Maternal anaesthesia in open and fetoscopic surgery of foetal open spinal neural tube defects: A 6-year observational study

BACKGROUND Prenatal myelomeningocele repair by open surgery can improve the neurological prognosis of children with this condition. A shift towards a fetoscopic approach seems to reduce maternal risks and improve obstetric outcomes. OBJECTIVE The aim of this study was to report on the anaesthetic management of women undergoing prenatal open or fetoscopic surgery for neural tube defects. DESIGN A retrospective cohort study. SETTING Prenatal myelomeningocele repair research group, Vall d'Hebron University Hospital, Spain. INTERVENTION Intra-uterine foetal repairs of spina bifida between 2011 and 2016 were reviewed. Anaesthetic and vasoconstrictor drugs, fluid therapy, maternal haemodynamic changes during surgery, blood gas changes during CO2 insufflation for fetoscopic surgery, and maternal and foetal complications were noted. RESULTS Twenty-nine foetuses with a neural tube defect underwent surgery, seven (24.1%) with open and 22 (75.9%) with fetoscopic surgery. There were no significant differences in maternal doses of opioids or neuromuscular blocking agents. Open surgery was associated with higher dose of halogenated anaesthetic agents [maximum medium alveolar concentration (MAC) sevoflurane 1.90 vs. 1.50%, P = 0.01], higher need for intra-operative tocolytic drugs [five of seven (71.4%) and two of 22 (9.1%) required nitroglycerine, P = 0.001], higher volume of colloids (500 vs. 300 ml, P = 0.036) and more postoperative tocolytic drugs (three drugs in all seven cases (100%) of open and in one of 21 (4.76%) of fetoscopic surgery, P 

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Intra-operative tachycardia is not associated with a composite of myocardial injury and mortality after noncardiac surgery: A retrospective cohort analysis

BACKGROUND Myocardial injury after noncardiac surgery (MINS) is a major contributor to peri-operative morbidity and mortality with a reported incidence of about 8%. Tachycardia increases myocardial oxygen demand, and decreases oxygen supply, and is therefore a potential cause of MINS. OBJECTIVE We tested the hypothesis that there is an association between intra-operative area above a heart rate (HR) of 90 bpm and a composite of MINS and in-hospital all-cause mortality. DESIGN Retrospective analyses. SETTING Major tertiary care hospital, Cleveland, USA. PATIENTS Adults having elective or nonelective noncardiac surgery and scheduled troponin monitoring during the first 3 postoperative days between 2010 and 2015. MAIN OUTCOME MEASURES All-or-none composite of myocardial injury (MINS), defined by a peak postoperative generation 4 troponin T concentration at least 0.03 ng ml−1, and in-hospital all-cause mortality. RESULTS Among 2652 eligible patients, 123 (4.6%) experienced MINS within 7 days after surgery and 6 (0.2%) died before discharge. Intra-operative area above HR more than 90 bpm was not associated with the all-or-none composite of MINS and in-hospital mortality, with an estimated odds ratio (95% confidence interval) of 0.99 (0.97 to 1.01) per 1 h bpm increase in area above HR more than 90 bpm. Secondary outcomes were also unrelated to the composite, with estimated odds ratios (98.3% confidence interval) of 0.99 (0.98 to 1.00) for area above HR more than 80, 0.98 (0.92 to 1.04) for area above HR more than 100 bpm, and 0.96 (0.88 to 1.05) for maximum HR. CONCLUSION There was no apparent association between various measures of tachycardia and a composite of MINS and death, a result that contradicts previously reported associations between other measures of intra-operative tachycardia and MINS/mortality. Correspondence to Kurt Ruetzler, MD, Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, P-77, Cleveland, OH 44195, USA Tel: +1 216 445 9857; fax: +1 216 444 6135; e-mail: kurt.ruetzler@reflex.at;web:www.or.org Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Examination of the enhanced recovery guidelines in thoracic surgery

Purpose of review Enhanced Recovery After Thoracic Surgery (ERATS) has gained momentum over the past few years, although the evidence base and expert recommendations lag behind other specialties. This review will present and examine key points from the first guidelines for enhanced recovery after lung surgery, released in 2018, jointly sponsored by the European Society of Thoracic Surgeons and the Enhanced Recovery After Surgery Society. Recent findings The recently released guidelines present core components of enhanced recovery as they pertain to lung resection surgery. Although evidence is still sparse in some areas, the guidelines summarize the available literature and incorporate levels of recommendation based upon the strength of available data as well as expert consensus. As of yet, the relative contribution of individual ERATS components to improvement in outcomes is unclear, but overall compliance does seem to be linked to positive results. Since the creation of the guidelines, additional literature related to ERATS has been released, and it will be incorporated and discussed into our review. Summary The creation of guidelines for enhanced recovery after lung resection will provide the thoracic anesthesiologist a framework upon which to build a comprehensive perioperative anesthetic plan. Correspondence to Emily G. Teeter, MD, FASE, Department of Anesthesiology, University of North Carolina at Chapel Hill, N2198 UNC Hospitals, CB #7010, Chapel Hill, NC 27599-7010, USA. Tel: 1 (919) 966 5136; E-mail: Emily_Teeter@med.unc.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Neuromonitoring in the elderly

Purpose of review To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. Recent findings The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0–100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. Summary Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly. Correspondence to Claudia Spies, Department of Anesthesiology and Operative Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany. Tel: +49 30 450 651 001; e-mail: claudia.spies@charite.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Incremental value of noncerebral somatic tissue oxygenation monitoring for patients undergoing surgery

Purpose of the review There is increasing interest in the use of noncerebral somatic tissue oxygen saturation (SstO2) monitoring on the basis of near-infrared spectroscopy in patients undergoing surgery or residing in intensive care unit. The relevant question is whether SstO2 monitoring can improve the quality of care. In this article, we reviewed the clinical application of SstO2 monitoring in acute care, focusing on its use in patients undergoing surgery. Recent findings Multiple small cohort studies conducted on pediatric patients reported close associations of SstO2 measurements over different regions such as the splanchnic and renal tissue beds with systemic oxygenation, transfusion, hemodynamic indices, morbidity, and mortality. Conversely, there is paucity of literature on SstO2 monitoring in adult patients. The limited number of reports suggests that SstO2 levels over bulk muscles such as the thenar eminence, forearm, and lower leg during surgery are correlated with postoperative outcomes including postoperative nausea and vomiting and the length of hospital stay in adult patients undergoing surgery. The only pilot, randomized interventional study based on 50 patients undergoing surgery did not find a difference in outcomes on the basis of the use of SstO2 monitoring. Summary Somatic tissue oxygenation may represent an essential aspect of human physiology in acute care, and it is likely outcome-relevant based on observational cohort studies. Future research should examine whether SstO2-guided care can further improve patient outcomes using randomized controlled trials. Correspondence to Lingzhong Meng, MD, Professor and Division Chief, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, PO Box 208051, New Haven, CT 06520, USA. Tel: +1 203 785 2802; e-mail: lingzhong.meng@yale.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Extravascular lung water monitoring for thoracic and lung transplant surgeries

Purpose of review Excessive accumulation of extravascular lung water (EVLW) resulting in pulmonary edema is the most feared complication following thoracic surgery and lung transplant. ICUs have long relied on chest radiography to monitor pulmonary status postoperatively but the increasing recognition of the limitations of bedside plain films has fueled development of newer technologies, which offer earlier detection, quantitative assessments, and can aide in preoperative screening of surgical candidates. In this review, we focus on the emergence of transpulmonary thermodilution (TPTD) and lung ultrasound with a focus on the clinical integration of these modalities into current intraoperative and critical care practices. Recent findings Recent studies demonstrate transpulmonary thermodilution and lung ultrasound provide greater sensitivity and earlier detection of lung water accumulation and are useful to guide clinical management. Assessments from these techniques have predictive value of postoperative outcome. Further, EVLW assessment shows promise as a preoperative screening tool in lung transplant patients. Summary Monitoring EVLW in the perioperative period offers clinicians a powerful tool to guide fluid therapy and manage pulmonary edema. Both TPTD and lung ultrasound have unique attributes in the care of thoracic surgery and lung transplant patients. Correspondence to Sherif Assaad, MD, Department of Anesthesiology, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA. Tel: +1 203 932 5711; fax: +1 203 937 4803; e-mail: sherif.assaad@yale.ed Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Spinal cord perfusion protection for thoraco-abdominal aortic aneurysm surgery

Purpose of Review Spinal cord ischemia (SCI) is a devastating complication after open or endovascular aortic repair for thoracoabdominal aortic disease. The underlying pathogenesis is not fully understood but appears multifactorial. Multiple spinal cord protection strategies and monitoring techniques are currently utilized with variable results seen. The purpose of this review is to summarize important and recent findings related to cause, monitoring and impact of multiple spinal cord protection strategies. Recent Findings Recent data suggests collateral blood flow as the major determinant of spinal cord perfusion instead of individual intercostal vessels, potential role of transcutaneous near-infrared spectroscopy for monitoring of spinal cord perfusion and positive impact of implementing multimodal spinal cord protection strategies on reducing the risk of SCI. Summary SCI leading to paraplegia is a multifactorial complication that remains a major concern in complex aortic surgeries. Although there are no sufficient data to document the efficacy of spinal cord protection techniques individually, their effect on lowering the risk of SCI is most evident when used concomitantly using a multimodal approach that encompasses the perioperative and early postoperative period. Correspondence to Lovkesh Arora, MD, 200 Hawkins drive, 6JCP, Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1079, USA. Tel: +1 319 384 6079; e-mail: Lovkesh-arora@uiowa.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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