but many clinicians do not use quantitative neuromuscular monitoring. OBJECTIVE The aim of this study was to develop a REsidual neuromuscular block Prediction Score (REPS) to predict postoperative rNMB and compare the predictive accuracy of the prediction score with train-of-four count (TOFC) measurement at the end of a surgical case. DESIGN Retrospective cohort study of data on file. DATA SOURCE Electronic patient data and peri-operative data on vital signs, administered medications, and train-of-four ratio (TOFR) obtained in the postoperative recovery rooms [postanaesthesia care unit (PACU)] at Massachusetts General Hospital in Boston, Massachusetts, USA. PATIENTS Quantitative TOFR measurements obtained on admission to the PACU were available from 2144 adult noncardiac surgical patients. MAIN OUTCOME MEASURE Presence of rNMB at PACU admission, defined as a TOFR of less than 0.9. RESULTS In the score development cohort (n=2144), rNMB occurred in 432 cases (20.2%). Ten independent predictors for residual paralysis were identified and used for the score development. The final model included: hepatic failure, neurological disease, high-neostigmine dose, metastatic tumour, female sex, short time between neuromuscular blocking agent administration and extubation, aminosteroidal neuromuscular blocking agent, BMI more than 35, absence of nurse anaesthetist and having an experienced surgeon. The model discrimination by C statistics was 0.63, 95% confidence interval (0.60 to 0.66), and risk categories derived from the REPS had a higher accuracy than the last documented intra-operative TOFC for predicting rNMB (net reclassification improvement score 0.26, standard error 0.03, P 

https://ift.tt/2IBhwGR

Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis

BACKGROUND Circulating cardiac troponin levels are powerful predictors of prognosis in many clinical settings, but their association with outcomes after noncardiac surgery is unclear. OBJECTIVES The aim of this systematic review was to summarise current evidence on the association of pre-operative troponin elevation with postoperative major adverse cardiac events (MACE) and mortality in patients undergoing noncardiac surgery. DESIGN Systematic review of observational studies with meta-analysis. DATA SOURCES PubMed, EMBASE and Science Citation Index Expanded (ISI Web of Science) from their inception to 1 October 2017. ELIGIBILITY CRITERIA Observational studies reporting the associations between pre-operative troponin levels and MACE and all-cause mortality after noncardiac surgeries were included. RESULTS Ten studies met the eligibility criteria. The entire body of evidence addressing the research question was based on a total of 10 371 patients: 4.7 to 68.3% (median 23.8%) of patients had elevated troponin levels before surgery. Elevated pre-operative troponin was significantly associated with short-term MACE (seven studies, 5180 patients: odds ratio (OR) 6.92, 95% confidence interval (CI) 3.85 to 12.42), short-term mortality (five studies, 6103 patients: OR 4.23, 95% CI 2.27 to 7.89) and long-term mortality (two studies, 760 patients: OR 2.51, 95% CI 1.47 to 4.29). The associations remained significant when only multivariate-adjusted results were analysed. Overall, the reviewers' certainty about the summary estimates of the associations was very low. CONCLUSION Current evidence suggests that pre-operative high troponin levels are significantly associated with adverse cardiac events and mortality after noncardiac surgery. TRIAL REGISTRATION This systematic review was registered in the International Prospective Register of Systematic Reviews (Centre for Reviews and Dissemination 42017077837).

https://ift.tt/2OyuxWX

Deep vs. moderate neuromuscular blockade during laparoscopic surgery: A systematic review and meta-analysis

BACKGROUND Previous studies have reported that deep neuromuscular block (posttetanic-count 1 to 2 twitches) improves surgical conditions during laparoscopy compared with moderate block (train-of-four count: 1 to 2 twitches). However, comparisons of surgical conditions were made using different scales and assessment intervals with variable results. OBJECTIVE To explore the heterogeneity of previous comparisons between deep and moderate neuromuscular block. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, EMBASE and Cochrane Central Register of Controlled Trials were searched from inception to October 2017. ELIGIBILITY CRITERIA Our meta-analysis included RCTs comparing the effects of deep with moderate neuromuscular block on surgical field conditions during laparoscopic surgery. The frequency of excellent or good operating conditions on a surgical rating scale was compared. Heterogeneity was assessed by subgroup analyses. RESULTS Eleven RCTs involving 844 patients were included. On the surgical rating scale, the frequency of excellent or good operating conditions was higher with deep block compared with a moderate block (odds ratio 2.83, 95% confidence interval 1.34 to 5.99, P = 0.007, I2 = 59%). We analysed surgical rating according to the number of assessments made. There was a significant difference in surgical rating with multiple assessments, but no difference when the assessment was made on only one occasion. A significant difference in rating was noted with variable abdominal pressures; there was no significant difference with the same fixed abdominal pressure. Trial sequential analysis demonstrated that the cumulative z-curve crossed the O′Brien–Fleming significance boundary. However, required information size was not achieved. CONCLUSION Deep block was associated with excellent or good surgical rating more frequently than moderate block. However, this finding was not consistent on subgroup analyses based on frequencies of assessment of surgical conditions and abdominal pressure. Further studies are required to address the heterogeneity and power shortage demonstrated by the trial sequential analysis.

https://ift.tt/2IBhm2d

Intra-operative cutaneous temperature monitoring with zero-heat-flux technique (3M SpotOn) in comparison with oesophageal and arterial temperature: A prospective observational study

BACKGROUND Continuous monitoring of core temperature is essential during major surgery as a way of improving patient safety. Oesophageal probes or specific arterial catheters are invasive methods used in this setting. A new noninvasive device based on zero-heat-flux (ZHF) technique (SpotOn) seems promising but has been poorly investigated during rapid core temperature changes (RCTC). OBJECTIVE To assess the accuracy of a SpotOn sensor vs. an oesophageal probe or specific arterial catheter during a slow change in core temperature of less than 1 °C within 30 min and RCTC ≥ 1 °C within 30 min. DESIGN Prospective observational study. SETTING Operating rooms at the University Hospital of Poitiers, France. PATIENTS Fifty patients scheduled for major abdominal surgery under general anaesthesia were enrolled from June 2015 to March 2016. Data from 49 patients were finally analysed. Among these, 15 patients were treated with hyperthermic intraperitoneal chemotherapy. INTERVENTION Each patient had a ZHF sensor placed on the skin surface of the forehead (TempZHF) and an oesophageal probe (TempEso) used as a reference method. Twenty-two patients also had a thermodilution arterial catheter (TempArt) placed in the axillary artery. MAIN OUTCOME MEASURES Core temperature was continuously recorded from the three devices after induction of anaesthesia. Comparison of temperature measurements between methods was made using the Bland and Altman method during two separate periods according to the speed of core temperature changes. RESULTS Compared with TempEso, bias and limits of agreement for TempZHF were 0.1 ± 0.5 °C during slow core temperature changes periods and 0.6 ± 1.8 °C during RCTC periods (P = 0.0002). Compared with TempArt, these values were −0.1 ± 0.4 and 0.5 ± 1.7 °C, respectively (P = 0.0039). The ZHF sensor was well tolerated. CONCLUSION A SpotOn sensor using the ZHF method seems reliable for core temperature monitoring during abdominal surgery when variations in core temperature are slow rather than rapid. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02869828.

https://ift.tt/2Oxxfw0

Comparison of noninvasive and minimally invasive pulse contour analysis to measure stroke volume during major surgery: A prospective observational study

No abstract available

https://ift.tt/2IBhbnz

Diagnostic accuracy of inferior vena caval respiratory variation in detecting fluid unresponsiveness: A systematic review and meta-analysis

BACKGROUND The accuracy of respiratory variation of the inferior vena cava (rvIVC) in predicting fluid responsiveness, particularly in spontaneously breathing patients is unclear. OBJECTIVES To consider the evidence to support the accuracy of rvIVC in identifying patients who are unlikely to benefit from fluid administration. DESIGN Systematic review and meta-analysis. DATA SOURCE We searched MEDLINE, EMBASE, Cochrane Library, KoreaMed, LILCAS and WHO Clinical Trial Registry from inception to June 2017. ELIGIBILITY CRITERIA Case–control or cohort studies that evaluated the accuracy of rvIVC in living adult humans were included. A study was included in the meta-analysis if data enabling construction of 2 × 2 tables were reported, calculated or could be obtained from authors and met the above cited criteria. RESULT A total of 23 studies including 1574 patients were included in qualitative analysis. The meta-analysis involved 20 studies and 761 patients. Pooled sensitivity and specificity of rvIVC in 330 spontaneously breathing patients were 0.80 [95% confidence interval (CI) 0.68 to 0.89] and 0.79 (95% CI 0.60 to 0.90). Pooled sensitivity and specificity of rvIVC in 431 mechanically ventilated patients were 0.79 (95% CI 0.67 to 0.86) and 0.70 (95% CI 0.63 to 0.76). CONCLUSION Decreased inferior vena caval respiratory variation is moderately accurate in predicting fluid unresponsiveness both in spontaneous and mechanically ventilated patients. The findings of this review should be used in the appropriate clinical context and in conjunction with other clinical assessments of fluid status. IDENTIFIER CRD 42017068028.

https://ift.tt/2OwOM7D

Device or target? A paradigm shift in airway management: Implications for guidelines, clinical practice and teaching

No abstract available

https://ift.tt/2IBpm3g

Haemodilution and head-down tilting induce functional injury in the rat optic nerve: A model for peri-operative ischemic optic neuropathy

BACKGROUND Mechanisms of peri-operative ischaemic optic neuropathy remain poorly understood. Both specific pre-operative and intra-operative factors have been examined by retrospective studies, but no animal model currently exists. OBJECTIVES To develop a rodent model of peri-operative ischaemic optic neuropathy. In rats, we performed head-down tilt and/or haemodilution, theorising that the combination damages the optic nerve. DESIGN Animal study. SETTING Laboratory. ANIMALS A total of 36 rats, in four groups, completed the functional examination of retina and optic nerve after the interventions. INTERVENTIONS Anaesthetised groups (n>8) were supine (SUP) for 5 h, head-down tilted 70° for 5 h, head-down tilted/haemodiluted for 5 h or SUP/haemodiluted for 5 h. We measured blood pressure, heart rate, intra-ocular pressure and maintained constant temperature. MAIN OUTCOME MEASUREMENTS Retinal function (electroretinography), scotopic threshold response (STR) (for retinal ganglion cells) and visual evoked potentials (VEP) (for transmission through the optic nerve). We imaged the optic nerve in vivo and evaluated retinal histology, apoptotic cells and glial activation in the optic nerve. Retinal and optic nerve function were followed to 14 and 28 days after experiments. RESULTS At 28 days in head down tilted/haemodiluted rats, negative STR decreased (about 50% amplitude reduction, P = 0.006), VEP wave N2-P3 decreased (70% amplitude reduction, P = 0.01) and P2 latency increased (35%, P = 0.003), optic discs were swollen and glial activation was present in the optic nerve. SUP/haemodiluted rats had decreases in negative STR and increased VEP latency, but no glial activation. CONCLUSION An injury partly resembling human ischaemic optic neuropathy can be produced in rats by combining haemodilution and head-down tilt. Significant functional changes were also present with haemodilution alone. Future studies with this partial optic nerve injury may enable understanding of mechanisms of peri-operative ischaemic optic neuropathy and could help discover preventive or treatment strategies.

https://ift.tt/2OzA7Z3

Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair: A randomised, blinded study

BACKGROUND Laparoscopic ventral hernia repair is a common surgical procedure. However, muscle contractions and general muscle tension may impair the surgical view and cause difficulties suturing the hernial defect. Deep neuromuscular blockade (NMB) paralyses the abdominal wall muscles and may help to create better surgical conditions. OBJECTIVES The current study investigated if deep compared with no NMB improved the surgical view during laparoscopic ventral hernia repair. DESIGN Crossover study. SETTING The study was carried out at Herlev and Gentofte Hospital, University of Copenhagen, Denmark and conducted from May 2015 until February 2017. PARTICIPANTS A total of 34 patients were randomised in an investigator-initiated, assessor-blinded crossover design of deep vs. no NMB during laparoscopic ventral hernia repair. INCLUSION CRITERIA Adults scheduled for elective laparoscopic ventral hernia repair. EXCLUSION CRITERIA Known allergy to any study medication, known homozygous variants in the butyrylcholinesterase gene, severe renal disease, neuromuscular disease, lactating or pregnant women, any indication for rapid sequence induction. INTERVENTIONS Deep NMB was established with rocuronium and reversed with sugammadex. Anaesthesia was conducted with propofol and remifentanil. MAIN OUTCOME MEASURES The primary outcome was evaluation of surgical view assessed on a five-point rating scale. Other outcomes included the surgical conditions during laparoscopic suturing of the hernia defect. RESULTS We found no difference in ratings for the surgical view when comparing deep with no NMB: mean −0.1 (95% confidence interval −0.4 to 0.2) (P = 0.521, paired t test). However, deep compared with no NMB improved the rating score for surgical conditions while suturing the hernia defect (P = 0.012, Mann–Whitney U test). No differences were found in either total length of surgery (P = 0.76) or hernia suturing time (P = 0.81). CONCLUSION Deep compared with no NMB did not change the rating score of the surgical view immediately after introduction of trocars during laparoscopic ventral hernia repair, but the surgical condition were improved during suturing of the hernia. TRIAL REGISTRATION ClinicalTrials.gov, NCT02247466.

https://ift.tt/2IDAX1w

End-tidal carbon dioxide monitoring improves patient safety during propofol-based sedation for breast lumpectomy: A randomised controlled trial

BACKGROUND The use of sedation is becoming more commonplace. Although pulse oximetry is a standard monitoring procedure during sedation, it cannot accurately detect early hypoventilation. End-tidal carbon dioxide (EtCO2) monitoring can be an earlier indicator of airway compromise; however, the existing literature is limited to a few studies with varying outcomes. OBJECTIVES To evaluate whether EtCO2 monitoring decreases the incidences of CO2 retention and apnoeic events in propofol-based sedation. DESIGN Randomised controlled study. SETTING A tertiary hospital. PATIENTS Two hundred women (aged 18 to 65 years, ASA physical status 1 or 2) who were scheduled for breast lumpectomy between June 2017 and August 2017. INTERVENTIONS Patients were allocated randomly to receive either standard monitoring or standard monitoring and EtCO2 monitoring. MAIN OUTCOME MEASURES The primary outcome was the incidence of CO2 retention. The secondary outcomes were the number of actions taken to restore ventilation, variations in PaCO2 and pH, the frequency of apnoea and the recovery time. RESULTS CO2 retention occurred significantly less often in the EtCO2 monitoring group (10 vs. 87%; P 

https://ift.tt/2OF9XVa

Haemodynamic evaluation and optimisation of brain-dead donors with oesophageal Doppler during organ harvesting: A feasibility study

No abstract available

https://ift.tt/2IzQcIV

Dexamethasone concentration affecting rocuronium-induced neuromuscular blockade and sugammadex reversal in a rat phrenic nerve-hemidiaphragm model: An ex vivo study

BACKGROUND The concentration range of dexamethasone that inhibits neuromuscular blockade (NMB) and sugammadex reversal remains unclear. OBJECTIVE To evaluate the effects of dexamethasone on rocuronium-induced NMB and sugammadex reversal. DESIGN Ex vivo study. SETTING Asan Institute for Life Sciences, Asan Medical Center, Korea, from July 2015 to November 2015. ANIMALS One hundred sixty male Sprague–Dawley rats. INTERVENTIONS We assessed the effect of four concentrations of dexamethasone [0, 0.5, 5 (clinical concentrations) and 50 μg ml−1 (experimental concentration)] on partial NMB on 40 phrenic nerve–hemidiaphragm preparations (n=10 per concentration). Once the first twitch of train-of-four (TOF) had been depressed by 50% with rocuronium, dexamethasone was administered. To assess the effect of dexamethasone on sugammadex reversal, 120 phrenic nerve–hemidiaphragm preparations were used in three subexperiments (n=40 per experiment), using three administration regimens of rocuronium–equimolar sugammadex: a single dose, a split-dose (split 1/2 and 1/2) and a reduced split-dose (split 1/2 and 1/4). After complete NMB was achieved, dexamethasone and sugammadex were administered. MAIN OUTCOME MEASURES The change in the first twitch height, the recovery time to a TOF ratio at least 0.9, and the TOF ratio at 30 min were evaluated. RESULTS There were no significant differences in the first twitch height among groups (P = 0.532). With a single dose of sugammadex, dexamethasone did not affect the recovery time to a TOF ratio at least 0.9 (P = 0.070). After using a split-dose of sugammadex, the recovery time to a TOF ratio at least 0.9 was delayed only at a concentration of 50 μg ml−1 of dexamethasone. With a reduced split-dose of sugammadex, the TOF ratio at 30 min was lowered only by a concentration of 50 μg ml−1 of dexamethasone (P 

https://ift.tt/2OtK1f5

Postoperative stroke: The picture is out of focus

No abstract available

https://ift.tt/2IBoVG5

Duration of the action of rocuronium in patients with BMI of less than 25: An observational study

BACKGROUND The duration of rocuronium in patients with BMI more than 30 kg m−2 is prolonged. Whether the reverse is true when BMI is less than 18.5 kg m−2 is unclear. OBJECTIVE The objective of this study was to investigate whether a BMI less than 25 kg m−2 affects the duration of rocuronium in doses adjusted for actual body weight. DESIGN A prospective, observational, single-centre study. SETTING The operating room of a teaching hospital from 1 June 2008 to 30 June 2015. PATIENTS Thirty patients with American Society of Anesthesiologists physical status I or II who were scheduled to undergo elective surgery (BMI 

https://ift.tt/2OGNs29

Translational pain research: an update from European Pain Federation educational platform

No abstract available

https://ift.tt/2ICEzRB

Effect of biodiesel on PAH, OPAH, and NPAH emissions from a direct injection diesel engine

Abstract

Polycyclic aromatic hydrocarbon (PAH), oxy- and nitro-derivate PAH (OPAH and NPAH) emissions from a direct injection diesel engine fueled with conventional fossil diesel (D), waste cooking oil biodiesel (B100), and their two blends (B20 and B50) were compared. The results show that B100 can reduce low molecular weight PAHs such as naphthalene, acenaphthylene, and fluorene as much as 90% compared with diesel. However, the emissions of high molecular weight PAHs including benzo[b]fluoranthene, benzo[k]fluoranthene, and benzo[a]pyrene decrease slightly when using B100. The emission levels for PAHs and OPAHs present comparable, while NPAH emission levels are five to ten times lower than those of PAHs and OPAHs. Compared with diesel, PAH and NPAH emissions significantly decrease. On the contrary, an increase trend of OPAH emission has been observed with adding biodiesel. For the specific parent PAHs and its oxygenated and nitrated derivatives, the fractions of parent PAHs gradually decrease with increasing biodiesel content in the blends, while the corresponding oxygenated and nitrated derivative fractions observably increase, especially for the high molecular weight compounds. Considering the increase of OPAH and NPAH fractions in total particle-phase PAHs when using biodiesel, in-depth biodiesel cytotoxicity assessment should be conducted.

https://ift.tt/2IAnvvn

The content of the potentially toxic elements, iron and manganese, in the grapevine cv Tamjanika growing near the biggest copper mining/metallurgical complex on the Balkan peninsula: phytoremediation, biomonitoring, and some toxicological aspects

Abstract

Plants growing in areas polluted by heavy metals represent excellent models for the investigations related to their potentials for hazardous metals accumulation which further may help in the estimation of plant practical biomonitoring and phytoremediation potentials. In this study, the potentials of the grapevine cultivar Tamjanika from a highly polluted region in Eastern Serbia, with intensive copper mining and metallurgical activities, were estimated in regard to the potentially toxic elements such as iron and manganese; the potential danger from these metals through fruit consummation is also considered. Used methods were the following: ICP-OES analysis, calculation of biological coefficients, the Pearson correlation study, one-way ANOVA, and hierarchical cluster analysis. The results revealed that a great majority of the recorded concentrations in different plant organs were in the range of normal concentrations, as well as that the calculated accumulation rates for both metals were very low. The data also pointed to generally minimal to moderate enrichment by these metals which represents totally dissimilar situation in comparison with other heavy metals detected in the very same plant samples. The results of this study suggested that the investigated plants of the grapevine cv Tamjanika assimilated iron and manganese predominately according to their individual needs, and confirmed that the utilization of this plant species can be very effective in different biomonitoring procedures and also in the phytoremediation procedure known as phytostabilization. At the same time, it was obvious that even in aggressive circumstances its fruit was protected from some serious contamination and kept pretty safe for consummation.

https://ift.tt/2O3PUA4

The use of rituximab in treatment of epidermolysis bullosa acquisita: Three new cases and a review of the literature

Dermatologic Therapy, EarlyView.


https://ift.tt/2DTLbvZ

Anterior, frontal congenital triangular alopecia, redundancy in therapy without improvement

Dermatologic Therapy, EarlyView.


https://ift.tt/2O22cJ6