Cost-effectiveness and efficacy of scalp block for elective supratentorial craniotomy in resource-limited settings: A randomized controlled trial.

Background: Remifentanil is favored for neurosurgical pain management, but its utilization in low- and middle-income countries (LMICs) is limited. Scalp block techniques are effective in LMICs, but cost-effectiveness is uncertain. This study compares costs and perioperative outcomes of scalp block versus fentanyl infusion in patients undergoing elective supratentorial craniotomy. Methods: A prospective double-blind randomized controlled trial was conducted with 36 patients aged 18- 65 years undergoing elective supratentorial craniotomy. Patients were randomly assigned to receive either scalp block with 0.5% bupivacaine (Group S) or fentanyl infusion (Group F), with normal saline placebo administered in both groups. The primary endpoint was the anesthetic costs, with secondary endpoints including perioperative opioid consumption, intraoperative hemodynamic changes, and perioperative complications. Results: The cost of fentanyl was significantly lower than that of local anesthetics (3.31 [3.31, 3.75] vs. 4.27 [4.27, 4.27] United States dollars, P < 0.001). However, the overall anesthetic cost did not differ significantly between groups. Group F demonstrated a significant reduction in mean arterial pressure immediately and 5 min after pin insertion compared to Group S (75.8 [13.9] vs. 92.5 [16.9] mmHg, P = 0.003 and 67.7 [6.4] vs. 78.5 [10.7] mmHg, P < 0.001, respectively). Conclusion: Fentanyl infusion presents cost advantages over scalp block in LMIC settings. However, prudent opioid use is imperative. This study underscores the need for ongoing research to optimize neurosurgical pain management and evaluate long-term safety implications.

Self-study and online interactive case-based discussion to improve knowledge of medical students in the COVID-19 era.

BACKGROUND: We aimed to determine whether a new online interactive learning method for fifth-year medical students could improve their knowledge of pre- and postoperative care during the COVID-19 era. METHODS: A retrospective cohort study was conducted from June 2020 to May 2022 during the pre- and postoperative care course for fifth-year medical students in a university hospital in southern Thailand. Students in the 2020 cohort received only a 60-minute lecture on spinal anesthesia via Zoom while a 3-step online interactive learning method was used for the 2021 cohort. Step 1: students performed self-study comprised of video lectures and case-based discussion one week before the online class with a pre-test submitted via Google forms. Step 2: an online interactive case-based discussion class was performed via Zoom by two experienced anesthesia staff and a post-test was submitted by the students via Google forms. Step 3: a small group discussion of course evaluation between 13 representatives of students and anesthesia staff was performed via Zoom. A comparison of the post-test and pre-test scores containing 20 multiple choice questions as well as the final exam scores before (2020) and after (2021) the new interactive learning was performed using a t-test. RESULTS: There were 136 and 117 students in the 2020 and 2021 academic years, respectively. The final mean (SD) exam scores for the 2020 and 2021 academic years were 70.3 (8.4) and 72.5 (9.0), respectively with a mean (95% confidence interval (CI)) difference of 2.2 (4.3, -0.02). In 2021, the mean (95% CI) difference between the post-test and pre-test scores was 5.8 (5.1, 6.5). The student representatives were satisfied with the new learning method and gave insightful comments, which were subsequently implemented in the 2022 academic year course. CONCLUSION: The new interactive learning method improved the knowledge of fifth-year medical students attending pre- and postoperative care course during the COVID-19 era. The final exam scores may not be suitable to represent the overall outcomes of the new interactive learning method. Using an online two-way communication method can improve the overall satisfaction and course adaptation during the COVID-19 era.

Improvement in Validity and Reliability of Airway Assessment Using Ultrasonography by Novice Personnel: A Learning Cohort Study.

Purpose: To assess improvements in the validity and reliability of novices' skills in performing ultrasonography for airway assessment. Patients and Methods: A learning cohort study was conducted with 20 anesthesiology residents and 10 volunteers in the Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University. The four parameters of airway assessment were soft tissue thickness at the level of 1) hyoid bone (STT-HY), 2) true vocal cords (STT-VC), 3) thyroid isthmus (STT-TI), and 4) suprasternal notch (STT-SN). The magnitude of discrepancies between the residents' and experienced anesthesiologists' measurements was evaluated over the sequence of measurements in the 10 volunteers. Results: The mean ultrasonic measurements of STT-HY by the experienced anesthesiologists and residents were significantly different (11.09 ± 3.14 mm vs 8.53 ± 3.02 mm, respectively; P = 0.008), whereas measurements of STT-VC, STT-TI, and STT-SN were not (7.18 ± 1.70 vs 7.14 ± 1.93, P = 0.32; 7.81 ± 2.14 vs 7.73 ± 2.19, P = 0.62; and 11.32 ± 3.33 vs 10.30 ± 3.02, P = 0.35, respectively). The mean discrepancy between the residents' and experienced anesthesiologists' measurements was close to zero throughout the sequence of measurements of STT-TI and STT-VC. However, the residents' measurements of STT-HY and STT-SN were considerably lower than those of anesthesiologists. The range of discrepancies between residents and experienced anesthesiologists in each sequential measurement was wide for all measurements, particularly for the measurement values of STT-HY, and the standard deviation of the discrepancies did not decrease over the sequence of measurements. Conclusion: Over the sequence of measurements for airway assessment in 10 volunteers by 20 residents in this learning trial, we found no evidence of improvement in measurement accuracy. Discrepancies between the residents' and anesthesiologists' measurements and the variability in discrepancy across residents were greatest in the measurement of STT-HY.

Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study.

BACKGROUND: In morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients. METHODS: This prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale. RESULTS: Mean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score. CONCLUSIONS: Age, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy.

The evaluation of using new trachea and skin manikins for practicing emergency anterior neck access.

Emergency anterior neck access may be performed if intubation and ventilation fail. Practicing this life-saving procedure with manikins before facing a real-life emergency anterior neck access is required to do this procedure successfully when we encounter a difficult airway situation. The current manikins are expensive and thus are sometimes difficult to acquire in low-cost settings such as Thailand. We devise a cost-effective training manikin using less expensive materials but retaining the simple design of the trachea and skin areas which are flexible polyurethane (PU) foam and silicone, but which still had the same utility as the current manikins. Five items were evaluated, and then scores were rated by experienced physicians from 1 to 5 points for each item, 1 being the least and 5 the highest. The mean score concerning the appropriate size of the manikins was 4.55 ± 0.56. The mean score of the ease of use for practicing was 4.58 ± 0.59. The mean score of the similarity of the skin of the manikins to human skin was 3.85 ± 0.66. The mean score of the similarity of the trachea of the manikins to the human trachea was 3.80 ± 0.69. The mean score of the sensation of inserting the tube in the manikin compared to a real trachea was 3.90 ± 0.67. The mean overall benefit score of practicing on the manikins was 4.38 ± 0.45. Our trial indicates that this low-cost and simply designed manikin can be useful for practicing emergency airway management procedures to save patients who are struggling with lack of oxygen or intubation failure or failure of ventilation or other airway equipment such as endotracheal intubation and supraglottic airway devices (SGA).

Premedication with oral paracetamol for reduction of propofol injection pain: a randomized placebo-controlled trial.

BACKGROUND: To compare the effect of premedication with 2 different doses of oral paracetamol to prevent pain at propofol intravenous injection. METHODS: We conducted a double-blind randomized controlled trial in which patients scheduled for induction of general anesthesia with intravenous propofol received either a placebo, 500 mg or 1000 mg of oral paracetamol (P500 and P1000, respectively) 1 h prior to induction. Two mg/kg of propofol was injected at a rate of 600 ml/hr. After 1/4 of the full dose had been injected, the syringe pump was paused, and patients were asked to rate pain at the injection site using a verbal numerical rating score (VNRS) from 0 to 10. RESULTS: Three hundred and twenty-four patients were included. Pain intensity was lower in both P500 and P1000 groups (median VNRS [interquartile range] = 2 [0-3] and 4 [2-5], respectively) than in the placebo group (8 [7-10]; P < 0.001)*. The rate of pain was lower in the P1000 group (70.4%) than in both the P500 and the placebo group (86.1 and 99.1%, respectively; P < 0.001)*. The respective rates of mild (VNRS 1-3), moderate (VNRS 4-6) and severe pain (VNRS 7-10) were 47.2, 23.2 and 0% in the P1000 group, 28.7, 50 and 7.4% in the P500 group, and 0, 22.2 and 76.9% in the placebo group (P < 0.001* for between group comparisons). Tolerance was similar in the 3 groups. CONCLUSIONS: A premedication with oral paracetamol can dose-dependently reduce pain at propofol intravenous injection. To avoid this common uncomfortable concern for the patients, this well-tolerated, available and cheap treatment appears as an option to be implemented in the current practice. TRIAL REGISTRATION: TCTR20150224002 . Prospectively registered on 24 February 2015.

Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury.

BACKGROUND: Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. MATERIALS AND METHODS: We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). RESULTS: A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). CONCLUSIONS: Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.

Supplemental oxygen for caesarean section during regional anaesthesia.

BACKGROUND: Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. This is an update of a review first published in 2013. OBJECTIVES: The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, issue 11), MEDLINE (1948 to November 2014) and EMBASE (1980 to November 2014). The original search was first performed in February 2012. We reran the search in CENTRAL, MEDLINE, EMBASE in February 2016. One potential new study of interest was added to the list of 'Studies awaiting Classification' and will be incorporated into the formal review findings during the next review update. SELECTION CRITERIA: We included randomized controlled trials (RCTs) of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses. MAIN RESULTS: We found one new included study in this updated version. In total, our updated review includes 11 trials (with 753 participants). The low quality of evidence showed no significant differences in average Apgar scores at one minute (N = six trials, 519 participants; 95% confidence (CI) -0.16 to 0.31, P = 0.53) and at five minutes (N = six trials, 519 participants; 95% CI -0.06 to 0.06, P = 0.98). None of the 11 trials reported maternal desaturation. The very low quality of evidence showed that in comparison to room air, women in labour receiving supplementary oxygen had higher maternal oxygen saturation (N = three trials, 209 participants), maternal PaO2 (oxygen pressure in the blood; N = six trials, 241 participants), UaPO2 (foetal umbilical arterial blood; N = eight trials, 504 participants; 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; N = 10 trials, 683 participants). There was high heterogeneity among these outcomes. A subgroup analysis showed no significant difference in UaPO2 between the two intervention groups in low-risk studies, whereas the high-risk studies showed a benefit for the neonatal oxygen group. AUTHORS' CONCLUSIONS: Overall, we found no convincing evidence that giving supplementary oxygen to healthy term pregnant women during elective caesarean section under regional anaesthesia is either beneficial or harmful for either the mother or the foetus' short-term clinical outcome as assessed by Apgar scores. Although, there were significant higher maternal and neonatal blood gas values and markers of free radicals when extra oxygen was given, the results should be interpreted with caution due to the low grade quality of the evidence.

Cardiac dysfunction following brain death after severe pediatric traumatic brain injury: A preliminary study of 32 children.

BACKGROUND: Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population. MATERIALS AND METHODS: We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003-2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death. RESULTS: In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2-6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024). CONCLUSIONS: The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.

Target Controlled Infusion versus Sevoflurane/Desflurane Anesthesia for Laparoscopic Cholecystectomy: Comparison Postoperative Nausea/Vomiting and Extubation Time.

BACKGROUND: Target-controlled infusion (TCI) systems have been developed from manually controlled infusion systems and have rapidly increased in popularity, especially in laparoscopic surgery. Propofol is claimed to decrease nausea and vomiting. OBJECTIVE: To compare anesthetic techniques, propofol-TCI, desflurane, and sevoflurane, for better results in terms of postoperative nausea and vomiting (PONV) and extubation times. MATERIAL AND METHOD: The present study was prospective with informed consent from 75 patients, ASA 1-3 scheduled for laparoscopic cholecystectomy, and classified by anesthetic technique into three groups. The patients were induced by propofol target plasma concentration 6 µg/ml in Group P, or 1-2 mg/kg in Group S and Group D, fentanyl 2 µg/kg and vecuronium 0.1 mg/kg followed by propofol 2 to 5 µg/mI in group P, sevoflurane 0.5 to 3% in Group S, and desflurane 2 to 6% in Group D. RESULTS: The incidence of postoperative nausea and vomiting was least in Group P, both at the PACU (p < 0.001) and ward (p = 0.01). Extubation time excluding outlier were Group P 11.17 ± 1.19 minutes, Group D 13.96 ± 1.17 minutes, Group S 11.75 ± 1.34 minutes (p = 0.25). There were no statistical differences in the amount of fentanyl (p = 0.38) and fluid replacements (p = 0.05). CONCLUSION: Laparoscopic cholecystectomy under propofol with TCI is one option of anesthetic technique with a significantly lower incidence of PONV compared with both sevoflurane and desflurane otherwise there is no statistical difference in the extubation time. Propofol-TCI technique is suggested for laparoscopic and ambulatory surgery.

Association between electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain injury.

INTRODUCTION: Abnormal electrocardiographic (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. The aim of this study was to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction, based on echocardiogram. METHODS: Data from adult patients with isolated TBI between 2003 and 2010 was retrospectively examined. Inclusion criteria included the presence of a 12-lead ECG within 24 h of admission and a formal echocardiographic examination within 72 h of admission after TBI. Patients with preexisting cardiac disease were excluded. Baseline clinical characteristics, 12-lead ECG, and echocardiogram report were abstracted. Logistic regression was used to identify the relationship of specific ECG abnormalities with cardiac dysfunction. RESULTS: We examined data from 59 patients with isolated TBI who underwent 12-lead ECG and echocardiographic evaluation. In this cohort, 13 (22%) patients had tachycardia (heart rate >100 bpm), 25 (42.4%) patients had a prolonged QTc, and 6 (10.2%) patients had morphologic end-repolarization abnormalities (MERA), with each having an association with abnormal echocardiographic findings: Odds ratios (and 95% confidence intervals) were 4.14 (1.02-17.05), 9.0 (1.74-46.65), and 5.63 (1.96-32.94), respectively. Ischemic-like ECG changes were not associated with echocardiographic abnormalities. CONCLUSIONS: Repolarization abnormalities (prolonged QTc and MERA), but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction prior to more expensive or invasive studies.

Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury.

PURPOSE: Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS: We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS: Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS: Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.

Preliminary report on cardiac dysfunction after isolated traumatic brain injury.

OBJECTIVE: The aim of this study was to examine cardiac dysfunction during the first 2 weeks after isolated traumatic brain injury and its association with in-hospital mortality. DESIGN: Retrospective. SETTING: Level 1 regional trauma center. PATIENTS: Adult patients with severe traumatic brain injury. METHODS: After institutional review board approval, data from adult patients with isolated traumatic brain injury who underwent echocardiography during the first 2 weeks after traumatic brain injury between 2003 and 2010 were examined. Patients with preexisting cardiac disease were excluded. Clinical characteristics and echocardiogram reports were abstracted. Cardiac dysfunction was defined as left ventricular ejection fraction less than 50% or presence of regional wall motion abnormality. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We examined data from 139 patients with isolated traumatic brain injury who underwent echocardiographic evaluation. Patients were 58 ± 20 years old, 66% were male patients, and 62.6% had subdural hematoma; admission Glasgow Coma Scale score was 3 ± 1 (3-15) and head Abbreviated Injury Scale was 4 ± 1 (2-5). Of this cohort, 22.3% had abnormal echocardiogram: reduced left ventricular ejection fraction was documented in 12% (left ventricular ejection fraction, 43% ± 8%) and 17.5% of patients had a regional wall motion abnormality. Hospital day 1 was the most common day of echocardiographic exam. Abnormal echocardiogram was independently associated with all cause in-hospital mortality (9.6 [2.3-40.2]; p = 0.002). CONCLUSIONS: Cardiac dysfunction in the setting of isolated traumatic brain injury occurs and is associated with increased in-hospital mortality. This finding raises the question as to whether there are uncharted opportunities for a more timely recognition of cardiac dysfunction and subsequent optimization of the hemodynamic management of these patients.

Supplemental oxygen for caesarean section during regional anaesthesia.

BACKGROUND: Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. OBJECTIVES: The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (1948 to February 2012) and EMBASE (1980 to February 2012). We did not apply language restrictions. SELECTION CRITERIA: We included randomized controlled trials of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses. MAIN RESULTS: We included 10 trials with a total of 683 participants. Supplementary oxygen administration varied widely in dose and duration between trials. No cases of maternal desaturation were reported, although none of the 10 trials focused on maternal desaturation. Significant differences were noted in maternal oxygen saturation (higher with oxygen, N = three trials; mean difference (MD) 1.6%, 95% confidence interval (CI) 0.8 to 2.3, P < 0.0001), maternal PaO2 (oxygen pressure in the blood; higher with oxygen, N = six trials; MD 141.8 mm Hg, 95% CI 109.3 to 174.3, P < 0.00001), neonatal UaPO2 (foetal umbilical arterial blood; higher with oxygen, N = eight trials; MD 3.3 mm Hg, 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; higher with oxygen, N = 10 trials; MD 5.9 mm Hg, 95% CI 3.2 to 8.5, P < 0.0001). No significant differences were reported in neonatal UapH (N = eight trials; MD 0.00, 95% CI -0.01 to 0.00, P = 0.26) and in average Apgar scores at one minute (N = five trials; MD 0.07, 95% CI -0.20 to 0.34, P = 0.6) and at five minutes (N = five trials; MD 0.00, 95% CI -0.06 to 0.05, P = 0.91).Only two out of 10 trials had a low risk of bias in all categories. When we separated the studies into low risk and high risk for bias, we found substantial statistical heterogeneity. None of the low-risk studies showed a significant difference in neonatal UaPO2 between the two intervention groups, whereas the high-risk studies showed a benefit for the neonatal oxygen group.The level of oxygen free radicals (malondialdehyde (MDA) and 8-isoprostane) was higher in participants who received supplementary oxygen (N = two trials; MD 0.2 µmol/L, 95% CI 0.1 to 0.4, P = 0.0002; MD 64.3 pg/mL, 95% CI 51.7 to 76.8, P < 0.00001, respectively). AUTHORS' CONCLUSIONS: Current evidence suggests that supplementary oxygen given to healthy term pregnant women during elective caesarean section under regional anaesthesia is associated with higher maternal and neonatal oxygen levels (maternal SpO2, PaO2, UaPO2 and UvPO2) and higher levels of oxygen free radicals. However, the intervention was neither beneficial nor harmful to the neonate's short-term clinical outcome as assessed by Apgar scores.

Myocardial dysfunction in acute traumatic brain injury relieved by surgical decompression.

Traumatic brain injury (TBI) is a major public health issue and is a leading cause of death in North America. After a primary TBI, secondary brain insults can predispose patients to a worse outcome. One of the earliest secondary insults encountered during the perioperative period is hypotension, which has been directly linked to both mortality and poor disposition after TBI. Despite this, it has been shown that hypotension commonly occurs during surgery for TBI. We present a case of intraoperative hypotension during surgery for TBI, where the use of transthoracic echocardiography had significant diagnostic and therapeutic implications for the management of our patient. We then discuss the issue of cardiac dysfunction after brain injury and the implications that echocardiography may have in the management of this vulnerable patient population.

Admission oxygenation and ventilation parameters associated with discharge survival in severe pediatric traumatic brain injury.

PURPOSE: Current Brain Trauma Foundation guidelines recommend avoiding hypoxemia after severe pediatric traumatic brain injury (TBI). Yet, recent studies on optimum admission oxygenation and ventilation parameters associated with discharge survival in pediatric TBI are lacking. MATERIALS AND METHODS: After IRB approval, a retrospective study involving pediatric patients ages ≤14 years with severe TBI (head Abbreviated Injury Scale (AIS) score of ≥3, Glasgow Coma Scale score of ≤8 on admission) admitted to Harborview Medical Center (level 1 pediatric trauma center), Seattle, WA, during 2003 to 2007 was performed. Admission demographics, clinical data, and laboratory characteristics were abstracted. Hypoxemia was defined as PaO2 < 60 mmHg, hypocarbia was defined as PaCO2 ≤ 35 mmHg, and hypercarbia was defined as PaCO2 ≥ 46 mmHg. RESULTS: One hundred ninety-four patients met inclusion criteria of which 162 (83.5 %) patients survived. Admission hypoxemia occurred in nine (5.6 %) patients who survived and eight (25 %) patients who died (p < 0.001). Children with admission PaCO2 between 36 and 45 mmHg had greater discharge survival compared with those with both admission hypocarbia (PaCO2 ≤ 35 mmHg) and hypercarbia (PaCO2 ≥ 46 mmHg). Admission PaO2 301-500 mmHg (adjusted odds ratio (AOR), 8.02 (95 % confidence interval (CI), 1.73-37.10); p = 0.008) and admission PaCO2 = 36-45 mmHg (AOR, 5.47 (95 % CI, 1.30-23.07); p = 0.02) were independently associated with discharge survival. CONCLUSIONS: Discharge survival after severe pediatric TBI was associated with admission PaO2 301-500 mmHg and PaCO2 = 36-45 mmHg. Admission hypocarbia and hypercarbia were each associated with increased discharge mortality.