Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study.

Data on safety and success rates of ultrasound-guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block-related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal-plus-sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain-related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain-related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035-1.092, p < 0.001) as well as with mid-abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69-29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38-9.5, p = 0.009) for respiratory problems. Ultrasound-guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid-abdominal surgical procedures are risk factors for pain-related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

BACKGROUND: The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs). METHODS: LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM. RESULTS: Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09-1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89-1.90; P=0.15). CONCLUSIONS: Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events. CLINICAL TRIAL REGISTRATION: NCT01601223.

Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients.

BACKGROUND: There is limited information concerning the current practice of intraoperative mechanical ventilation in obese patients, and the optimal ventilator settings for these patients are debated. We investigated intraoperative ventilation parameters and their associations with the development of postoperative pulmonary complications (PPCs) in obese patients. METHODS: We performed a secondary analysis of the international multicentre Local ASsessment of VEntilatory management during General Anesthesia for Surgery' (LAS VEGAS) study, restricted to obese patients, with a predefined composite outcome of PPCs as primary end-point. RESULTS: We analysed 2012 obese patients from 135 hospitals across 29 countries in Europe, North America, North Africa, and the Middle East. Tidal volume was 8.8 [25th-75th percentiles: 7.8-9.9] ml kg-1 predicted body weight, PEEP was 4 [1-5] cm H2O, and recruitment manoeuvres were performed in 7.7% of patients. PPCs occurred in 11.7% of patients and were independently associated with age (P<0.001), body mass index ≥40 kg m-2 (P=0.033), obstructive sleep apnoea (P=0.002), duration of anaesthesia (P<0.001), peak airway pressure (P<0.001), use of rescue recruitment manoeuvres (P<0.05) and routine recruitment manoeuvres performed by bag squeezing (P=0.021). PPCs were associated with an increased length of hospital stay (P<0.001). CONCLUSIONS: Obese patients are frequently ventilated with high tidal volume and low PEEP, and seldom receive recruitment manoeuvres. PPCs increase hospital stay, and are associated with preoperative conditions, duration of anaesthesia and intraoperative ventilation settings. Randomised trials are warranted to clarify the role of different ventilatory parameters in obese patients. CLINICAL TRIAL REGISTRATION: NCT01601223.

Patient's and health care provider's perspectives on music therapy in palliative care - an integrative review.

BACKGROUND: The use of music as therapy in multidisciplinary end-of-life care dates back to the 1970s and nowadays music therapy (MT) is one of the most frequently used complementary therapy in in-patient palliative care in the US. However existing research investigated music therapy's potential impact mainly from one perspective, referring to either a quantitative or qualitative paradigm. The aim of this review is to provide an overview of the users' and providers' perspectives on music therapy in palliative care within one research article. METHODS: A systematic literature search was conducted using several databases supplemented with a hand-search of journals between November 1978 and December 2016. Inclusion criteria were: Music therapy with adults in palliative care conducted by a certified music therapist. Both quantitative and qualitative studies in English, German or a Scandinavian language published in peer reviewed journals were included. We aimed to identify and discuss the perspectives of both patients and health care providers on music therapy's impact in palliative care to forward a comprehensive understanding of it's effectiveness, benefits and limitations. We investigated themes mentioned by patients within qualitative studies, as well as commonly chosen outcome measures in quantitative research. A qualitative approach utilizing inductive content analysis was carried out to analyze and categorize the data. RESULTS: Twelve articles, reporting on nine quantitative and three qualitative research studies were included. Seven out of the nine quantitative studies investigated pain as an outcome. All of the included quantitative studies reported positive effects of the music therapy. Patients themselves associated MT with the expression of positive as well as challenging emotions and increased well-being. An overarching theme in both types of research is a psycho-physiological change through music therapy. CONCLUSIONS: Both quantitative as well as qualitative research showed positive changes in psycho-physiological well-being. The integration of the users´ and providers´ perspectives within future research applicable for example in mixed-methods designs is recommended.

An observational study of the macro- and micro-haemodynamic implications of epidural anaesthesia in children.

The haemodynamic implications of epidural anaesthesia in children are poorly documented. We report macro- and micro-haemodynamic data from an observational study of 25 children ranging from neonates to six-years old, who underwent surgery conducted with a specific combination of monitoring systems. We analysed 90 min of study-related monitoring after epidural catheterisation, with skin incision taking place after around 30 min. We recorded macrohaemodynamic parameters (monitored using LiDCOrapid) including heart rate, mean arterial pressure, cardiac output, stroke volume, systemic vascular resistance and stroke volume variation. Microhaemodynamic parameters (monitored using Invos™) included cerebral and peri-renal oxygenation. Based on the entire 90 min of study-related monitoring, we found significant increases in cardiac output (p = 0.009), stroke volume (p = 0.006) and stroke volume variation (p = 0.008), as well as decreases in systemic vascular resistance (p = 0.007) around 30 min after epidural blockade. There were no significant changes in heart rate, arterial pressure and cerebral or peri-renal oxygenation during these 90 min. Considering that the microhaemodynamic parameters were not affected by the macrohaemodynamic changes, we conclude that autoregulation of the brain and the kidneys was maintained in children under epidural anaesthesia.

Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications.

PURPOSE: Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes. METHOD: This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes. RESULTS: Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8-1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable. CONCLUSION: In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.

Clinical ex vivo lung perfusion--pushing the limits.

Ex vivo lung perfusion (EVLP) provides the ability to evaluate donor lungs before transplantation. Yet, limited prospective clinical data exist with regard to its potential to recondition unacceptable donor lungs. This paper summarizes the results of a prospective study of lung transplantation using only initially unacceptable donor lungs, which were improved by EVLP for 2-4 h. From March 2010-June 2011, 13 lungs were evaluated ex vivo. Median donor PaO(2) at FiO(2) 1.0/PEEP5 was 216 mmHg (range 133-271). Four lungs, all with trauma history, showed no improvement and were discarded. Nine lungs improved to a ΔPO(2) higher than 350 mmHg. Median PvO(2) at final assessment in these lungs was 466 mmHg (range 434-525). These lungs were transplanted with a median total ischemic time of 577 min (range 486-678). None of the patients developed primary graft dysfunction grades 2 or 3 within 72 h after transplantation. One patient with secondary pulmonary hypertension was left on a planned prolonged extracorporeal membrane oxygenation postoperatively. Median intubation time was 2 days. Thirty-day mortality was 0%. During the observation period, 119 patients received standard lung transplantation with comparable perioperative outcome. EVLP has a significant potential to improve the quality of otherwise unacceptable donor lungs.

Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation.

BACKGROUND: In several clinical situations, lung separation and single-lung ventilation (SLV) is essential. In these cases, the double-lumen tube (DLT) is the most widely used device. Bronchial blocker such as Univent or Arndt Blocker serves as an alternative. The EZ-Blocker(®) (EZ; AnaesthetIQ B.V., Rotterdam, The Netherlands) is a new device promising to exceed clinical performance of DLT. The aim of this study was to assess the clinical performance of EZ in comparison with conventional left-sided DLT. METHODS: Forty adult patients undergoing elective thoracic surgery requiring thoracotomy and SLV were included in this study. The patients were randomly assigned to one of two groups: EZ (combined with conventional 7.5 or 8.5 mm single-lumen tube) or DLT (37 or 39 Fr left-sided DLT). Time for intubation procedure and time to verification of the correct position of EZ or DLT using fibreoptic bronchoscopy (FOB) were recorded. After surgery, a thoracic surgeon rated the quality of collapse of the lung (1-3 on a three-level scale). RESULTS: Time for intubation using DLT 85.5 (54.8) s was significantly faster (P<0.001) than using EZ 192 (89.7) s, whereas time for bronchoscopy was not significantly different (P=0.556). Conditions of surgery were rated equally [DLT 1.3 (0.6) vs EZ 1.4 (0.6), P=0.681]. CONCLUSIONS: Although time for intubation was longer with the EZ, the device proved to be an efficient and easy-to-use device. The EZ is a valuable alternative device to conventional DLT. Verification of the correct position of the EZ by FOB seems to be obligatory. This study was registered at http://www.clinicaltrials.gov (identifier: NCT01171560).

Simulation and analysis of conjunctive use with MODFLOW's farm process.

The extension of MODFLOW onto the landscape with the Farm Process (MF-FMP) facilitates fully coupled simulation of the use and movement of water from precipitation, streamflow and runoff, groundwater flow, and consumption by natural and agricultural vegetation throughout the hydrologic system at all times. This allows for more complete analysis of conjunctive use water-resource systems than previously possible with MODFLOW by combining relevant aspects of the landscape with the groundwater and surface water components. This analysis is accomplished using distributed cell-by-cell supply-constrained and demand-driven components across the landscape within "water-balance subregions" comprised of one or more model cells that can represent a single farm, a group of farms, or other hydrologic or geopolitical entities. Simulation of micro-agriculture in the Pajaro Valley and macro-agriculture in the Central Valley are used to demonstrate the utility of MF-FMP. For Pajaro Valley, the simulation of an aquifer storage and recovery system and related coastal water distribution system to supplant coastal pumpage was analyzed subject to climate variations and additional supplemental sources such as local runoff. For the Central Valley, analysis of conjunctive use from different hydrologic settings of northern and southern subregions shows how and when precipitation, surface water, and groundwater are important to conjunctive use. The examples show that through MF-FMP's ability to simulate natural and anthropogenic components of the hydrologic cycle, the distribution and dynamics of supply and demand can be analyzed, understood, and managed. This analysis of conjunctive use would be difficult without embedding them in the simulation and are difficult to estimate a priori.

Cyclohexadiene ring opening observed with 13 fs resolution: coherent oscillations confirm the reaction path.

The third harmonic (270 nm, 11 fs), produced in a short argon cell from Ti-sapphire laser pulses (810 nm, 12 fs), was used to excite 1,3-cyclohexadiene to its lowest pipi* state (1B). Probing was done by transient ionization by the 810 nm pulses, measuring the yields of the parent and a fragment ion. As previously found with 10 times longer pulses, the molecule leaves in two steps (time constants tau(1), tau(2)) from the spectroscopic (1B) to a dark (2A) state and from there (within tau(3)) to the ground-state surface. In addition to slightly improved values for tau(1)-tau(3), we found in all three locations (L(1)-L(3)) on the potentials coherent oscillations, which can be assigned to vibrations. They are stimulated by slopes (driving forces) of the potentials, and the vibrational coordinates indicate the slope directions. From them we can infer the path following the initial excitation: the molecule is first not only accelerated towards CC stretching in the pi system but also along a symmetric C[double bond, length as m-dash]C twist. The latter motion-after some excursion-also erects and stretches the CH(2)-CH(2) bond, so that Woodward-Hoffmann interactions are activated after this delay (in L(2)). On leaving L(2) (the 1B minimum) around the lower cone of the 1B/2A conical intersection, the wave packet is rapidly accelerated along an antisymmetric coordinate, which breaks the C(2) symmetry of the molecule and eventually leads in a ballistic path to (and through) the last (2A/1A) conical intersection. The ring opening begins already on the 1B surface; near the 2A minimum it is already far advanced, but is only completed on the ground-state surface.