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BACKGROUND The identification of factors associated with perioperative red blood cell (RBC) transfusion provides an opportunity to optimize the patient and surgical plan, and to guide perioperative crossmatch and RBC orders. We examined the association among potential bleeding risk factors and RBC requirements to develop a novel predictive model for RBC transfusion in patients undergoing brain tumor surgery. METHODS This retrospective study included 696 adults who underwent brain tumor surgery between 2008 and 2018. Multivariable logistic regression with backward stepwise selection for predictor selection was used during modeling. Model performance was evaluated using area under the receiver operating characteristic curve, and calibration was evaluated with Hosmer-Lemeshow goodness-of-fit χ2-estimate. RESULTS Preoperative hemoglobin level was inversely associated with the probability of RBC transfusion (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.39-0.63; P

Background Dexmedetomidine is frequently used for sedation during deep brain stimulator implantation in patients with Parkinson's disease, but its effect on subthalamic nucleus activity is not well known. The aim of this study was to quantify the effect of increasing doses of dexmedetomidine in this population. Methods Controlled clinical trial assessing changes in subthalamic activity with increasing doses of dexmedetomidine (from 0.2 to 0.6 μg kg−1 h−1) in a non-operating theatre setting. We recorded local field potentials in 12 patients with Parkinson's disease with bilateral deep brain stimulators (24 nuclei) and compared basal activity in the nuclei of each patient and activity recorded with different doses. Plasma levels of dexmedetomidine were obtained and correlated with the dose administered. Results With dexmedetomidine infusion, patients became clinically sedated, and at higher doses (0.5–0.6 μg kg−1 h−1) a significant decrease in the characteristic Parkinsonian subthalamic activity was observed (P Conclusions Patients needing some degree of sedation throughout subthalamic deep brain stimulator implantation for Parkinson's disease can probably receive dexmedetomidine up to 0.6 μg kg−1 h−1 without significant alteration of their characteristic subthalamic activity. If patients achieve a ‘sedated' state, subthalamic activity decreases, but they can be easily awakened with a non-pharmacological external stimulus and recover baseline subthalamic activity patterns in less than 10 min. Clinical trial registration EudraCT 2016-002680-34; NCT-02982512.

BACKGROUND: During magnetic resonance–guided focused ultrasound for essential or parkinsonian tremor, adverse events (headache, nausea/vomiting, or anxiety) may alter the outcome of the procedure despite being mostly transient and mild. OBJECTIVES: Our aim was to analyze the relationship between demographic, procedural, and anesthetic characteristics with magnetic resonance/ultrasound‐related events. METHODS: This was a retrospective study at the Clinica Universidad de Navarra of patients undergoing thalamotomy with magnetic resonance–guided focused ultrasound between September 2018 and October 2019. The anesthesia protocol included headache and nausea/vomiting prophylaxis and rescue therapy. Dexmedetomidine was used for anxiolysis in some patients after thorough multidisciplinary assessment. RESULTS: A total of 123 patients were included. Headache was directly related to skull density ratio (P

To evaluate the relationship between pharmacokinetic descriptors of dexmedetomidine (predicted area under the curve during the procedure, predicted plasma level at the end of the procedure, and duration of procedure) and sedation depth (proportion of time with bispectral index

Background Deep brain stimulation electrodes can record oscillatory activity from deep brain structures, known as local field potentials. The authors’ objective was to evaluate and quantify the effects of dexmedetomidine (0.2 μg·kg-1·h-1) on local field potentials in patients with Parkinson disease undergoing deep brain stimulation surgery compared with control recording (primary outcome), as well as the effect of propofol at different estimated peak effect site concentrations (0.5, 1.0, 1.5, 2.0, and 2.5 μg/ml) from control recording. Methods A nonrandomized, nonblinded controlled clinical trial was carried out to assess the change in local field potentials activity over time in 10 patients with Parkinson disease who underwent deep brain stimulation placement surgery (18 subthalamic nuclei). The relationship was assessed between the activity in nuclei in the same patient at a given time and repeated measures from the same nucleus over time. Results No significant difference was observed between the relative beta power of local field potentials in dexmedetomidine and control recordings (−7.7; 95% CI, −18.9 to 7.6). By contrast, there was a significant decline of 12.7% (95% CI, −21.3 to −4.7) in the relative beta power of the local field potentials for each increment in the estimated peak propofol concentrations at the effect site relative to the control recordings. Conclusions Dexmedetomidine (0.2 μg·kg-1·h-1) did not show effect on local field potentials compared with control recording. A significant deep brain activity decline from control recording was observed with incremental doses of propofol.

Resumen Introduccion El objetivo de este estudio fue evaluar el efecto de diferentes dosis de carga de dexmedetomidina (formulacion Dexdor®) en el tiempo para lograr y mantener un nivel optimo de sedacion, y su repercusion hemodinamica. Material y metodos Estudio observacional aprobado por el CEIC-Navarra en pacientes programados para cirugia oral y maxilofacial ambulatoria con dexmedetomidina en la Clinica Universidad de Navarra entre febrero de 2013 y noviembre de 2014. En funcion de la dosis de carga los pacientes fueron agrupados en 3 categorias: 0,5 μg/kg. El nivel optimo de sedacion se definio como un indice biespectral Resultados Ochenta y un pacientes fueron evaluados. La hazard ratio de alcanzar un indice biespectral 0,5 μg/kg fue de 1,5 (IC 95% 0,9; 2,6) y 1,8 (IC 95% 0,8; 3,9), respectivamente, en comparacion con el grupo inferior. Cinco pacientes (6,2%) precisaron de atropina. Los pacientes en el grupo de > 0,5 μg/kg mostraron mayor riesgo de requerir atropina respecto al grupo de Conclusion Una dosis de carga de Dexdor® > 0,5 μg/kg parece reducir el tiempo necesario para alcanzar y mantener un nivel optimo de sedacion durante los primeros 60 min de procedimiento. La posible relacion entre la dosis de carga y los requerimientos de atropina precisa una investigacion mas exhaustiva.

Deep brain stimulation electrodes can record oscillatory activity from deep brain structures, known as local field potentials. The authors' objective was to evaluate and quantify the effects of dexmedetomidine (0.2 μg·kg·h) on local field potentials in patients with Parkinson disease undergoing deep brain stimulation surgery compared with control recording (primary outcome), as well as the effect of propofol at different estimated peak effect site concentrations (0.5, 1.0, 1.5, 2.0, and 2.5 μg/ml) from control recording.A nonrandomized, nonblinded controlled clinical trial was carried out to assess the change in local field potentials activity over time in 10 patients with Parkinson disease who underwent deep brain stimulation placement surgery (18 subthalamic nuclei). The relationship was assessed between the activity in nuclei in the same patient at a given time and repeated measures from the same nucleus over time.No significant difference was observed between the relative beta power of local field potentials in dexmedetomidine and control recordings (-7.7; 95% CI, -18.9 to 7.6). By contrast, there was a significant decline of 12.7% (95% CI, -21.3 to -4.7) in the relative beta power of the local field potentials for each increment in the estimated peak propofol concentrations at the effect site relative to the control recordings.Dexmedetomidine (0.2 μg·kg·h) did not show effect on local field potentials compared with control recording. A significant deep brain activity decline from control recording was observed with incremental doses of propofol.

Background The anesthetic management of patients requiring surgery for movement disorders needs to balance microrecording quality and patient cooperation with safety and comfort. Anesthetics can alter microrecording, although the effect on outcome is debatable. They also provide a rested and cooperative patient and minimize complications such as intracranial hemorrhage by providing better hemodynamic control. Most teams use local anesthesia with monitored anesthesia care or conscious sedation with propofol. Recently, dexmedetomidine has emerged as an alternative that, at low doses, does not affect microrecording, and that does not impair respiratory drive. Methods In the past 15 years, we have used in our institution local anesthesia, remifentanil, or dexmedetomidine sedation. We compared functional outcome and rate of complications in a group of 145 patients with similar characteristics. Results We found 5 (3.4%) intracranial hemorrhages. Two (1.4%) were symptomatic. The remifentanil group had the highest risk of having systolic blood pressure >160 mm Hg during surgery (odds ratio [OR], 2.8; 95% confidence interval [CI], 0.9–9.9), whereas the dexmedetomidine group had the lowest (OR, 0.7; 95% CI, 0.2–1.8), compared with the local anesthesia group. Surgical time was shortest with dexmedetomidine (mean, 283 minutes) and longest with local anesthesia only (mean, 328 minutes). Functional outcome (Unified Parkinson's Disease Rating Scale, Part III motor component scale) was similar among groups. The dexmedetomidine group had a statistically significant lower risk of perioperative neurologic events compared with the local anesthesia group (OR, 0.09; 95% CI, 0.002–0.68). Conclusions Sedation can be used safely without affecting outcome, and dexmedetomidine provides better hemodynamic management. Clinical significance remains unclear and larger studies need to be undertaken.

Introduction: Dexmedetomidine is an α2-agonist recently proposed as a potentially ideal drug for sedation during the surgical treatment of Parkinsonʼs disease (PD). This report documents the incidence of changes in motor symptoms (especially tremor) in PD patients sedated with dexmedetomidine for deep brain stimulation or ablation procedures. Methods: We reviewed a retrospective cohort of 22 patients who underwent surgery for PD with dexmedetomidine sedation at a single institution from 2010 to 2014. A logistic regression analysis was performed to analyze possible confounding factors. Results: 14 cases of tremor reduction or suppression were recorded (cumulative incidence: 63.6%; 95% CI: 40.7-82.8). No association could be identified between loading dose, β-blocker use and preoperative total Unified Parkinson's Disease Rating Scale III, with tremor changes. The maintenance dose of dexmedetomidine was higher in patients who did not experience changes [median and range for patients with and without tremor alteration 0.75 (0.2-1.0) and 1.0 µg × kg-1 × h-1 (0.7-1.4), respectively; p = 0.021]. Conclusion: Dexmedetomidine provides adequate sedation during surgery for PD, but it might affect motor signs making intraoperative testing difficult or even impossible. Dosage appears not to be the determining factor in motor changes, whose cause remains unclear.

The PiCCO™ monitor (Pulsion Medical System, Melsungen, Hessen, Germany) has become an alternative method of haemodynamic invasive monitoring for the critically ill patient. The determination of the continuous cardiac output by arterial pulse contour analysis requires the periodic calibration of the monitor. This calibration is performed by the injection of a bolus of 15–20 ml cold saline through a central line catheter [1-3]. We present the case of a 54-year-old woman with breast cancer who underwent cord decompression surgery for bone metastasis. On the seventh postoperative day she developed multiorgan system failure (septic shock + respiratory insufficiency + acute renal failure + disseminated intravascular coagulopathy) due to nosocomial pneumonia. The patient was admitted to the intensive care unit and the PiCCO™ monitor was used for invasive haemodynamic monitoring. A Certofix™ Trio HF catheter (Braun, Munich, Bayern, Germany) was placed uneventfully in the right internal jugular vein to carry out continuous venous–venous haemodialysis (CVVH-D). The Certofix™ Trio HF is a triplelumen catheter made of polyurethane with three lumens (first channel, distal = 16 G; second channel, middle = 12 G; and third channel, proximal = 12 G). The distal lumen was used for the calibrations of the PiCCO™ monitor due to the highrisk of insertion of another central line in a patient with severe coagulopathy. The analysis of the area under the thermodilution curve showed a hypodynamic state that was treated

BACKGROUND 5-Aminolevulinic acid (5-ALA) is used for brain tumor identification during surgery through fluorescence. Its use is linked to side effects such as photodermatosis, anemia, or plaquetopenia. Many institutions take very strict precautions to prevent them. Our hospital's protocol mandates avoidance of direct sunlight during the first 24 hours only. METHODS Retrospective cohort observational study of 207 consecutive patients who underwent 5-ALA-guided brain tumor resection between 2008 and 2013, and compared with a control group of 53 patients without 5-ALA. RESULTS No skin reaction was reported. No difference was found in hemoglobin or platelet level comparisons at different points in time. There was no difference in trends within groups. Mean duration of surgery was longer in the 5-ALA group; the subgroup of patients undergoing their first surgery had a positive correlation with lower hemoglobin levels. In postoperative magnetic resonance imaging, patients in the 5-ALA group had a lower percentage of residual bleeding (19% of all patients; 17.9% in 5-ALA group and 22.7% in non-ALA [P=0.04]). Eight patients in the 5-ALA group required blood transfusion (3.9%), compared with 2 in the control group (3.8%). Four patients in the 5-ALA group required reintervention in the first 48 hours due to bleeding, although none had platelets