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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.

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.

Introduction By maintaining sufficient cerebral blood flow and oxygenation, the goal of cardiopulmonary resuscitation (CPR) is to preserve the pre-arrest neurological state. To date, cerebral monitoring abilities during CPR have been limited. Therefore, we investigated the time-course of cerebral oxygen saturation values (rSO2) during advanced life support in out-of-hospital cardiac arrest. Our primary aim was to compare rSO2 values during advanced life support from patients with return of spontaneous circulation (ROSC) to patients who did not achieve ROSC. Methods We performed an observational study to measure rSO2 using Equanox™ (Nonin, Plymouth, MI) from the start of advanced life support in the pre-hospital setting. Results rSO2 of 49 consecutive out-of-hospital cardiac arrest patients were analyzed. The total increase from initial rSO2 value until two minutes before ROSC or end of advanced life support efforts was significantly larger in the group with ROSC 16% (9 to 36) compared to the patients without ROSC 10% (4 to 15) (P = 0.02). Mean rSO2 from the start of measurement until two minutes before ROSC or until termination of advanced life support was higher in patients with ROSC than in those without, namely 39% ± 7 and 31% ± 4 (P = 0.05) respectively. Conclusions During pre-hospital advanced life support, higher increases in rSO2 are observed in patients attaining ROSC, even before ROSC was clinically determined. Our findings suggest that rSO2 could be used in the future to guide patient tailored treatment during cardiac arrest and could therefore be a surrogate marker of the systemic oxygenation state of the patient.

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.

It is often said that regional anesthesia is the practice of applied anatomy. Therefore, it is fitting that on the occasion of his 500th birthday, we celebrate the life and work of the brilliant Flemish anatomist, Andreas Vesalius (1514-1564), the founder of modern anatomy. ispartof: Regional Anesthesia and Pain Medicine vol:39 issue:6 pages:450-455 ispartof: location:England status: published

Interleukin-6 (IL-6) plays a major role in hematopoiesis, immune functioning, and the acute phase response. In umbilical cord blood, this cytokine was thought to be a marker of neonatal defense to stress and infection, however, neonatal IL-6 production is immature. We speculated that a maternal influence exists on neonatal IL-6, at least during uncomplicated deliveries. Of the 81 healthy parturients included in this study, 51 delivered vaginally, 20 with and 31 without epidural analgesia, and 30 underwent elective cesarean section, 20 with epidural and 10 with general anesthesia. Maternal blood was sampled on hospital admission and just after delivery. Neonatal blood was collected from the umbilical cord. A significant positive correlation was found between neonatal cord blood interleukin-6 levels and maternal serum IL-6 levels on admission (r = 0.57, p

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.

SELECTIVE spinal injection procedures have become an integral part of the interdisciplinary treatment of patients with lumbar disc disease. These procedures can be powerful therapeutic tools in controlling pain and allowing early protected mobilization. Injection of the epidural space, spinal nerves, facet joints, and intervertebral discs cannot be performed safely and reliably without radiographic assistance. Epidural steroids have been used for many years to manage low back pain and sciatica but are still controversial. 1-3 The anesthesiologist is totally dependent on the epidural anatomy and resistance to spread medication around or up to the front of the dural sac. In patients with lumbar disc herniations and radiculopathy, the target site is the interface between the posterior annulus of the intervertebral disc and the ventral dural sac or root sleeve. The commonly used transforaminal injection technique, as described in several reports, improves the delivery of a high concentration of medication to the ventral epidural space. 4-7 Here, we describe a case of a transforaminal sleeve infiltration of the L3 nerve root. After positioning the needle, 2 ml dye was injected, and a discogram was visualized. In a MEDLINE search, we found no previous publications describing this inadvertent event. Possible implications for the interpretation of this observation in daily practice are discussed.

Introduction: Current monitoring during cardiopulmonary resuscitation (CPR) is limited to clinical observation of consciousness, breathing pattern and presence of a pulse. At the same time, the adequacy of cerebral oxygenation during CPR is critical for neurological outcome and thus survival. Cerebral oximetry, based on near-infrared spectroscopy (NIRS), provides a measure of brain oxygen saturation. Therefore, we examined the feasibility of using NIRS during CPR. Methods: Recent technologies (FORE-SIGHT (TM) and EQUANOX (TM)) enable the monitoring of absolute cerebral tissue oxygen saturation (SctO(2)) values without the need for pre-calibration. We tested both FORE-SIGHT (TM) (five patients) and EQUANOX Advance (TM) (nine patients) technologies in the in-hospital as well as the out-of-hospital CPR setting. In this observational study, values were not utilized in any treatment protocol or therapeutic decision. An independent t-test was used for statistical analysis. Results: Our data demonstrate the feasibility of both technologies to measure cerebral oxygen saturation during CPR. With the continuous, pulseless near-infrared wave analysis of both FORE-SIGHT (TM) and EQUANOX (TM) technology, we obtained SctO(2) values in the absence of spontaneous circulation. Both technologies were able to assess the efficacy of CPR efforts: improved resuscitation efforts (improved quality of chest compressions with switch of caregivers) resulted in higher SctO(2) values. Until now, the ability of CPR to provide adequate tissue oxygenation was difficult to quantify or to assess clinically due to a lack of specific technology. With both technologies, any change in hemodynamics (for example, ventricular fibrillation) results in a reciprocal change in SctO(2). In some patients, a sudden drop in SctO(2) was the first warning sign of reoccurring ventricular fibrillation. Conclusions: Both the FORE-SIGHT (TM) and EQUANOX (TM) technology allow non-invasive monitoring of the cerebral oxygen saturation during CPR. Moreover, changes in SctO(2) values might be used to monitor the efficacy of CPR efforts. The authors are indebted to all physicians and emergency medical technicians involved in the prehospital care of the patients reported in this study, as well as to the whole nursing staff of the department of Emergency Medicine ZOL, Genk (Belgium). This study is part of the Limburg Clinical Research Program (LCRP) UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital.

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.

Clara cell protein (CC16) is an endogenous anti-inflammatory agent. It is produced mainly in the respiratory and urogenital tracts. CC16 has been quantified in serum, but not in cerebrospinal fluid (CSF). The aim of this study was to examine CSF CC16 in relation to age, gender and serum CC16, and to examine CC16 levels in parturients. If CC16 levels are increased with age and during pregnancy, it may be responsible for the attenuation of inflammatory diseases such as multiple sclerosis during these conditions. CC16 was measured in CSF and serum taken just before Caesarean section (n=33) or just before an elective surgical procedure in females (n=52) or males (n=31). Fetal serum, amniotic fluid, and maternal urine were also sampled during Caesarean section. CC16 levels in CSF did not differ between parturients and an age and gender matched non-pregnant group, but was higher in male than in female patients. There was a significant and positive relationship between age and CSF CC16 levels and between serum and CSF CC16 levels. Fetal CC16 was significantly and positively correlated with amniotic fluid CC16. The present study suggests that CC16 found in CSF originates from passive diffusion from blood, and that CC16 found in amniotic fluid is derived from the fetal lung. During pregnancy, CC16 does not appear to contribute to alterations which occur in the progression of inflammatory disorders.

Levels of plasma cytokines, their receptors or immune-related peptides, are used in experimental and clinical medicine. However, no standards are available regarding the use of anticoagulants or blood processing including the technique of blood collection or time delay between blood sampling and centrifugation. Blood was collected from 10 patients in order to assay interleukin 6, soluble interleukin 6 receptor, soluble interleukin 2 receptor and soluble transferrin receptor by enzyme-linked immunosorbent assay (ELISA). At the time of sampling, five different collecting tubes were used: allowing coagulation, in the presence of EDTA, with EDTA being administered to the serum after its separation, in citrated and in heparinized blood. Blood was centrifuged 10 min after collection and separated serum or plasma was immediately frozen at -20 degrees C. To study the effect of time delay between blood sampling and processing, blood from 11 other patients was sampled, allowing coagulation; or in EDTA tubes and stored at 4 degrees C. The blood was centrifuged 10 min, 8 h and 24 h later, and the separated serum or EDTA plasma was stored at -20 degrees C until thawed for protein determination. Plasma interleukin 6 and soluble interleukin 6 receptor concentrations did not depend on the type of anticoagulant used or the time delay between sampling and processing. Soluble interleukin 2 receptor concentrations were not influenced by time delay before centrifugation, but concentrations were increased 10-fold in EDTA plasma exclusively when EDTA had contact with blood cells. Soluble transferrin receptor concentrations rose progressively with storage time before centrifugation. Contact of EDTA to whole blood or serum resulted in the same increase of soluble transferrin receptor concentration. The results suggest that standardization of the use of anticoagulant and time delay before centrifugation and serum or plasma separation is necessary for soluble interleukin 2 receptor and soluble transferrin receptor.

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.