Depth of anaesthesia monitoring during procedural sedation and analgesia: A systematic review and meta-analysis

ObjectivesProcessed electroencephalogram-based depth of anaesthesia monitoring devices provide an additional method to monitor level of consciousness during procedural sedation and analgesia. The objective of this systematic review was to determine whether using a depth of anaesthesia monitoring device improves the safety and efficacy of sedation.DesignSystematic review and meta-analysis.Data sourcesElectronic databases (CENTRAL; Medline; CINAHL) were searched up to May 2015.Review methodsRandomised controlled trials that compared use of a depth of anaesthesia monitoring device to a control group who received standard monitoring during procedural sedation and analgesia were included. Study selection, data extraction and risk of bias assessment (Cochrane risk of bias tool) were performed by two reviewers. Safety outcomes were hypoxaemia, hypotension and adverse events. Efficacy outcomes were amount of sedation used, duration of sedation recovery and rate of incomplete procedures.ResultsA total of 16 trials (2138 participants) were included. Evidence ratings were downgraded to either low or moderate quality due to study limitations and imprecision. Meta-analysis of 8 trials (766 participants) found no difference in hypoxaemia (RR 0.87; 95% CI = 0.67–1.12). No statistically significant difference in hypotension was observed in meta-analysis of 8 trials (RR 0.96; 95% CI = 0.54–1.7; 942 participants). Mean dose of propofol was 51 mg lower for participants randomised to depth of anaesthesia monitoring (95% CI = −88.7 to −13.3 mg) in meta-analysis of results from four trials conducted with 434 participants who underwent interventional endoscopy procedures with propofol infusions to maintain sedation. The difference in recovery time between depth of anaesthesia and standard monitoring groups was not clinically significant (standardised mean difference −0.41; 95% CI = −0.8 to −0.02; I² = 86%; 8 trials; 809 participants).ConclusionsDepth of anaesthesia monitoring did impact sedation titration during interventional procedures with propofol infusions. For this reason, it seems reasonable for anaesthetists to utilise a depth of anaesthesia monitoring device for select populations of patients if it is decided that limiting the amount of sedation would be beneficial for the individual patient. However, there is no need to invest in purchasing extra equipment or training staff who are not familiar with this technology (e.g. nurses who do not routinely use a depth of anaesthesia monitoring device during general anaesthesia) because there is no high quality evidence suggestive of clear clinical benefits for patient safety or sedation efficacy.     

Narcotrend监测在颅脑肿瘤切除手术中的应用

目的探讨Narcotrend监测在开颅脑肿瘤切除手术中的应用价值。方法全麻下行开颅脑肿瘤切除术患者50例,ASAⅠ或Ⅱ级,随机均分为Narcotrend监测组(A组)和对照组(B组)。A组以Narcotrend监测结果判断麻醉深度并调整用药,使Narcotrend指数(NI)维持在D2～E1水平;B组由同一麻醉医师根据临床经验调节麻醉用药。记录术中麻醉药用量、脑电分级情况、患者恢复情况及术后不良反应。结果 A组麻醉深度在预设定目标水平D2～E1的比例明显高于B组(P<0.01)。与B组比较,A组苏醒时间和听从指令的时间明显缩短(P<0.05),术后恶心呕吐发生率明显降低(P<0.05)。两组麻醉药用量差异无统计学意义,均无术中知晓发生。结论 Narcotrend监测有利于调控麻醉深度,缩短患者复苏时间,降低术后恶心呕吐发生率。     

Minimizing Permanent Pacemaker Following Repositionable Self-Expanding Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to minimize the risk of permanent pacemaker implantation (PPMI) with contemporary repositionable self-expanding transcatheter aortic valve replacement (TAVR).BackgroundSelf-expanding TAVR traditionally carries a high risk of PPMI. Limited data exist on the use of the repositionable devices to minimize this risk.MethodsAt NYU Langone Health, 248 consecutive patients with severe aortic stenosis underwent TAVR under conscious sedation with repositionable self-expanding TAVR with a standard approach to device implantation. A detailed analysis of multiple factors contributing to PPMI was performed; this was used to generate an anatomically guided MInimizing Depth According to the membranous Septum (MIDAS) approach to device implantation, aiming for pre-release depth in relation to the noncoronary cusp of less than the length of the membranous septum (MS).ResultsRight bundle branch block, MS length, largest device size (Evolut 34 XL; Medtronic, Minneapolis, Minnesota), and implant depth > MS length predicted PPMI. On multivariate analysis, only implant depth > MS length (odds ratio: 8.04; 95% confidence interval: 2.58 to 25.04; p < 0.001) and Evolut 34 XL (odds ratio: 4.96; 95% confidence interval: 1.68 to 14.63; p = 0.004) were independent predictors of PPMI. The MIDAS approach was applied prospectively to a consecutive series of 100 patients, with operators aiming to position the device at a depth of < MS length whenever possible; this reduced the new PPMI rate from 9.7% (24 of 248) in the standard cohort to 3.0% (p = 0.035), and the rate of new left bundle branch block from 25.8% to 9% (p < 0.001).ConclusionsUsing a patient-specific MIDAS approach to device implantation, repositionable self-expanding TAVR achieved very low and predictable rates of PPMI which are significantly lower than previously reported with self-expanding TAVR.     

婴儿体外循环后使用深度水解蛋白营养治疗对术后并发症的影响韩霞1 孔令爱2 郑璇3 郑萍4

目的 婴儿期先天性心脏病患儿体外循环后进行营养治疗,观察比较深度水解蛋白营养剂与传统营养液对术后并发症的影响。方法 研究2012年6月至2014年6月经体外循环行外科手术治疗的262例先天性心脏病患儿,随机分为2组,分别给予深度水解蛋白营养剂（试验组）和普通婴儿奶粉（对照组）进行喂养,对比研究两组患儿术前、术后WAZ值、血生化指标（总蛋白、白蛋白、前白蛋白）变化、术后疾病的恢复情况及并发症的发病率等。结果 试验组患儿喂养的平均热卡量较对照组明显高（65.5 kcal·kg-1·d-1比57.2 kcal·kg-1·d-1）,差异有统计学意义（P<0.01）;两组患儿术后WAZ有明显差异（P<0.05）,试验组患儿术后营养不良发病率较对照组明显降低（42.6%比50.0%）;短期营养治疗后两组患儿血清白蛋白、前白蛋白有明显差异（P<0.05）;体外循环术后两组患儿相关并发症（喂养不耐受、感染、乳糜胸发病率及恢复时间、呼吸机使用时间、ICU留观时间）等经统计学分析均有明显差异（P<0.01）。结论 体外循环后的先天性心脏病患儿短期内给予深度水解蛋白营养剂,可以明显改善体外循环营养丢失,减少术后相关并发症的发生,缩短患儿术后恢复时间。     

The effect of heating rate on the surface chemistry of NiTi

The impact of the heating rate on the Ni content at the surface of the oxide layer of biomedical NiTi is explored. Heat treatment emulating common shape-setting procedures was performed by means of conventional and inductive heating for similar annealing time and temperature, applying various heating rates from ∼0.25 K s⁻¹ to 250 K s⁻¹. A glow discharge optical emission spectroscopy method was established and employed to evaluate concentration profiles of Ni, Ti and O in the near-surface region at high resolution. The Ni content at the surface of the differently treated samples varies significantly, with maximum surface Ni concentrations of ∼20 at.% at the lowest and ∼1.5 at.% at the highest heating rate, i.e. the total amount of Ni contained in the surface region of the oxide layer decreases by >15 times. Consequently, the heating rate is a determinant for the biomedical characteristics of NiTi, especially since Ni available at the surface of the oxide layer may affect the hemocompatibility and be released promptly after surgical application of a respective implant. Furthermore, apparently contradictory results presented in the literature reporting surface Ni concentrations of ∼3 at.% to >20 at.% after heat treatment are consistently explained considering the ascertained effect of the heating rate.     

臀大肌注射深度探索及护理对策

目的进一步明确肌肉注射的深度。方法以臀大肌注射为研究对象 ,通过B超观察 5 2 4例皮肤到臀大肌之间的距离 ,以确定针头进入的深度。结果男性组皮肤与皮下组织的平均厚度为 1 34± 0 6 3cm ,女性组平均厚度为 3 4 1± 0 98cm ,两组相比P <0 0 5 ,差异有显著性意义。结论教科书上的进针深度标准 ,目前只适用于男性。故在执行肌肉注射时 ,除了根据药物的性质和粘稠度选择不同的针头外 ,还要根据性别、胖瘦选择合适的针头     

Impaired distance perception and size constancy following bilateral occipitoparietal damage

Accurate distance perception depends on the processing and integration of a variety of monocular and binocular cues. Dorsal stream lesions can impair this process, but details of this neurocognitive relationship remain unclear. Here, we tested a patient with bilateral occipitoparietal damage and severely impaired stereopsis. We addressed four related questions: (1) Can distance and size perception survive limitations in perceiving monocular and binocular cues? (2) Are egocentric (self-referential) and allocentric (object-referential) distance judgments similarly impaired? (3) Are distance measurements equally impaired in peripersonal and extrapersonal space? (4) Are size judgments possible when distance processing is impaired? The results demonstrate that the patient’s lesions impaired both her distance and size perception, but not uniformly. Her performance when using an egocentric reference frame was more impaired than her performance when using an allocentric reference frame. Likewise, her distance judgments in peripersonal space were more impaired than those in extrapersonal space. The patient showed partial preservation in size processing of novel objects even when familiar size cues were removed.     

Ground-plane influences on size estimation in early visual processing

Ground-planes have an important influence on the perception of 3D space (Gibson, 1950) and it has been shown that the assumption that a ground-plane is present in the scene plays a role in the perception of object distance (Bruno & Cutting, 1988). Here, we investigate whether this influence is exerted at an early stage of processing, to affect the rapid estimation of 3D size. Participants performed a visual search task in which they searched for a target object that was larger or smaller than distracter objects. Objects were presented against a background that contained either a frontoparallel or slanted 3D surface, defined by texture gradient cues. We measured the effect on search performance of target location within the scene (near vs. far) and how this was influenced by scene orientation (which, e.g., might be consistent with a ground or ceiling plane, etc.). In addition, we investigated how scene orientation interacted with texture gradient information (indicating surface slant), to determine how these separate cues to scene layout were combined. We found that the difference in target detection performance between targets at the front and rear of the simulated scene was maximal when the scene was consistent with a ground-plane - consistent with the use of an elevation cue to object distance. In addition, we found a significant increase in the size of this effect when texture gradient information (indicating surface slant) was present, but no interaction between texture gradient and scene orientation information. We conclude that scene orientation plays an important role in the estimation of 3D size at an early stage of processing, and suggest that elevation information is linearly combined with texture gradient information for the rapid estimation of 3D size.     

The influence of the depth of embryo transfer into the uterine cavity on implantation rate

ObjectiveTo assess the effect of the depth of embryo transfer replacement on implantation and clinical pregnancy rates in intracytoplasmic sperm injection cycles.Materials and methodsThis study was conducted on 90 consecutive patients. All patients underwent a standard down regulation protocol for ovarian stimulation. Oocytes retrieval was performed at 36h after HCG administration. Embryo transfer took place 2–4days after oocyte retrieval. The patients were grouped according to the distance between the tip of the catheter and the uterine fundus at transfer (group I <0.75cm, group II 0.75–<1.5cm, group III 1.5–2cm).ResultsImplantation and clinical pregnancy rates varied significantly between group I and other groups: 10.3% and 13.3%, respectively, in group I; 26.7% and 53.3%, respectively, in group II; 27.8% and 53.3%, respectively, in group III.ConclusionThe depth of embryo replacement inside the uterine cavity may influence implantation rates and should be considered as an important factor to improve the success of implantation and pregnancy rates.