Sedation with Propofol plus Paracetamol in External Cephalic Version: An Observational Study.

Although the influence of neuraxial anesthesia or sedation with remifentanil in external cephalic version (ECV) is widely known, ECV results using propofol have not been previously analyzed. This study aimed to evaluate ECV outcomes when propofol was used. An observational analysis of ECV was performed between 1 January 2018 and 31 December 2020. ECV was accomplished with tocolysis and propofol. One hundred and thirty-one pregnant women were recruited. The propofol mean dose was 156.1 mg (SD 6.1). A cephalic presentation was achieved in 61.1% (80/131) of the pregnant women. In total, 56.7% (38/67) of pregnant women with cephalic presentation at labor had a spontaneous delivery, 26.9% (18/67) had an operative delivery, and an intrapartum urgent cesarean section was performed in 16.4% (11/67). In total, 46 pregnant women (35.9%) were scheduled for an elective cesarean section due to non-cephalic presentation. The emergency cesarean section rate during the following 24 h was 10.7% (14/131). A major ECV complication arose in 15 cases (11.5%). ECV outcomes when propofol was used seems to be similar to those with other anesthetic adjunct, so sedation with propofol could be an adequate option for ECV. More studies are needed to compare its effectiveness with neuraxial techniques.

A dose-response relationship study of hypertonic saline on brain relaxation during supratentorial brain tumour craniotomy.

Background: A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 2 doses of 3% HS during elective supratentorial brain tumour surgery.Methods: 60 patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 3 mL/kg (group L) or 5 mL/kg (group H) of 3% HS administered at skin incision. Brain relaxation was assessed after dura opening on a scale ranging 1-4 (1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm brain, 4 = bulging brain). Hemodynamic variables and laboratory values (blood gases, osmolarity, haematocrit, and lactate) were collected before HS infusion and 30, 120 and 360 min after it. Presence of midline shift, postoperative complications, PCU and hospital stay, and mortality after 30 days were also recorded.Results: There was no difference in brain relaxation, with 2.0 (1.0-3.0) and 2.0 (1.0-2.3) (P = 0.535) for patients in groups L and H, respectively. If adjusted for the presence of midline shift, 50% of patients had adequate brain relaxation scores (grades 1 and 2) in group L and 61% in group H (OR 0.64, CI = 0.16-2.49, P = 0.515). No significant differences in perioperative outcome, mortality and length of PCU and hospital stay were observed.Conclusion: 3 mL/kg of 3% HS result in similar brain relaxation scores as 5 mL/kg in patients undergoing craniotomy for supratentorial brain tumour. This study reveals that both high and low doses of 3% HS may be less effective on intraoperative brain relaxation in patients with midline shift.

Assessment of Preoperative Anxiety in Cardiac Surgery Patients Lacking a History of Anxiety: Contributing Factors and Postoperative Morbidity.

OBJECTIVES: The aim of this study was to measure the level of preoperative anxiety in patients scheduled for cardiac surgery, identify any influencing clinical factors, and assess the relationship between anxiety and postoperative morbidity. DESIGN: A prospective and consecutive study. SETTING: A single university hospital. PARTICIPANTS: The study comprised 200 patients scheduled for cardiac surgery. INTERVENTIONS: Each patient was asked to grade his or her preoperative anxiety level using the Visual Analogue Scale for Anxiety, Amsterdam Preoperative Anxiety and Information Scale, and set of specific anxiety-related questions. Demographic data (age, sex, body mass index) and anesthetic and surgical data (American Society of Anesthesiologists physical status, EuroSCORE surgical risk, preoperative length of stay, and previous anesthetic experience) were registered. Also, postoperative morbidity was assessed. MEASUREMENTS AND MAIN RESULTS: Twenty-eight percent of the patients developed high preoperative anxiety. The mean Amsterdam Preoperative Anxiety and Information Scale score was 11.4 ± 4.3, and the mean Visual Analogue Scale for Anxiety score was 48 ± 21. Patients scheduled for coronary artery bypass surgery, who had no previous anesthetic experience, and who were hospitalized before surgery, had higher anxiety scores. Coronary bypass surgery (odds ratio 3.026; 1.509-6.067; p = 0.002) was associated independently with preoperative high-level anxiety. Anxiety most commonly was caused by waiting for surgery, not knowing what is happening, fearing not being able to awaken from anesthesia, and being at the mercy of staff. Anxiety did not modify the postoperative course. CONCLUSIONS: In patients waiting to undergo cardiac surgery, both fear of the unknown and lack of information, especially related to the surgery, are crucial factors in high levels of preoperative anxiety in cardiac surgery. Coronary bypass surgery is a determining factor for preoperative anxiety. The anxiety level did not modify the postoperative course in these patients.

Equiosmolar Solutions of Hypertonic Saline and Mannitol Do Not Impair Blood Coagulation During Elective Intracranial Surgery.

BACKGROUND: The authors investigated the effect of equiosmolar, equivolemic solutions of 3% hypertonic saline (HS) and 20% mannitol on blood coagulation assessed by rotational thromboelastometry (ROTEM) and standard coagulation tests during elective craniotomy. METHODS: In a prospective, randomized, double-blind trial, 40 patients undergoing elective craniotomy were randomized to receive 5 mL/kg of either 20% mannitol or 3% HS for intraoperative brain relaxation. Fibrinogen, activated partial thromboplastin time, prothrombin time, hemoglobin, hematocrit, and platelet count were simultaneously measured intraoperatively with ROTEM for EXTEM, INTEM, and FIBTEM analysis. ROTEM parameters were: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle. RESULTS: No significant differences between groups were found in ROTEM variables CT, CFT, MCF, α-angle (EXTEM and INTEM), and MCF (FIBTEM) nor standard coagulation tests. ROTEM parameters did not show changes after administration of hyperosmolar solutions relating to basal values, except for an increase of CFT EXTEM (118±28 vs. 128±26 s) and decrease of CT INTEM (160±18 vs. 148±15 s) with values within normal range. Significant decreases from baseline levels were observed for hematocrit (-7%), platelet count (-10%), and fibrinogen (-13%) after HS infusion, and hematocrit (-9%), platelet count (-13%), and fibrinogen (-9%) after mannitol infusion, but remaining normal. CONCLUSIONS: The use of 5 mL/kg of equiosmolar solutions of 3% HS and 20% mannitol applied to reach a brain relaxation during elective craniotomy does not induce coagulation impairment as evidenced by ROTEM and standard coagulation tests.

A comparison of equivolume, equiosmolar solutions of hypertonic saline and mannitol for brain relaxation during elective supratentorial craniotomy.

BACKGROUND: Hyperosmolar solutions have been used in neurosurgery to reduce brain volume and facilitate surgical exposure. The purpose of this study was to compare the effects of equivolume, equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation, intensive care unit (ICU) and hospital stay, postoperative outcomes and incidence of side-effects in patients undergoing elective supratentorial craniotomy. METHODS: In a randomised, prospective, double-blind study, 60 patients undergoing elective supratentorial craniotomy were randomised 1:1 to receive 3 ml/kg of either 20% mannitol or 3% HS. The primary outcome was the surgical condition of the brain assessed by the neurosurgeon using a 4-point scale after opening the dura (1 = relaxed, 2 = satisfactory, 3 = firm and 4 = bulging). Secondary outcomes were electrolytes, blood gases, plasma osmolality and haemodynamic variables measured at 0 min, 30 min, 2 h and 6 h after infusion. Also, predefined postoperative complications, length of ICU and hospital stay were recorded. Appropriate statistical tests were used for comparison; p < 0.05 was considered significant. RESULTS: There was no difference in brain relaxation [mannitol, 1(1-3) versus HS, 1(1.4) points; p = 0.55]. Patients with brain midline shift showed a worse response to hyperosmolar solutions than those without midline shift: 37% versus 8%, respectively; OR = 6.6 (95% CI, 1.54-28.83); p = 0.006. Plasma osmolality increased during the study period (6 h) in both the groups (p < 0.05 compared with baseline). No significant differences in postoperative complications or length of ICU and hospital stay were observed between the groups. CONCLUSIONS: Single doses of 3 ml/kg of 20% mannitol and 3% HS are safe and effective for intraoperative brain debulking during elective supratentorial craniotomy, but less effective in patients with pre-existing mass effect and midline shift.

Alteraciones de la hemostasia durante la cirugía con quimioterapia intraperitoneal hipertérmica en pacientes con carcinomatosis peritoneal / Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis

INTRODUCCIÓN: La cirugía citorreductora seguida de quimioterapia intraperitoneal hipertérmica (HIPEC) se asocia frecuentemente a alteraciones de la hemostasia y a elevados requerimientos transfusionales perioperatorios. El propósito de este estudio fue analizar los trastornos hemostáticos asociados a cada una de las fases de este procedimiento terapéutico mediante tromboelastometría rotacional (ROTEM), niveles de fibrinógeno y recuento plaquetario, así como su posible relación con las necesidades transfusionales. MÉTODOS: Se efectuó un estudio prospectivo longitudinal. Se registraron niveles de hemoglobina, recuento plaquetario, niveles de fibrinógeno y parámetros tromboelastométricos: tiempo de coagulación (CT), tiempo de formación del coágulo (CFT), firmeza máxima del coágulo (MCF), y ángulo α (EXTEM, INTEM, FIBTEM). Las mencionadas determinaciones se realizaron: antes del inicio de la cirugía; al finalizar la cirugía citorreductora y al concluir la HIPEC. Se utilizaron los test estadísticos apropiados. Los valores de p < 0,05 se consideraron estadísticamente significativos. RESULTADOS: Se incluyó en el estudio a 41 mujeres con una mediana de edad de 54 años (rango: 34-76). Tras la cirugía citorreductora se observó una caída de la tasa de hemoglobina desde 11,4 ± 1,5 a 10,6 ± 1,6 g/dl; un descenso del fibrinógeno sérico desde 269 ± 69 hasta 230 ± 48 mg/dl (p < 0,01) y una reducción de MCF en FIBTEM desde 20 ± 10 hasta 16 ± 8 mm (p < 0,01). La HIPEC no se asoció a alteraciones hemostáticas. Se observó una moderada relación negativa entre el número de concentrados de hematíes administrados y los niveles de fibrinógeno (ρ = −0,5; p = 0,002) y los valores de MCF EXTEM (ρ = −0,43; p = 0,006) registrados tras la HIPEC. CONCLUSIONES: Las alteraciones hemostáticas observadas aparecen tras la cirugía citorreductora, probablemente a consecuencia de la hemorragia quirúrgica. Se requieren más estudios para confirmar una correlación entre las necesidades transfusionales y las pruebas de coagulación postoperatorias

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4 ± 1,5 g/dl to 10,6 ± 1,6 g/dl, a reduction of serum fibrinogen level from 269 ± 69 mg/dl to 230 ± 48 mg/dl (P<.01) and MCF decline from 20 ± 10 to 16 ± 8 mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = −0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests

Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4±1,5g/dl to 10,6±1,6g/dl, a reduction of serum fibrinogen level from 269±69mg/dl to 230±48mg/dl (P<.01) and MCF decline from 20±10 to 16±8mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = -0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests.

Comparison of the Effects of Propofol and Sevoflurane Combined With Remifentanil on Transcranial Electric Motor-evoked and Somatosensory-evoked Potential Monitoring During Brainstem Surgery.

BACKGROUND: We compared the effect of propofol and sevoflurane combined with remifentanil under comparable bispectral index (BIS) levels on transcranial electric motor-evoked potentials (TceMEPs) and somatosensory-evoked potentials (SSEPs) during brainstem surgery. MATERIALS AND METHODS: A total of 40 consecutive patients (20 per group) undergoing brainstem surgery were randomly assigned to 2 groups receiving either 0.5 MAC sevoflurane or propofol at an effect-site concentration of 2.5 µg/mL for maintenance of anesthesia. Remifentanil was administered to both groups at a rate of 0.25 to 0.35 µg/kg/min along with cisatracurium (0.03 to 0.04 mg/kg/h). TceMEP recordings were carried out in the abductor pollicis brevis, abductor hallucis, and tibialis anterior muscles, whereas cortical SSEPs were measured with posterior tibial nerve stimulation. Amplitudes and latencies of TceMEPs and SSEPs were recorded at 1, 2, 3, and 4 hours after the induction of anesthesia. RESULTS: BIS values remained in the 45 to 60 range. Amplitudes of TceMEPs were significantly higher in the propofol group than those in the sevoflurane group (P<0.05, at all study time points in abductor pollicis brevis and abductor hallucis muscles and only 4 h after anesthetic induction for tibialis anterior muscle), whereas latencies were shorter in the propofol group than those in the sevoflurane group (P<0.05). No differences were observed in latency and amplitude while recording SSEPs between the 2 anesthetic techniques. None of the patients had TceMEPs and SSEPs amplitude or latency changes, exceeding our set limit. CONCLUSIONS: Both sevoflurane and propofol at low dosages combined with remifentanil under comparable BIS values and partial muscle relaxation can be used when monitoring of TceMEPs and SSEPs is required for brainstem surgery.

Transient postoperative neurologic deficit after lumbar laminectomy.

UNLABELLED: New neurological deficit after spinal surgery is a rare complication that requires a quick diagnostic and therapeutic approach to reduce the risk of permanent neurological disabilities. We report a patient who presented with transient neurologic deficit after surgery for lumbar disk herniation resulting from bupivacaine diffusion to either the epidural or the subarachnoid space occurring after the anesthetic infiltration of the surgical wound. Early magnetic resonance imaging excluded more serious causes of such neurological deterioration after lumbar laminectomy. This complication should be considered by the anesthesiologist in the differential diagnosis of neurological deficits after operations on the lumbar spine. IMPLICATIONS: We report a patient who presented in the recovery room with a transient neurologic deficit likely resulting from surgical injection of local anesthetic after lumbar laminectomy. This uncommon complication should be considered in the differential diagnosis of postoperative neurological deficits. Early magnetic resonance imaging excluded more serious causes of this complication.