Fluid preloading before beach chair positioning for arthroscopic shoulder procedures: a randomized controlled trial

Abstract Background and objectives The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. Methods This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10 mL.kg-1 of ideal body weight was administered intravenously 30 min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. Results The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p= 0.001, p= 0.016, p= 0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p= 0.016, p= 0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p= 0.003, p= 0.018, p= 0.019, respectively). Conclusion Consequently, preloading can be favorable approach to preserve hemodynamic stability.

Comparison of analgesic consumption of hemophilic and non-hemophilic patients in knee arthroplasty.

BACKGROUND: Hemophilia is a rare hereditary bleeding disorder that develops as a result of factor VIII or IX deficiency. Long-term complications of hemophilia such as arthropathy, synovitis, and arthritis can lead to the development of recurrent chronic pain. Pain is therefore a critical aspect of hemophilia. The gold standard treatment for end-stage hemophilic knee arthropathy is total knee arthroplasty (TKA). The hypothesis of this study was that after knee replacement surgeries that cause severe post-operative pain, hemophilia patients with chronic analgesic consumption may experience higher levels of pain than non-hemophilic patients, and use more opioid and non-opioid drugs. METHODS: This retrospective study included 82 patients who were hemophilic and non-hemophilic TKA patients operated under general anesthesia. Seventy-three patients were evaluated and divided into two groups according to the diagnosis of hemophilia: 36 patients were investigated in the hemophilic group and 37 patients in the non-hemophilic group. RESULTS: Post-operative tramadol consumption (p=0.002) and pethidine consumption (p=0.003) were significantly higher in the group hemophilia. The length of stay in the hospital was also significantly longer in the hemophilic group (p=0.0001). CONCLUSION: In the light of these informations, we think that acute post-operative pain management of hemophilia patients should be planned as personalized, multimodal preventive, and pre-emptive analgesia.

Postoperative Pain in Adolescent Idiopathic Scoliosis Surgery: A Randomized Controlled Trial.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis, and its treatment is essentially surgical for curves above 40 degrees. Posterior spinal instrumentation (PI) is the usual technique, while the vertebral body tethering (VBT) method is tested technique for this study as a new treatment option. OBJECTIVES: To compare postoperative pain outcomes between PI and VBT with mini-thoracotomy surgeries performed in AIS patients. STUDY DESIGN: Prospective, randomized controlled study registered with the Clinical Trials Portal (NCT04822935). SETTING: Department of Anesthesiology. METHODS: We randomly divided 31 adolescents (28 women, 3 men) aged 11 to 18, with a diagnosis of AIS into 2 groups using computer software: the PI and the VBT groups. Postoperative morphine consumption and the Numeric Pain Rating Scale (NRS) scores at the 1st, 4th, 8th, 12th, 24th, and 48th hours and at 4 weeks were recorded. Length of hospital stays, length of intensive care unit (ICU) stays, duration of operation, postoperative patient satisfaction with the Likert scale, and complications such as bleeding and respiratory distress were recorded. Preoperative and follow-up Oswestry Disability Index (ODI) questionnaires were obtained to assess patient outcomes at 4 weeks postoperatively. RESULTS: Postoperative morphine consumption and the NRS scores at the 1st, 4th, 8th, 12th, 24th, and 48th hours were significantly higher in group VBT (P < 0.05). The amount of bleeding was significantly higher in group PI (P = 0.002). The ICU and the hospital length of stays in the VBT group were significantly higher (respectively, P = 0.011; P = 0.032). Discharge NRS scores, ODI scores as well as patients' satisfaction were similar in both groups (P > 0.05). LIMITATIONS: Firstly, this was a single-centered study with a small sample owing to the rarity of AIS surgeries. Moreover, double-blinding was not applied to the patients and doctors because of the surgery incision places. CONCLUSION: From our results, both techniques can be employed for AIS surgery, but a meticulous approach is essential for the prevention of acute pain for VBT.

Comparison of nighttime and daytime operation on outcomes of supracondylar humeral fractures: A prospective observational study.

Supracondylar humeral fractures are seen in children and treatment is usually closed reduction and percutaneous pinning (CRPP). This surgery can be performed at night, depending on its urgency. Fatigue and sleep deprivation can impact performance of doctors during night shifts. The purpose of this study is to investigate the association between night shifts postoperative morbidity and mortality of supracondylar fracture operations compared to daytime procedures. This prospective observational study included 94 patients who were aged 5 to 12 years with ASA I to III who had supracondylar humeral fractures, underwent CRPP under general anesthesia. Patients were stratified by the time of surgery using time of induction of anesthesia as the starting time of the procedure, into 2 groups: day (07:30 am-06:29 pm) and night (06:30 pm-07:29 am). In total, 82 patients completed the study: 43 in Group Day and 39 in Group Night. The operation duration in Group Night (114.66 ± 29.46 minutes) was significantly longer than in Group Day (84.32 ± 25.9 minutes) (P = .0001). Operation duration (OR: 0.007; P = .0001) and morbidities (OR: 0.417; P = .035) were independent risk factors in Group Night. Children who had supracondylar humeral fractures, undergoing urgent CRPP surgery, in-hospital mortality was associated with the time of day at which the procedure was performed. Patient safety is critically important for pediatric traumatic patient population. Therefore, we suggested to increase the number of healthcare workers and improve the education and experience of young doctors during night shifts.

Effects of Changes in Body Temperature on Perioperative Bleeding in Adolescent Idiopathic Scoliosis Surgery.

Perioperative bleeding is a critical challenge in adolescent idiopathic scoliosis (AIS) surgery. Preventing hypothermia is associated with decreased development of coagulopathy, blood transfusion rate in various surgery groups. We hypothesized that blood loss would be reduced in patients who were kept normothermic by implementation of aggressive warming methods in AIS. This randomized-controlled study included patients aged 12-18 years who were scheduled to undergo elective scoliosis deformity correction surgery. The patients were divided into two groups: the study group (Group S) was heated aggressively with three different heaters including compressed-air blower heater, intravenous fluid heating, and a heating bed, while the control group (Group C) received only heating with a standard compressed-air blower heater. Tympanic, esophageal, and axillary body temperatures were measured, and hemoglobin and arterial blood gas analyses were repeated during the anesthesia period. Daily bleeding-coagulation parameters were recorded on postoperative days 0, 1, and 2. Forty-eight patients were randomized, and 39 patients were included into the final analysis. The total amount of intraoperative bleeding (p = 0.027) was significantly lower, and duration of surgery (p = 0.025) and length of hospital stay (p = 0.002) were significantly shorter in Group S. Significant linear relationships were found between the core body temperature and the amount of bleeding (ß = 0.0001; p = 0.009), operation time (ß = 0.003; p = 0.015), and length of hospital stay (ß = 0.027; p = 0.044) with linear logistic regression analysis. We reported that normothermia was preserved in the multiheated group, which diminished blood loss, operation time, and the length of hospital stay. Consequently, we suggested that active heating should be applied in AIS surgeries. ClinicalTrials.gov (NCT04686214).

Fluid preloading before beach chair positioning for arthroscopic shoulder procedures: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: The Beach Chair Position (BCP) has many advantages such as less neurovascular injury and better intra-articular visualization, but it has also negative consequences, including hemodynamic instability. Although maintaining normal Mean Arterial Pressure (MAP) is important, fluid management is also a crucial concept for hemodynamic stability. The main objective of this study is whether preloading before positioning would be effective for less hemodynamic instability. METHODS: This randomized, controlled study was conducted in a single center in the Istanbul University, Istanbul Faculty of Medicine. Forty-nine patients undergoing elective arthroscopic surgery in the BCP were recruited. In the study group, crystalloid fluid at 10...mL.kg-1 of ideal body weight was administered intravenously 30...min before the BCP for preloading. The primary outcome measures were differences of hemodynamic variables as MAP, Stroke Volume (SV), Heart Rate (HR), and Cardiac Output (CO). The secondary outcome measures were Postoperative Nausea and Vomiting (PONV) rates in postoperative first day, surgical satisfaction scale, total ephedrine dose used during surgery, and total amount of fluid. RESULTS: The MAP, CO, and SV measurements of the study group were higher than those of the control group in the 5th minute after the BCP (respectively, p...=...0.001, p...=...0.016, p...=...0.01). The total amount of crystalloid and surgical satisfaction scales were higher in the study group (respectively, p...=...0.016, p...=...0.001). Total amount of colloid and ephedrine dose used in the intraoperative period, and PONV rates were lower in the study group (p...=...0.003, p...=...0.018, p...=...0.019, respectively). CONCLUSION: Consequently, preloading can be favorable approach to preserve hemodynamic stability.

Anesthetic management of scoliosis operation in a pediatric patient with Frank-ter Haar syndrome: a case report.

Frank-ter Haar syndrome is a rare disorder characterized by multiple skeletal, cardiovascular abnormalities, and facial features. Some of these characteristic facial features are important for anesthesiologists to predict the difficult airway. We present the anesthesia management of an 8-year-old boy with Frank-ter Haar syndrome who underwent posterior spinal instrumentation operation for scoliosis. In these patients, it is vital to anticipate possible difficult intubation before surgery and make all necessary preparations.

The Role of Indirect Laryngoscopy, Clinical and Ultrasonographic Assessment in Prediction of Difficult Airway.

OBJECTIVES: Pre-operative airway evaluation is essential to decrease the proportion of possible mortality and morbidity due to difficult airway (DA). The study aimed to evaluate the accuracy of pre-operative ultrasonographic airway assessment (UAA) and indirect laryngoscopy (IL) in predicting DA. STUDY DESIGN: Prospective obsevational study. METHODS: Preoperative clinical examination (body mass index [BMI], mallampati classification [MP], thyromental distance, sternomental distance, neck circumference), UAA (epiglottis-skin distance [ESD], hyoid bone-skin distance [HSD], the thickness of tongue root [ToTR], anterior commissure-skin distance [ACSD]) and IL with the rigid 70-degree laryngoscope were performed to predict DA (Cormack-Lehane grade 3 and 4). The sensitivity, specificity, positive predictive value (PP), and negative predictive values of the parameters were assessed. RESULTS: Twenty-two of 140 (15.7%) patients were diagnosed with DA. The cut-off points of ESD, HSD, ToTR, ACSD, and BMI were 2.09 cm, 0.835 cm, 4.05 cm, 0.545 cm, and 27.10, respectively. AUC values were 0.874, 0.885, 0.871, 0.658, and 0.751 in the same order. AUC values for IL and MP were 0.773 and 0.925, respectively. MP and HSD had the best sensitivity (91%), IL grading had the best specificity (100%), and PP (100%) value among all measurements. The best-balanced sensitivity (91%), specificity (97%), and PP (88%) values were obtained by combining the IL with MP and ESD or with MP and HSD. CONCLUSIONS: Ultrasonographic measurements and IL were found significantly correlated to predict DA. Combined parameters, the IL with MP and ESD or with MP and HSD, are the best parameters in predicting the DA. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E555-E560, 2021.

The effect of intravenous tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A randomized, double-blinded, placebo-controlled pilot study.

OBJECTIVE: The aim of this study was to determine the effect of intravenous (IV) tranexamic acid (TRX) use on visual clarity during arthroscopic rotator cuff repair. METHODS: This prospective, randomized, double-blinded, placebo-controlled study was conducted in patients scheduled for an arthroscopic rotator cuff repair. In total, 60 patients were randomly distributed into two groups: control (28 patients: 11 male, 17 female; mean age=53 years, age range=19-65) and TRX (32 patients: 15 male, 17 female; mean age=50, age range=18-69). In the TRX group, the arthroscopy was performed through the bolus IV administration of 10 mg/kg TRX in 100 ml isotonic saline solution. In the control group, the arthroscopy was performed through the bolus IV administration of 100 ml isotonic saline solution. In both the groups, the IV administration was carried out after the induction of anesthesia. At the end of each procedure, the surgeon rated the visual clarity on a scale from 1 to 10. In addition, operation time (minutes), irrigation amount used in operation (lt), and the need of pressure increase because of bleeding were recorded. RESULTS: No adverse effects were seen during the study period. Visual clarity in TRX group was significantly better than the control group (the mean visual clarity scores=8.1/10 (range=7-10) vs 7/10 (range=5-9); p=0.018). The amount of solution was significantly less in the TRX group (10.2 lt (range=3.5-21)) than in the control group (15.8 lt (range=5.8-27); p=0.007, post-hoc power=95.7%), although the operation time was slightly longer in the TRX group (106 minutes (range=50-210)) than in the control group (99 minutes (range=45-165); p=0.24). Moreover, the need for the increase in pressure owing to bleeding was found significantly less in the TRX group (5.8 times (range=(0-9)) than in the control group (9.6 times (range=0-13); p=0.04, post-hoc power=94.5%). CONCLUSION: Preoperative IV TRX administration seems to be effective in improving visual clarity and reducing the need for high pressure and the amount of irrigation fluid during the arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level II, Therapeutic study.

Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway.

BACKGROUND: The aim of this study was to investigate the success rates of ultrasound (US) and palpation methods in identifying the cricothyroid membrane (CTM), and compare the results with the gold standard method-computed tomography (CT) scan. METHODS: A total of 110 patients were included into the study. The midline was estimated by a single investigator using both the US and palpation methods from the prominence of the thyroid cartilage to the center of the sternal notch, and the distance was measured (in millimeters) between the two points: Point A (the midpoint of CTM) and Point B (the inferior process of thyroid cartilage). Furthermore, the distance between Point A and Point B was calculated using the CT images. Time taken to assess the CTM by using US and palpation methods were recorded. Moreover, difficulty in using the two methods was measured with the visual analog scale (VAS). In addition, demographic and morphometric characteristics of the patients were noted. RESULTS: The CTM was detected accurately in 50 (45.5%) patients with palpation and 82 (74.5%) with US. In the Bland-Altman analysis, a better agreement was observed with US. The time to assess CTM was shorter with US than with palpation, p<0.001. The VAS scores for the palpation and US difficulty were 5.13+-1.1 and 3.32+-0.9 (p<0.001), respectively. While an increased neck circumference and thyromental distance were found to be independent risk factors for the success rates of determining the CTM by palpation, body mass index is an independent risk factor for US. CONCLUSION: Localization of the CTM is more accurate and easier with US than palpation. Furthermore, the results gathered with US are in a closer range to CT scan.

The relationship between neutrophil to lymphocyte ratio and postoperative pain in total knee and hip arthroplasty / Relação entre a proporção neutrófilo/linfócito e a dor pós-operatória em artroplastia total de joelho e quadril

Abstract Background and objectives: Neutrophil to lymphocyte ratio is a simple, cost-effective and easily applicable inflammation indicator that is being used frequently in mortality, morbidity and prognosis studies in the recent years. We evaluated the relationship between neutrophil to lymphocyte ratio and postoperative pain in patients undergoing total hip arthroplasty and total knee arthroplasty. Material and methods: We included 101 patients who preferred spinal anesthesia and intravenous patient-controlled analgesia in accordance and divided them into two groups, total hip arthroplasty and total knee arthroplasty. We recorded demographic information, duration of operation, length of hospital stay, analgesics consumption, neutrophil to lymphocyte ratio results and postoperative pain using Visual Analog Scale. Results: The morphine consumption of the patients was as follows in group total hip arthroplasty and total knee arthroplasty: at the 4th hour: 7.38 mg, 7.80 mg; 8th hour: 12.19 mg, 13.29 mg; 12th hour: 16.94 mg, 19.18 mg; 24th hour: 25.97 mg, 27.98 mg; 48th hour: 36.38 mg, 39.59 mg. The Visual Analog Scale scores of the patients was as follows in group total hip arthroplasty and total knee arthroplasty: at the 4th hour: 4.10, 4.51; 8th hour: 3.02, 3.43; 12th hour: 2.29, 2.55; 24th hour: 1.90, 1.87; 48th hour: 1.08, 1.13. In group total hip arthroplasty, we found a statistically significant association between postoperative neutrophil to lymphocyte ratio and the Visual Analog Scale values on the 48th hour in a positive direction (r = 0.311; P = 0.031; P < 0.05). Conclusion: Neutrophil to lymphocyte ratio can be accepted as a relatively objective method for the diagnosis of postoperative pain.

Resumo Justificativa e objetivos: A proporção entre neutrófilo/linfócito é um indicador de inflamação simples, custo-efetivo e de fácil aplicação que vem sendo usado com frequência em estudos de mortalidade, morbidade e prognóstico nos últimos anos. Avaliamos a relação entre a proporção neutrófilo/linfócito e a dor pós-operatória em pacientes submetidos à artroplastia total de quadril e artroplastia total de joelho. Material e métodos: No total, 101 pacientes que preferiram a raquianestesia e a analgesia venosa controlada pelo paciente foram incluídos e divididos em dois grupos neste estudo: artroplastia total de quadril e artroplastia total de joelho. Os dados demográficos e os tempos de operação, internação hospitalar e consumo de analgésicos e os resultados da proporção neutrófilo/linfócito e da dor pós-operatória foram registrados usando uma escala visual analógica. Resultados: O consumo de morfina dos pacientes submetidos à artroplastia total de quadril e artroplastia total de joelho nas horas 4, 8, 12, 24 e 45 foi de, respectivamente: 7,38 mg e 7,80 mg; 12,19 mg e 13,29 mg; 16,94 mg e 19,18 mg; 25,97 mg e 27,98 mg; 36,38 mg e 39,59 mg. Os escores obtidos na escala visual analógica dos pacientes submetidos à artroplastia total de quadril e artroplastia total de joelho nas horas 4, 8, 12, 24 e 48 foram, respectivamente: 4,10 e 4,51; 3,02 e 3,43; 2,29 e 2,55; 1,90 e 1,87; 1,08 e 1,13. Na artroplastia total do quadril, uma associação estatisticamente significativa foi encontrada entre a proporção neutrófilo/linfócito no pós-operatório e os valores da escala visual analógica na 48ª hora em uma direção positiva (r = 0,311; p = 0,031; p < 0,05). Conclusão: A proporção neutrófilo/linfócito pode ser aceita como um método relativamente objetivo para o diagnóstico da dor pós-operatória.

[The relationship between neutrophil to lymphocyte ratio and postoperative pain in total knee and hip arthroplasty]. / Relação entre a proporção neutrófilo/linfócito e a dor pós­operatória em artroplastia total de joelho e quadril.

BACKGROUND AND OBJECTIVES: Neutrophil to lymphocyte ratio is a simple, cost-effective and easily applicable inflammation indicator that is being used frequently in mortality, morbidity and prognosis studies in the recent years. We evaluated the relationship between neutrophil to lymphocyte ratio and postoperative pain in patients undergoing total hip arthroplasty and total knee arthroplasty. MATERIAL AND METHODS: We included 101 patients who preferred spinal anesthesia and intravenous patient-controlled analgesia in accordance and divided them into two groups, total hip arthroplasty and total knee arthroplasty. We recorded demographic information, duration of operation, length of hospital stay, analgesics consumption, neutrophil to lymphocyte ratio results and postoperative pain using Visual Analog Scale. RESULTS: The morphine consumption of the patients was as follows in group total hip arthroplasty and total knee arthroplasty: at the 4th hour: 7.38mg, 7.80mg; 8th hour: 12.19mg, 13.29mg; 12th hour: 16.94mg, 19.18mg; 24th hour: 25.97mg, 27.98mg; 48th hour: 36.38mg, 39.59mg. The Visual Analog Scale scores of the patients was as follows in group total hip arthroplasty and total knee arthroplasty: at the 4th hour: 4.10, 4.51; 8th hour: 3.02, 3.43; 12th hour: 2.29, 2.55; 24th hour: 1.90, 1.87; 48th hour: 1.08, 1.13. In group total hip arthroplasty, we found a statistically significant association between postoperative neutrophil to lymphocyte ratio and the Visual Analog Scale values on the 48th hour in a positive direction (r=0.311; P=0.031; P<0.05). CONCLUSION: Neutrophil to lymphocyte ratio can be accepted as a relatively objective method for the diagnosis of postoperative pain.

Postoperative analgesia after arthroscopic shoulder surgery: A comparison between single-shot interscalene block and single-shot supraclavicular block.

OBJECTIVES: In arthroscopic rotator cuff surgery for postoperative analgesia opioids, nonsteroid analgesics, and local anesthetics can be used. This study aimed to compare the effectiveness, additional analgesic requirements, patients satisfaction, and complications of single-shot interscalene and supraclavicular blocks. METHODS: After obtaining the ethics committee's approval and informed consent, 50 ASA I-II patients were randomized to either the interscalene (GISB) or supraclavicular (GSCB) group. Preoperatively, patients received an ultrasonography-guided block using 30 ml of 0.5% bupivacaine. In the postoperative period, morphine patient-controlled analgesia was administered as a 0.3-mg/h basal dose and 1-mg bolus dose, with a 20-min lockout time. Postoperative visual analog scale (VAS; 0-10 cm) scores of the patients were evaluated at 4, 8, 12, and 24 h postoperatively; additional analgesic requirements, adverse effects, and complications were recorded. Patient satisfaction (PS) scores were evaluated after 24 h. RESULTS: VAS scores at 4 h were lower in the GSCB group than in the GISB group, and the VAS scores at 8, 12, and 24 h were lower in the GISB group than in the GSCB group, with no statistical significance. Additional analgesic requirements was 28% in the GISB group and 68% in the GSCB group (p < 0.05). Total morphine consumption was lower in the GISB group than in the GSCB group (18.95±9.2 mg vs. 30.6 ± 9.6 mg; p < 0.001). PS scores were higher in the GISB group than in the GSCB group (7.0±1.0 vs. 6.1±0.9; p < 0.01). Adverse effects and complication rates were similar in both the groups. In GISB group, seven patients (28%) had nausea/vomiting, whereas in the GSCB group, 12 patients (48%) had nausea/vomiting. This difference was statistically insignificant. CONCLUSION: Supraclavicular block can be considered as an alternative to interscalene block for arthroscopic shoulder surgery.

Brachial Plexus Injury Associated With Subclavian Vein Cannulation: A Case Report.

We documented brachial plexus injury by electromyography and magnetic resonance imaging secondary to needle sticks for central line insertion. This type of complication is rare in the literature, as few case reports exist. Brachial plexus injury can happen because of anatomic variations. Nevertheless, multiple attempts or introducer needle rotations should be avoided during subclavian vein catheterization. Pain that emerges in the ipsilateral arm after subclavian catheter placement should be taken into serious consideration. It is important to identify the cause of pain as soon as possible so that the correct treatment can be efficiently provided. Use of an ultrasound-guided catheterization may be a better choice for preventing complications.

Endovascular Stent Grafting for Aortic Arch Aneurysm in Aortoiliac Occlusive Disease following Aortic Arch Debranching and Aortobifemoral Reconstruction.

Treatment of thoracic aortic aneurysms constitutes high mortality and morbidity rates despite improvements in surgery, anesthesia, and technology. Endovascular stent grafting may be an alternative therapy with lower risks when compared with conventional techniques. However, sometimes the branches of the aortic arch may require transport to the proximal segments prior to successful thoracic aortic endovascular stent grafting. Atherosclerosis is accounted among the etiology of both aneurysms and occlusive diseases that can coexist in the same patient. In these situations stent grafting may even be more complicated. In this report, we present the treatment of a 92-year-old patient with aortic arch aneurysm and proximal descending aortic aneurysm. For successful thoracic endovascular stent grafting, the patient needed an alternative route other than the native femoral and iliac arteries for the deployment of the stent graft. In addition, debranching of left carotid and subclavian arteries from the aortic arch was also required for successful exclusion of the thoracic aneurysm.

Pulse Pressure Variation and Weight-Loss Percentage Predict Hypotension After Anesthesia Induction in Neurosurgery Patients: A Prospective, Observational, Blinded Study.

BACKGROUND: Hypotension after anesthesia induction is a common problem and is partly related to patient volume status. The present study aimed to investigate the correlation between blood pressure change and pulse pressure variation (PPV), and percentage of weight loss while determining threshold for hypotension by receiver operating characteristic analysis. METHODS: We analyzed 231 neurosurgery patients. In all patients, propofol was used for standard anesthesia induction. Patient demographics, medical histories, fasting duration, percentage weight loss, baseline blood pressure, and PPV during normal tidal volume breathing and that during forced inspiratory breathing (PPVfi) were recorded. Hemodynamic changes within 10 minutes of intubation were observed. Patients developing hypotension and severe hypotension were determined; lowest mean arterial pressure (MAP) and systolic arterial pressure (SAP) values were recorded, and their differences relative to baseline values were calculated. RESULTS: The incidence of hypotension was 18.6%. Both percentage weight loss and PPVfi were correlated with the changes in MAP and SAP. A PPVfi>14 identified all observed hypotensive episodes with 86% sensitivity and 86.2% specificity, whereas percentage weight loss >1.75% identified all observed hypotensive episodes with 81.4% sensitivity and 70.7% specificity. Furthermore, PPVfi>16.5 identified severe hypotension with 85% sensitivity and 90.5% specificity, whereas percentage weight loss >1.95% identified severe hypotension with 85% sensitivity and 73% specificity. CONCLUSIONS: Percentage weight loss and PPVfi are good predictors of hypotension after anesthesia induction and, thus, may allow anesthesiologists to adopt preventative measures and ensure safer anesthesia induction.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia

Abstract Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p < 0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20 min.

Resumo Justificativa e objetivos: Demonstrar as possíveis alterações hemodinâmicas e do fluxo sanguíneo cerebral (FSC) em pacientes que foram posicionados de supinação para cadeira de praia (CP) e detectar se a mudança de posição causa alguma alteração na atividade cortical como mensurado pelo monitor de EEG com quatro canais. Métodos: Foram incluídos 35 pacientes. Antes da indução, os valores da PAM e do IEP foram registrados (T0). Após a intubação, ultrassonografias com Doppler da carótida interna e artérias vertebrais dos pacientes foram avaliadas para adquirir os valores do FSC a partir da fórmula. Em supinação, os valores da PAM, IEP e FSC foram registrados (T1) e o paciente foi posicionado em CP. Após cinco minutos, todas as mensurações foram repetidas (T2). As mensurações do IEP e PAM foram repetidas após 20 (T3) e 40 minutos (T4). Resultados: Houve uma diminuição significativa entre T0 e T1 na FC (80,5 ± 11,6 vs. 75,9 ± 14,4 bpm), PAM (105,8 ± 21,9 vs. 78,9 ± 18,4 mmHg) e IEP (88,5 ± 8,3 vs. 30,3 ± 9,7) (p < 0,05 para todos). A PAM diminuiu significativamente após a mudança de posição e permaneceu diminuída em relação a T1. A análise global dos valores do IEP (T1-T4) não mostrou mudança significativa, mas a comparação de apenas T1 e T2 resultou em redução estatisticamente significativa do IEP. Houve redução significativa do FSC após o posicionado em CP. Conclusão: O posicionado em CP foi associado à diminuição do FSC e dos valores do IEP. O IEP foi afetado pela mudança gravitacional do FSC; no entanto, ambos os fatores não estavam diretamente correlacionados. Além disso, a diminuição do valor do IEP foi transitória e voltou aos valores normais dentro de 20 minutos.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

Efficacy of preoperative administration of single high dose intravenous tranexamic acid in reducing blood loss in total knee arthroplasty: A prospective clinical study.

OBJECTIVE: The aim of this study was to analyse the effectiveness of single dose of 20 mg/kg intravenous tranexamic acid (TXA), in reducing the blood loss in patients undergoing total knee arthroplasty (TKA). MATERIAL AND METHOD: 70 patients (65.5 ± 8.1 years old) that have undergone TKA were divided in two groups. The 20 mg/kg IV TXA was given before the skin incision to one group (study group). On the control group, TKA was performed without TXA. The demographic data, body mass index, amount of bleeding and erythrocyte infusion during the operation, hemoglobin and hematocrit values (preoperative and 48th hour), the amount of drainage after the operation were compared between the groups. RESULTS: The total amount of bleeding in the study group was 634.03 ± 182.88 ml and 1166.42 ± 295.92 ml in the control group (p < 0.001). Perioperative bleeding was 252.01 ± 144.13 ml in the study group and 431.33 ± 209.10 ml in the control group (p = 0.018). The drainage after the operation was 311.11 ± 141.64 ml at the 24th hour in the study group, 640.74 ± 279.43 ml at the 24th hour in the control group (p < 0.001). The drainage after 24th hour was 97.96 ± 115.86 ml in the study group and 112.96 ± 64.43 ml in the control group (p = 0.584). CONCLUSION: A high, single dose of TXA intravenously given to the patient prior to the TKA significantly reduces the bleeding during the operation and within the postoperative 24 h. There is no significant change in the bleeding amount after the 24th hour following the operation.

[Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position]. / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.