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Background Near-infrared spectroscopy non-invasively measures regional cerebral oxygen saturation. Intraoperative cerebral desaturations have been associated with worse neurological outcomes. We investigated whether perioperative cerebral desaturations are associated with postoperative delirium in older patients after cardiac surgery. Methods Patients aged 70 yr and older scheduled for on-pump cardiac surgery were included between 2015 and 2017 in a single-centre, prospective, observational study. Baseline cerebral oxygen saturation was measured 1 day before surgery. Throughout surgery and after ICU admission, cerebral oxygen saturation was monitored continuously up to 72 h after operation. The presence of delirium was assessed using the confusion assessment method for the ICU. Association with delirium was evaluated with unadjusted analyses and multivariable logistic regression. Results Ninety-six of 103 patients were included, and 29 (30%) became delirious. Intraoperative cerebral oxygen saturation was not significantly associated with postoperative delirium. The lowest postoperative cerebral oxygen saturation was lower in patients who became delirious (P=0.001). The absolute and relative postoperative cerebral oxygen saturation decreases were more marked in patients with delirium (13 [6]% and 19 [9]%, respectively) compared with patients without delirium (9 [4]% and 14 [5]%; P=0.002 and P=0.001, respectively). These differences in cerebral oxygen saturation were no longer present after excluding cerebral oxygen saturation values after patients became delirious. Older age, previous stroke, higher EuroSCORE II, lower preoperative Mini-Mental Status Examination, and more substantial absolute postoperative cerebral oxygen saturation decreases were independently associated with postoperative delirium incidence. Conclusions Postoperative delirium in older patients undergoing cardiac surgery is associated with absolute decreases in postoperative cerebral oxygen saturation. These differences appear most detectable after the onset of delirium. Clinical trial registration NCT02532530.

The objective of this study was to describe changes in cerebral tissue oxygen saturation (SctO2) due to changes in body position in healthy volunteers and in patients undergoing surgery under general anesthesia in the beach chair position (BCP) and lateral decubitus position (LDP).In this prospective observational study, SctO2 was measured in 85 awake volunteers serially positioned every 15 min, beginning with the supine position (SP) and followed by the beach chair, supine, and lateral decubitus positions. Cerebral tissue oxygen saturation was also measured supine and in either the BCP or the LDP in 195 patients (according to surgical preference) undergoing elective arthroscopic shoulder surgery. We measured the lowest stable SctO2 values in each position as well as changes in blood pressure and heart rate.In healthy volunteers, the median (interquartile range [IQR]) lowest stable SctO2 value in the SP was 69 [66-71] %. A change in position to the BCP caused a small but statistically significant decrease in the median [IQR] lowest SctO2 value to 67 [65-70] % (P = 0.028 compared with baseline). This decrease was associated with an increase in median [IQR] arterial pressure from 83 [78-88] mmHg in the SP to 85 [81-93] mmHg in the BCP (P0.001 compared with baseline). In patients undergoing surgery in the BCP, the median [IQR] lowest stable SctO2 value was 55 [51-59] %, which was significantly lower (P0.001) than the median [IQR] lowest SctO2 value in patients in the LDP (66 [62-69] %). More patients in the BCP group (57%) showed SctO2 values ≤ 55% and/or a decrease of ≥ 20% from baseline (57%) compared with the LDP group (5% and 6%, respectively; P0.001 for each comparison).More than 55% of patients undergoing arthroscopic shoulder surgery in the BCP experience cerebral desaturation events. In volunteers without anesthesia, no desaturation events were observed. The clinical importance of these findings needs further investigation.

Item does not contain fulltext BACKGROUND AND AIMS: Persistent low back pain after initially successful surgery that is not attributed to structural deficits is called failed back surgery syndrome (FBSS). When conservative and minimal invasive therapy fail, the recommended treatment is spinal cord stimulation (SCS). Because epidural fibrosis can be a contributing factor in the majority of FBSS patients, lumbosacral epiduroscopic lysis of adhesions may be considered as a less invasive alternative treatment option. We hypothesized that the use of epiduroscopic lysis of adhesions could reduce the need for SCS. METHODS: A pilot study was performed in 35 consecutive patients with FBSS who underwent epiduroscopic lysis of adhesions. SCS was considered if epiduroscopic lysis of adhesions gave less than 50% global perceived effect (GPE) improvement after 15 months of follow-up. The GPE was measured 1 week and 6 months after the procedure. RESULTS: Over a period of 69 months, 35 patients were included. After 15 months of follow-up, 43% of patients required SCS. Eight of the 15 patients who reported no short-term improvement needed SCS; those patients had severe epidural fibrosis. One week after epiduroscopic lysis of adhesions, 34%, 23%, and 43% of patients reported GPE improvement of > 50%, 20% to 50%, and < 20%, respectively. After 6 months, 5 patients were lost to follow-up, and 30%, 17%, and 16% of patients reported improvement of > 50%, 20% to 50%, and < 20%, respectively. CONCLUSIONS: In this pilot study we observed a reduced need for SCS when lumbosacral epiduroscopic lysis of adhesions was used for patients with FBSS and magnetic resonance imaging-proven adhesions. These observations justify the evaluation of both treatment options in a prospective observational trial.

Background:Less than 50% of patients experience sufficient pain relief with current drug therapy for neuropathic pain. Minocycline shows promising results in rodent models of neuropathic pain but was not studied in humans with regard to the treatment of neuropathic pain.Methods:In this randomized, double-blind, placebo-controlled clinical trial, patients with subacute lumbar radicular pain received placebo, amitriptyline 25 mg, or minocycline 100 mg once a day (n = 20 per group) for 14 days. Primary outcome measure was the pain intensity in the leg as measured by a numeric rating scale ranging from 0 to 10 on days 7 and 14. Secondary outcome measures were the reduction of neuropathic pain symptoms in the leg as determined with a neuropathic pain questionnaire, consumption of rescue medication, and adverse events on days 7 and 14.Results:Sixty patients were randomized and included in an intention-to-treat analysis. After 14 days, patients in the minocycline and amitriptyline groups reported a reduction of 1.47 (95% confidence interval, 0.16–2.83; P = 0.035) and 1.41 (95% confidence interval, 0.05–2.78; P = 0.043), respectively, in the numeric rating scale compared to the placebo group. No differences were seen in the neuropathic pain questionnaire values at any time point during treatment between the three groups. The rate of adverse events in the amitriptyline group was 10% versus none in the minocycline and placebo groups. No differences were noted in the consumption of rescue medication.Conclusions:Although both groups differed from placebo, their effect size was small and therefore not likely to be clinically meaningful.

Aim of the study This observational study was performed to assess the cerebral tissue oxygen saturation during and after therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest. Methods We performed a prospective observational study on the cerebral tissue oxygen saturation (SctO 2 ) in post-cardiac arrest patients treated with therapeutic hypothermia (TH) between March 2011 and April 2012. SctO 2 (measured by near-infrared spectroscopy) was non-invasively and continuously measured in 28 post-cardiac arrest patients during hypothermia and active rewarming. Results At the start of mechanically induced TH, SctO 2 was 68% (65–72) and PaCO 2 was 47.2mmHg (36.9–51.4). SctO 2 and PaCO 2 significantly decreased to 59% (57–64; p =0.006) and 36.6mmHg (33.9–44.7; p =0.002), respectively, within the first 3h of mechanically induced TH. Cerebral tissue oxygen saturation was significantly lower in non-survivors ( n =10) compared with survivors ( n =18) at 3h after induction of hypothermia ( p =0.02) while the decrease in PaCO 2 was similar in both groups. During TH maintenance, SctO 2 gradually returned to baseline values (69% (63–72)) at 24h, with no differences between survivors and non-survivors ( p =0.65). Carbon dioxide remained within the range of mild hypocapnia (32–38mmHg) throughout the hypothermic period. During rewarming, SctO 2 further increased to 71% (67–78). Conclusions Induction of TH in comatose post-CA patients changes the balance between oxygen delivery and supply. The decrease in SctO 2 was less pronounced in patients surviving to hospital discharge.

Item does not contain fulltext BACKGROUND: In recent literature, it has been suggested that deep neuromuscular block (NMB) improves surgical conditions during laparoscopy; however, the evidence supporting this statement is limited, and this was not investigated in laparoscopic bariatric surgery. Moreover, residual NMB could impair postoperative respiratory function. We tested the hypotheses that deep NMB could improve the quality of surgical conditions for laparoscopic bariatric surgery compared with moderate NMB and investigated whether deep NMB puts patients at risk for postoperative respiratory impairment compared with moderate NMB. METHODS: Sixty patients were evenly randomized over a deep NMB group (rocuronium bolus and infusion maintaining a posttetanic count of 1-2) and a moderate NMB group (rocuronium bolus and top-ups maintaining a train-of-four count of 1-2). Anesthesia was induced and maintained with propofol and remifentanil. The primary outcome measures were the quality of surgical conditions assessed by a single surgeon using a 5-point rating scale (1 = extremely poor, 5 = optimal), the number of intra-abdominal pressure increases >18 cmH2O and the duration of surgery. Secondary outcome measure was the postoperative pulmonary function assessed by peak expiratory flow, forced expiratory volume in 1 second, and forced vital capacity, and by the need for postoperative respiratory support. Data are presented as mean +/- standard deviation with estimated treatment effect (ETE: mean difference [95% confidence interval]) for group comparisons. RESULTS: There was no statistically significant difference in the surgeon's rating regarding the quality of the surgical field between the deep and moderate NMB group (4.2 +/- 1.0 vs 3.9 +/- 1.1; P = .16, respectively; ETE: 0.4 [-0.1, 0.9]). There was no difference in the proportional rating of surgical conditions over the 5-point rating scale between both groups (P = .91). The number of intra-abdominal pressure increases >18 cmH2O and the duration of surgery were not statistically different between the deep and moderate NMB group (0.2 +/- 0.9 vs 0.3 +/- 1.0; P = .69; ETE: -0.1 [-0.5, 0.4] and 61.3 +/- 15.1 minutes vs 70.6 +/- 20.8 minutes; P = .07, ETE: -9.3 [-18.8, 0.1], respectively). All the pulmonary function tests were considerably impaired in both groups when compared with baseline (P < .001). There was no statistically significant difference in the decrease in peak expiratory flow, forced expiratory volume in 1 second, and forced vital capacity (expressed as % change from baseline) between the deep and the moderate NMB group. CONCLUSIONS: Compared with a moderate NMB, there was insufficient evidence to conclude that deep NMB improves surgical conditions during laparoscopic bariatric surgery. Postoperative pulmonary function was substantially decreased after laparoscopic bariatric surgery independently of the NMB regime that was used. The study is limited by a small sample size.

Item does not contain fulltext IMPLICATIONS: That IL-6 is an interesting target in the study of pain is underscored by its biomolecular properties, its localization after experimental pain, and its modulating effect on pain after administration.

Background: Interleukin-6 is a pleiotropic cytokine with a wide range of physiological activities. It plays an important role in the immuno-neuro-humoral axis during stress and surgery. Methods: Serum interleukin-6 in parturients was measured on hospital admission, immediately after birth and 12 and 24 hours later. All parturients had uncomplicated pregnancies, and delivered vaginally without (n=31) or with (n=20) epidural analgesia, or underwent Caesarean section under epidural (n=20) or general (n=10) anaesthesia. Results: Serum interleukin-6 assayed immediately following Caesarean section was low, but peaked 12 hours later, irrespective of the anaesthetic technique or other foetomaternal characteristics. Patients who delivered vaginally showed the highest interleukin-6 levels immediately after delivery. These were positively correlated with serum interleukin-6 on admission and duration of labour. Serum interleukin-6 was significantly higher in parturients who had epidural analgesia, and was significantly lower in those receiving intravaginal prostaglandins compared to those without prostaglandins. Conclusion: The interleukin-6 response after Caesarean section can be explained by a generalized acute phase response to surgery, with no anaesthetic, maternal or neonatal interference. The rapid increase in peripartum serum interleukin-6 levels after vaginal delivery reflects, in part, cervical ripening or labour, their physiological triggers and psychological or physical stress. Regional anaesthesia, duration of labour and exogenous prostaglandin administration can modulate the peripartum interleukin-6 response and subsequently the physiological effects of this cytokine.

NMDA receptors are involved in the modulation of neuropathic pain behavior and central sensitization. In vivo, this is mostly demonstrated by the use of specific antagonists Such as MK801. Because studies evaluating the direct impact of spinal NMDA in neuropathic pain models are lacking, we performed a series of experiments to study the role of spinal NMDA injection on existing cold allodynia, as a measurement of neuropathic pain behavior in rodents. Intrathecal. injection of NMDA resulted in an enhanced neuropathic pain behavior in CCI rats on a cold plate. The activity was present from a dose of 5 ng/rat onward and Could selectively be reversed by intraperitoneal injections of doses of >= 0.01 mg/kg MK801. These results support the regulatory role of NMDA receptors in the hypersensitivity to cold observed in neuropathic pain behavior in rodents. (c) 2005 Elsevier Inc. All rights reserved.

UNLABELLED We evaluated the efficacy of intraarticular sufentanil in the prevention of postoperative pain after day-case arthroscopic procedures. Sixty patients were randomly assigned to receive either intraarticular sufentanil, 5 or 10 microg, and saline IV, or intraarticular saline and sufentanil 5 microg IV (control). All study medication was administered in a double-blinded fashion. Postoperatively and the day after surgery, pain levels at rest and during movement (i.e., active flexion of the knee), measured by a visual analog scale, were significantly lower in the Sufentanil groups compared with the Control group. Moreover, intraarticular sufentanil significantly reduced the postoperative consumption of analgesics. The time until discharge from the postanesthesia care unit (assessed by the Aldrete score) was significantly shorter in the patients receiving sufentanil intraarticularly. There were no significant differences between the two Sufentanil groups either in the intensity of postoperative pain or in discharge times from the postanesthesia care unit. We conclude that intraarticular sufentanil in arthroscopic knee procedures is a simple, effective, safe and well-tolerated analgesic technique for outpatients undergoing arthroscopic procedures. Increasing the dose sufentanil from 5 to 10 microg intraarticularly offered no additional advantage. Intraarticular sufentanil (5-10 microg) administration improves postoperative management after day-case diagnostic arthroscopic knee procedures. IMPLICATIONS Intraarticular sufentanil (5-10 microg) administration improves postoperative management after day-case diagnostic arthroscopic knee procedures.

Study Objective: To assess the anesthetic effects of clonidine during sevoflurane anesthesia guided by the bispectral index (BIS), which is a processed EEG variable correlated with anesthetic-hypnotic depth. Design: Placebo-controlled, double-blind clinical trial Settings: Elective laparoscopic surgery Patients: 60 ASA physical status I patients scheduled for laparoscopic surgery Interventions: Patients received either clonidine (3 μg/kg, 15 min before induction) or placebo premedication for a sevoflurane-induced and sevoflurane-maintained anesthesia. Sevoflurane was titrated against a BIS held between 40 and 50. Analgesia was provided by local infiltration with bupivacaine. Need for postoperative analgesia was recorded. Results and Conclusion: Mean sevoflurane requirements were not lower with clonidine pretreatment. There was statistically better perioperative hemodynamic stability (i.e., fewer episodes of hypertension and tachycardia) without clinical relevance. A decreased need for postoperative analgesia was observed.

Editor, We have read with great interest the article by Fielmuth and Uhlig [1] on the role of somatosensory-evoked potentials (SSEPs) in detecting cerebral ischaemia during carotid endarterectomy. The authors made an assessment of the validity of SSEP monitoring during carotid endarterectomy in awake patients under locoregional anaesthesia. They correctly reported the current substantial variety of SSEP parameters and thresholds related to these SSEP parameters used to detect critical deterioration in cerebral blood flow (CBF). Their study was designed to compare SSEP tracings with the objective clinical–neurological examination in order to evaluate the reliability of the different SSEP-generated criteria. They referred to Shapiro and Aidinis [2], who developed a model, which can be seen as the methodological basis for current neuromonitoring during carotid surgery. This model correlates neuronal integrity and electrical activity with CBF. Using this approach to interpret changes in SSEP tracing as a perfusion-dependent neuronal metabolic situation, different parameters and values have been established to detect a relevant reduction in CBF.

Method: We conducted a database study at Cochin hospital in Paris, France. Between December 2006 and January 2010, we included 381 patients who were all resuscitated from an OHCA (excepted those with a primary neurological cause or moribunds). A moderate glycemic control was applied in all patients (aiming to maintain glycemia between 5.1 and 7.7mmol/l). BG was measured every 3h during the first 48h. The median glycemia and the largest delta were assessed. Amultivariate analysis was performed to determine parameters that independently influenced the main outcome (CPC level at ICU discharge). Results: 136/381 patients (36%) had a favorable outcome (CPC 1–2). Median BG level was 7.6mmol/l [6.3–9.8] in patients with a favorable outcome compared to 9.0mmol/l (IQR: 7.1–10.6) for patientswithanunfavorableneurologic outcome (p 8.4mmol/l) was found to be an independent predictor of poor neurological issue (OR=0.43; 95% CI [0.24–0.78], p=0.006). Other predictive factors of poor outcome were an unshockable rhythm, cardiac arrest location, a no flow >4min and a low flow >15min. Finally an increase in median BG was associated with an increase in the proportion of patients with a poor neurological outcome (Fig. 1). Conclusion: Even after adjustment with usual prognostic factors, an increase in glycemia during the first 48h is associated with an unfavorable neurological outcome.

Standard clinical practice in patients with elevated intracranial pressure (ICP) is to keep cerebral perfusion pressure (CPP) at (or above) 60 mmHg: we performed this retrospective study to analyze whether induction of barbiturate coma impedes compliance to this target CPP value. It has been repetitively shown that, although proven as an efficient therapy for refractory elevated ICP, barbiturate coma may cause a decrease in mean arterial pressure (MAP) and CPP [1].

Summary Two patients are described in whom fulminant haemoptysis occurred during extracorporeal circulation. The use of high frequency jet ventilation resulted in a dramatic decrease of blood loss from the tracheal tube, avoiding the need for more aggressive management.

Birth is a stressful event for the child. A lot of physiological changes happen during the early extrauterine period to make an independent existence possible. He must breathe air, change his circulatory pattern, maintain his body temperature, limit the invasion of microorganisms, ingest, digest, and assimilate food for activity and growth, provide new routes for excretion of metabolic end products, restrict the hemorrhage of trauma, and expand his hematopoietic system. In these processes, cytokines might play an important role.

Cerebral oximetry, using near-infrared spectroscopy to measure cerebral tissue oxygen saturation (SctO2), is being increasingly used in the ICU. We hypothesized that if a patient becomes brain dead in the ICU, this must be reflected in SctO2 values. This might help in the timing of invasive procedures such as angiography, sometimes necessary in the confirmation of brain death.

Background: Incidence and characteristics of post-cooling fever were rarely described. In this study, we analysed the possible link between cardiac arrest (CA), therapeutic hypothermia and fever. Patients and Methods: Data of 11 post-CA pts were analysed. All hemodynamic, respiratory and laboratory data were collected. Hyperthermia was defined as a core (rectal) temperature exceeding 37.7°C, Results: Of the 11 pts, there were 5 (45%) survivors and 6 (55%) non-survivors, 2 died of hemodynamic shock (first 24hrs), 4 died due to post-ischemic brain damage. Results: All pts were successfully cooled (33° for 24hrs). Rewarming procedure was uneventfull. Results: Eight (89%) pts developed hyperthermia at the end of rewarming. Six (75%) of them did so immediately, while the other 2 pts developed fever 2 to 5 hours after rewarming. Three (37.5%) pts showed short periods of fever (2 -10hrs), while the remaining 5 (62.5%) had fever for a few days. In all patients, WBC at admission were significantly increased whereas CRP only increased after 2–3 days ICU-admission, in 8 patients this occurred simultaneously with the post-cooling fever. In 7 of these 8 pts, antibiotic treatment was initiated. In 5 of 8 pts, pneumonia, prolonged weaning and awakening, but did not influence final mortality. Conclusion: We found a 89% incidence of post-cooling fever, associated with ending of rewarming and increase in inflammatory parameters (CRP).