Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries

BACKGROUND

Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients.

OBJECTIVES

To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs.

DESIGN

This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification.

PATIENTS AND SETTING

Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes.

RESULTS

A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure.

CONCLUSION

The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov, number NCT01601223.

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 transfusion practices in Europe

BACKGROUND

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe.

METHODS

We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013.

RESULTS

The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2).

CONCLUSION

Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold.

CLINICAL TRIAL REGISTRATION

NCT 01604083.

Efficacy of intravenous acetaminophen and lidocaine on propofol injection pain

BACKGROUND

Different methods and propofol formulations have been used to decrease propofol injection pain, but it remains an unresolved problem. We aimed to investigate the effect of i.v. acetaminophen pretreatment on the propofol injection pain.

METHODS

One hundred and fifty ASA I-II patients undergoing general anaesthesia were randomly allocated into three groups. A 20-gauge catheter was inserted into a superficial radial vein of the left hand, and after the occlusion of venous drainage, Groups I, II, and III were pretreated with 40 mg of lidocaine in saline, 50 mg of i.v. acetaminophen, and 5 ml of saline, respectively. The occlusion was released after 2 min and one-fourth of the total propofol dose was injected into the vein over a period of 5 s. During the injection of both pretreatment solution and propofol, patients' pain was assessed and recorded as 0-3, corresponding to no, mild, moderate or severe pain, respectively. Chi2 and Kruskal-Wallis tests were used for the statistical analysis. For all analyses, differences were considered to be significant at P<0.05.

RESULTS

Patient characteristics were similar among the groups. Incidence of pain on injection of propofol in control, i.v. acetaminophen, and lidocaine groups was 64%, 22% and 8%, respectively (P<0.05).

CONCLUSIONS

Pretreatment with i.v. acetaminophen seems to be effective in attenuating pain during i.v. injection of propofol.

A clinical comparison of etomidate-lipuro, propofol and admixture at induction

OBJECTIVE

The purpose of this study was to compare etomidate-lipuro and propofol and 50%, (1:1) admixture of these agents at induction with special reference to injection pain, hemodynamic changes, and myoclonus.

METHODS

Ninety patients were assigned at random to three groups in which induction was performed with either etomidate-lipuro, propofol or etomidate-lipuro-propofol admixture. After monitorization with bispectral index (BIS) all agents were given with infusion with a perfuser at a constant rate of 200 ml/min till the BIS values decreased to 40. Blood pressure and heart rate were measured every 30 s at this period. Patients were asked for pain at the injection site and observed visually for myoclonus. The time BIS values decreased to 40 (BIS 40 time) and total amounts of induction doses were measured.

RESULTS

BIS 40 time measurements were P > E > PE (199.4 ± 40.9, 176.9 ± 31.6, 163.5 ± 20.6 s). The hemodynamic (systolic, diastolic and mean blood pressures, heart rate) changes were minimal in group PE than other two groups (P = 0.017). The intensity of myoclonus was graded as mild in 9, moderate in 12, and severe in 5 patients in the group E (76.3%). Myoclonus was not observed in group PE and group P. There were no injection pain in group PE as the incidence were (83.8%) in group P and in (63.2%) group E.

CONCLUSION

Incidence of hemodynamic changes, myoclonus, and injection pain is significantly lower in group PE. BIS 40 times is least in group PE. We concluded that 1:1 admixture of etomidate-lipuro and propofol is a valuable agent for induction.

Effect of laparoscopic cholecystectomy techniques on postoperative pain: a prospective randomized study

PURPOSE

Minimally invasive surgical technics have benefits such as decreased pain, reduced surgical trauma, and increased potential to perform as day case surgery, and cost benefit. The primary aim of this prospective, randomized, controlled study was to compare the effects of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) procedures regarding postoperative pain.

METHODS

Ninety adult patients undergoing elective laparoscopic cholecystectomy were included in the study. Patients were randomized to either SILC or CLC. Patient characteristics, postoperative abdominal and shoulder pain scores, rescue analgesic use, and intraoperative and early postoperative complications were recorded.

RESULTS

A total of 83 patients completed the study. Patient characteristics, postoperative abdominal and shoulder pain scores and rescue analgesic requirement were similar between each group except with the lower abdominal pain score in CLC group at 30th minute (P = 0.04). Wound infection was seen in 1 patient in each group. Nausea occurred in 13 of 43 patients (30%) in the SILC group and 8 of 40 patients (20%) in the CLC group (P > 0.05). Despite ondansetron treatment, 6 patients in SILC group and 7 patients in CLC group vomited (P > 0.05).

CONCLUSION

In conclusion, in patients undergoing laparoscopic surgery, SILC or CLC techniques does not influence the postoperative pain and analgesic medication requirements. Our results also suggest that all laparoscopy patients suffer moderate and/or severe abdominal pain and nearly half of these patients also suffer from some form of shoulder pain.

The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study

BACKGROUND

It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average ΔP (ΔPTW) with PPCs. We also tested the association of ΔPTW with intraoperative adverse events.

METHODS

Posthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events.

RESULTS

The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔPTW was not different between groups. The association of ΔPTW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P <  0.001 versus 1.05 [95%CI 1.05 to 1.05], P <  0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P <  0.001). The association of ΔPTW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P <  0.001 versus 1.07 [95%CI 1.05 to 1.10], P <  0.001; risk difference 0.05 [95%CI 0.030.07], P <  0.001).

CONCLUSIONS

ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery.

TRIAL REGISTRATION

LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).

Renal effects of coronary artery bypass graft surgery in diabetic and non-diabetic patients: a study with urinary neutrophil gelatinase-associated lipocalin and serum cystatin C

BACKGROUND/AIMS

Cardiac surgery and diabetes are major causes of acute kidney injury (AKI). We aimed to investigate the value of urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C, as early biomarkers for prediction of AKI in diabetic and non-diabetic adult patients undergoing cardiac surgery.

METHODS

15 non-diabetic and 15 diabetic adult patients undergoing cardiac surgery were enrolled. Peri-operative clinical and laboratory variables were recorded. Urinary NGAL, serum cystatin C, serum creatinine (Cre) and blood urea nitrogen (BUN) were evaluated.

RESULTS

AKI was detected in 4 patients in non-diabetic group and 12 patients in diabetic group. Urinary NGAL levels of diabetic and non-diabetic patients and serum cystatin C levels of diabetic patients exceed upper normal limits or cutoff values much earlier than BUN and Cre. cystatin C levels of non-diabetic patients remain unchanged. Cystatin C and NGAL levels of patients meeting AKI criteria and NGAL levels of patients not meeting AKI criteria exceeded upper normal limits or cut off values much earlier in than BUN and Cre.

CONCLUSIONS

Measurement of cystatin C level in both diabetic and non-diabetic patients may reveal AKI earlier than NGAL and BUN. In diabetic patients, measurement of urinary NGAL and serum cystatin C levels may indicate AKI signs earlier than BUN and Cre.

Endovenous laser ablation under general anesthesia for day surgery: feasibility and outcomes of the 300 patients

PURPOSE

Endovenous laser ablation (EVLA) for superficial venous insufficiency is traditionally performed under tumescent local anesthesia as day case surgery. The aim of this study is to evaluate the feasibility of general anesthesia in addition to tumescent anesthesia in patients undergoing EVLA.

METHODS

The anesthesia and clinical registration records of 341 extremities of 300 adult patients were reviewed and analyzed retrospectively. Demographic and clinical data, preoperative anesthetic evaluation data (ASA physical status, preoperative airway assessment, Mallampati score), type of supraglottic device, duration of anesthesia and surgery, any surgical and/or anesthetic complication, timing of mobilization and discharge, and postoperative course were evaluated.

RESULTS

Mean duration of operation and anesthesia was 28 (12-55) and 40 (20-65) minutes, respectively. Mobilization and discharge timing was 25 (11-45) and 139 (110-200) minutes, respectively. All patients were discharged the same day of surgery.

CONCLUSION

The combination technique of administering general anesthesia with supraglottic device and tumescent anesthesia is a safe and effective method to reduce the patients' pain and discomfort during the EVLT procedure within the scope of day case surgery.

Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study

BACKGROUND

In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes.

METHODS

This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression.

RESULTS

In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE.

CONCLUSIONS

The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Is a neutral head position as effective as head rotation during landmark-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial

OBJECTIVE

Central venous access remains a cornerstone procedure for a variety of clinical conditions. Ultrasound studies suggest that rotation of the head increases the magnitude of the overlap of the internal jugular vein with the carotid artery. The authors assessed whether a neutral position of the head during anatomic landmark-guided cannulation of the internal jugular vein (IJV) was an attractive alternative to rotating the neck to a >45° head turn.

DESIGN

A prospective, randomized, controlled study.

SETTING

An education and research hospital and a university-affiliated hospital.

PARTICIPANTS

Eighty patients requiring central venous catheterization in the right IJV.

INTERVENTIONS

Under general anesthesia, patients were positioned in the Trendelenburg position with extension of the neck. In the rotated group, the head was rotated to the left at >45°. In the neutral group, the head was placed in the neutral position. Right IJV cannulation was performed using the central approach with the needle angled toward the ipsilateral nipple. The primary outcome variable was the cumulative success rate, which was defined as IJV puncture achieved in the first 3 attempts using a finder needle. A p value of <0.05 was considered statistically significant.

MEASUREMENTS AND MAIN RESULTS

Groups were similar in terms of demographic data. The success rates of finder needle passes into the IJV on the first attempt were 87.5% and 37.5% (p < 0.05), and the cumulative success rates on the first 3 attempts were 97.5% and 57.5% in the rotated and neutral groups, respectively (p < 0.05). Carotid artery puncture only occurred in 2 patients in the rotated group.

CONCLUSIONS

Because of the lower success rate, the neutral head position is not an attractive alternative for IJV catheterization when compared with the rotated head position in a central landmark IJV approach.

The analgesic efficacy of intra-articular acetaminophen in an experimental model of carrageenan-induced arthritis

BACKGROUND

Acetaminophen is one of the most common drugs used for the treatment of pain and fever.

OBJECTIVES

To examine the effects of intra-articular (IA) acetaminophen on carrageenan-induced arthritic pain-related behaviour and spinal c-Fos expression in rats.

METHODS

The present study was performed using 20 Sprague Dawley rats. Forty microlitres of IA 0.9% NaCl was injected in the control group, and 40 µL of IA carrageenan was injected in the carrageenan group. One hour after carrageenan injection, 400 µg of IA acetaminophen was injected in the IA acetaminophen group, and 400 µg of intraperitoneal (IP) acetaminophen was injected in the IP acetaminophen group. One day before injection, and 4 h and 8 h after injection, diameters of both knee joints, motility of the rat, paw loading and joint mobility were assessed. After the rats were euthanized, L3 and L4 spinal segments were excised for c-Fos assessment.

RESULTS

IA acetaminophen decreased both the severity and distribution of c-Fos expression. IP acetaminophen decreased only the distribution of c-Fos expression. IA acetaminophen decreased knee diameter at 8 h. IA and IP acetaminophen increased rat motility and paw loading scores. Joint mobility scores of IP acetaminophen were similar to saline at 8 h.

CONCLUSIONS

Results of the present study indicate an analgesic and⁄or possible anti-inflammatory effect of IA acetaminophen and provide further evidence on the efficacy of systemic acetaminophen injection in reducing arthritic pain.

Management of postdural puncture headache with epidural saline patch in a 10-year-old child after inguinal hernia repair: a case report

Spinal anesthesia (SA) is becoming increasingly popular among pediatric anesthetists. Postdural puncture headache (PDPH) has been reported in children. PDPH generally spontaneously resolves within a few days with bed rest and nonopioid analgesics, but it may last for several days. If the symptoms persist, an epidural blood patch is considered as an effective treatment. We describe the successful use of an epidural saline patch in a 10 year-old child with PDPH who did not respond to conservative treatment.

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

BACKGROUND

Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients.

METHODS

Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs.

RESULTS

Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs.

CONCLUSIONS

Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.

Anesthetic management of a newborn with trisomy 18 undergoing closure of patent ductus arteriosus and pulmonary artery banding

BACKGROUND

Peri-operative management of infants with trisomy 18 syndrome is challenging due to various congenital cardiac and facial anomalies.

CASE REPORT

We report the anaesthetic management of a 13-day-old neonate with 1 540 g body weight, undergoing closure of patent ductus arteriosus and pulmonary artery banding. Anaesthesia was induced with sevoflurane, fentanyl and rocuronium. Despite dysmorphic facial features, ventilation and endotracheal intubation were achieved uneventfully. Anaesthesia was maintained with sevoflurane and fentanyl and was uneventful. The patient was transferred to the neonatal ICU intubated and with ventilatory support. The baby was extubated on the second day postoperatively.

CONCLUSION

Our knowledge of the proper anaesthetic technique for children undergoing palliative or corrective surgery is limited. Further case reports will increase our experience in peri-operative management of children with trisomy 18.

The effects of intra-articular injection of ibuprofen on knee joint cartilage and synovium in rats

OBJECTIVE

The aim of this animal study was to investigate the short and long-term local histomorphologic effects and the utility of intra-articular application of ibuprofen.

METHODS

Forty-six Wistar Albino rats were used in the study. The rats were randomized into 5 groups of 8 and a sham group of 6. The 40 rats in the study groups were anaesthetised with 60 mg/kg of ketamine, then 0.25 ml ibuprofen (25 mg) was injected to the right knee joint of each rat (ibuprofen group) and 0.25 ml 0.9% saline to the left knee joint as the control group. To the 6 rats in the sham group, only puncture was applied to both knee joints. The rats in each of the 5 study groups were sacrificed on days 1, 2, 7, 14 and 21 respectively. The histomorphologic changes were graded on a 6-point scale regarding inflammation of the synovia, cartilage tissue, and subchondral bone. Inflammation scores were compared using the Mann Whitney U-test and comparisons of the sacrifice day and drug used were evaluated with the Kruskal Wallis test. The p values below 0.05 were considered as significant.

RESULTS

Statistically significant difference was found between the ibuprofen injected knees (10/40) and the saline injected (0/40) and sham knees (0/12) in respect of hematoma positivity (p = 0.002). Significantly higher inflammation scores were found in ibuprofen injected knees on the 1st, 2nd, 7th and 14th days compared to controls and sham (p < 0.05). Inflammation scores were similar in ibuprofen injected knees with and without hematoma (p > 0.05). Inflammation of the ibuprofen injected group was most severe on day one and the severity of inflammation reduced gradually throughout the 3 weeks.

CONCLUSION

Our results show that intra-articular injection of ibuprofen can cause intra-articular hematoma. It also leads to transient inflammation of the synovia that is more severe in the early period, which gradually recovers.

Iliac Artery Injury During Lumbar Disc Hernia Surgery

BACKGROUND

Vascular injury complications during lumbar discectomy are rare but potentially life-threatening. Therefore, an early diagnosis and effective treatment management is required for these complications.

CASE DESCRIPTION

A 50-year-old female patient was admitted to our outpatient clinic with severe back and right leg pain. She underwent surgery for right L4-5 extruded disc herniation with general anesthesia. Sudden arterial hemorrhage occurred during discectomy performed with straight disc forceps and was controlled using hemostatic materials, with no significant decrease in blood pressure. However, the patient became hypotensive near the end of the operation. The incision was quickly closed, and she was turned to supine position. Emergency abdominal ultrasound, computed tomography, and computed tomography angiography revealed an injury of the left main iliac artery, which was repaired by endovascular stenting. Laparotomy and Bogota bag were applied because of increased intrabdominal pressure at 3 hours postoperative. In addition, a retroperitoneal catheter was placed into the area of the right retroperitoneal hematoma on the first postoperative day. Tissue plasminogen activator was administered through the catheter. On postoperative day 3, the Bogota bag was removed, and the abdomen was closed. The patient was discharged without neurodeficit on day 27. Her abdominal fascial defect was closed with a synthetic graft after 5 months.

CONCLUSIONS

Although lumbar discectomy is one of the most commonly performed neurosurgical procedures, the routine rules of discectomy should not be neglected. Early detection and a multidisciplinary approach can help prevent mortality in the event of vascular injury.

In vitro vasoactive effects of dexmedetomidine on isolated human umbilical arteries

OBJECTIVE

We aimed to investigate the vasoactive effects of dexmedetomidine on isolated human umbilical arteries and possible mechanisms involved.

METHODS

Human umbilical artery strips were suspended in Krebs-Henseleit solution and dose-response curves were obtained for cumulative dexmedetomidine before and after incubation with different agents; propranolol, atropine, yohimbine, prazosin, indomethacin, verapamil. Effects of calcium on cumulative dexmedetomidine-induced contractions were also studied.

RESULTS

Cumulative dexmedetomidine resulted in dose dependent contraction responses. Incubation with propranolol (Emax: 93.3 ± 3.26 %), atropine (Emax: 92.0 ± 6.54 %), or indomethacin (Emax: 94.25 ± 2.62 %), did not attenuate dexmedetomidine-elicited contractions (p > 0.05). There were significant decreases in the contraction responses of cumulative dexmedetomidine with yohimbine (Emax: 12.1 ± 11.9 %), prazosin (Emax: 28.8 ± 4.6 %) and verapamil (Emax: 11.2 ± 13.6 %) (p < 0.05). In Ca+2 free medium contraction responses to cumulative dexmedetomidine was insignificant (Emax: 5.20 ± 3.42 %). Addition of cumulative calcium to the Ca+2 free medium resulted in concentration dependent increase in contractions (Emax: 64.83 ± 37.7 %) (p < 0.05).

CONCLUSION

Dexmedetomidine induces vasoconstriction in endothelial-free umbilical arteries via both, α1- and α2-adrenergic receptors and also extracellular Ca+2 concentrations play a major role. β-adrenergic receptors, muscarinic cholinergic receptors, and inhibition of cyclooxygenase enzyme are not involved in this vasoconstriction (Fig. 3, Ref. 36).

Effects of propofol and sevoflurane on isolated human umbilical arteries pre-contracted with dopamine, adrenaline and noradrenaline

AIM

To assess the effects of propofol and sevoflurane on the contraction elicited by dopamine, adrenaline and noradrenaline on isolated human umbilical arteries.

METHODS

Umbilical arteries were cut into endothelium-denuded spiral strips and suspended in organ baths containing Krebs-Henseleit solution bubbled with O2 +CO2 mixture. Control contraction to phenylephrine (10(-5)  M) was recorded. Response curves were obtained to 10(-5)  M dopamine, 10(-5)  M adrenaline or 10(-5)  M noradrenaline. Afterwards, either cumulative propofol (10(-6)  M, 10(-5)  M and 10(-4)  M) or cumulative sevoflurane (1.2%, 2.4% and 3.6%) was added to the organ bath, and the responses were recorded. Responses are expressed percentage of phenylephrine-induced contraction (mean ± standard deviation) (P < 0.05 = significance).

RESULTS

Propofol and sevoflurane elicited concentration-dependent relaxations in strips pre-contracted with dopamine, adrenaline and noradrenaline (P < 0.05). Highest (10(-4)  M) concentration of propofol caused significantly higher relaxation compared with the highest (3.6%) concentration of sevoflurane in the contraction elicited by dopamine. High (10(-5)  M) and highest concentrations of propofol caused significantly higher relaxation compared with the high (2.4%) and highest concentrations of sevoflurane on the contraction elicited by adrenaline. High and highest concentrations of sevoflurane caused significantly higher relaxation compared with the high and highest concentrations of propofol on the contraction elicited by noradrenaline.

CONCLUSION

Dopamine, adrenaline and noradrenaline elicit contractions in human umbilical arteries, and noradrenaline causes the highest contraction. Both propofol and sevoflurane inhibit these contractions in a dose-dependent manner. Propofol caused greater relaxation in the contractions elicited by dopamine and adrenaline while sevoflurane caused greater relaxation in the contraction elicited by noradrenaline.

Cardiac angiosarcoma: A case with bilateral pleural and pericardial effusion

Cardiac sarcomas are rare malignant tumors. Angiosarcoma is the most common cardiac sarcoma and is present in up to 33% of cases. Angiosarcomas have a poor prognosis, with a short survival expectancy. We report a case of a right atrial angiosarcoma treated by partial tumor resection followed by chemotherapy.

Outcomes in patients with chronic heart failure undergoing non-cardiac surgery: a secondary analysis of the METREPAIR international cohort study

INTRODUCTION

Heart failure is a frequent comorbidity in patients undergoing non-cardiac surgery and an acknowledged risk factor for postoperative mortality. The associations between stable chronic heart failure and postoperative outcomes have not been explored extensively. The aim of this study was to determine associations between stable chronic heart failure and its peri-operative management and postoperative outcomes after major non-cardiac surgery.

METHODS

This is a secondary analysis of MET-REPAIR, an international prospective cohort study including patients undergoing non-cardiac surgery aged ≥ 45 y with increased cardiovascular risk. Main exposures were stable chronic heart failure and availability of a pre-operative transthoracic echocardiogram. The primary endpoint was the incidence of postoperative major adverse cardiovascular events at 30 days. Secondary endpoints included 30-day mortality and severe in-hospital complications. Multivariable logistic regression models were calculated.

RESULTS

Of 15,158 included patients, 3880 (25.6%) fulfilled the diagnostic criteria for stable chronic heart failure, of whom 1397 (36%) were female. Chronic heart failure was associated with increased risk of postoperative 30-day major adverse cardiovascular events (OR 2.04, 95%CI 1.59-2.60), 30-day mortality (OR 1.50, 95%CI 1.17-1.92) and in-hospital complications (OR 1.47, 95%CI 1.30-1.66). Transthoracic echocardiography was performed in 1267 (32.7%) patients with heart failure; 146 (11.5%) patients with heart failure presented with a left ventricular ejection fraction < 40%. Reduced ejection fraction was associated with major adverse cardiovascular events (OR 2.0, 95%CI 1.01-3.81).

DISCUSSION

Stable chronic heart failure is independently associated with major adverse cardiovascular events, mortality and severe postoperative complications when measured 30 days after non-cardiac surgery.

Can Gastric Volume be Accurately Estimated by Ultrasound?

OBJECTIVE

Knowing the degree of gastric fullness is critical in determining the potential risk of pulmonary aspiration prior to urgent or elective intubation. This study aims to investigate the role of ultrasound in predicting the gastric volume accurately.

METHODS

176 patients who underwent upper gastric endoscopy after 12-hour fasting were examined by gastric US. The patients were ran- domly divided into 6 groups according to the volume of ingested semifluid meal: (1) empty stomach (no volume), (2) 50 mL, (3) 100 mL, (4) 200 mL, (5) 300 mL, and (6) 400 mL. Antral cross-sectional area (CSA) was measured by US after each ingestion.

RESULTS

We found a strong linear correlation between antral CSA and gastric volume up to 200 mL. The diagnostic performance of ultra- sound was found to be more powerful in the supine position than in the right lateral position. A new mathematical model was established to predict gastric volume. The threshold value for antral cross-sectional area at risk of pulmonary aspiration was determined as 3.1 cm2 by sonographic measurement.

CONCLUSION

Ultrasonography could be preferred to gastric endoscopy or scintigraphy in terms of non-invasiveness and easiness, although it still merits further investigation.

Effects of Sevoflurane and Propofol Anesthesia on Cerebral Oxygenation in Patients Undergoing Carotid Endarterectomy

AIM

To compare the effects of sevoflurane and propofol anesthesia on perioperative cerebral oxygenation in patients undergoing carotid endarterectomy (CEA) under general anesthesia by using near-infrared spectroscopy (NIRS) monitoring.

MATERIAL AND METHODS

Institutional approval was obtained, and the perioperative data of 33 patients undergoing CEA were retrospectively evaluated. The study groups were organized according to the anesthesia drugs used for maintenance: sevoflurane (n=17) and propofol (n=16). The regional cerebral oxygen saturation (rScO < sub > 2 < /sub > ) of the ipsilateral and contralateral hemispheres was monitored continuously using a NIRS instrument and analyzed at specific time points starting from induction to the 12th hour postoperation. The data were analyzed using the appropriate tests, and a p value of < 0.05 was considered significant.

RESULTS

Compared with those of groups with non-clamped hemispheres, the rScO < sub > 2 < /sub > values of the sevoflurane and propofol groups decreased significantly during clamping (p < 0.05) and increased to above-preoperative values after declamping (p < 0.05). When the sevoflurane and propofol groups were compared, a significant decrease in rScO < sub > 2 < /sub > was noted during extubation in the sevoflurane group (p < 0.05). In the propofol group, female patients had significantly lower rScO < sub > 2 < /sub > values compared with male patients during clamping of the carotid artery (p < 0.05). None of the observed decreases was greater than 20%, which is considered an indication for shunting.

CONCLUSION

Our NIRS monitoring results indicate that sevoflurane or propofol anesthesia does not generally cause significant differences in cerebral oxygenation during and after cross-clamping in patients undergoing CEA. The finding of sex-related differences in cerebral oxygenation in patients receiving propofol and decreased oxygenation during extubation in patients receiving sevoflurane warrants further studies.