Effect of depth of neuromuscular blockade on the abdominal space during pneumoperitoneum establishment in laparoscopic surgery

Study ObjectiveTo evaluate the effect of neuromuscular blockade (NMB) upon the abdominal space during pneumoperitoneum establishment in laparoscopic surgery, comparing moderate NMB and deep NMB.DesignProspective, randomized, crossover clinical trial.SettingOperating room.PatientsSeventy-six American Society of Anesthesiologists 1 to 2 patients scheduled for elective laparoscopic surgery.InterventionsTwo independent evaluations were performed at the establishment of pneumoperitoneum for a preset intraabdominal pressures (IAPs) of 8 and 12 mm Hg, both during moderate NMB (train-of-four count, 1-3) and deep NMB (posttetanic count, < 5). Rocuronium was used to induce NMB, and sugammadex was used for reversal.MeasurementsWe evaluated (i) the volume of CO₂ introduced in 41 patients and (ii) the skin-sacral promontory distance in 35 patients, at pneumoperitoneum establishment.ResultsCompared to moderate NMB, deep NMB increased, in a significant manner, both the intraabdominal volume of CO₂ insufflated (mean [SD], 2.24 [1.10] vs 2.81 [1.13] L at 8 mm Hg IAP, P < .001, and 3.52 [1.31] vs 4.09 [1.31] L at 12 mm Hg IAP, P < .001) and the skin-sacral promontory distance (11.78 [1.52] vs 12.16 [1.51] cm at 8 mm Hg IAP, P = .002, and 13.34 [1.87] vs 13.80 [1.81] cm at 12 mm Hg IAP, P < .001). Increase in intraabdominal volume after inducing deep NMB was observed in 88% and 81.7% of patients at 8 and 12 mm Hg pneumoperitoneum, with a volume increase of mean of 36.8% (95% confidence interval [CI], 22.8-50.8) and 25% (95% CI, 13.7-36.4), respectively (P = .003). Increase in distance was observed in 61% and 82% of patients at 8 and 12 mm Hg pneumoperitoneum, with a mean distance increase of 3.3% (95% CI, 1.3-5.4) and 3.6% (95% CI, 1.9-5.2), respectively (P = .840).ConclusionsDeep NMB, in comparison to moderate NMB, increased in a significant manner the abdominal space at pneumoperitoneum establishment. However, the effective increase in the abdominal cavity dimensions could be low, the increase showed a great interindividual variability, and it was not observed in every patient. Clinical significance of this increase on surgical conditions is yet to be demonstrated.     

Consecuencias renales de la hipertensión intraabdominal en modelo porcino. Búsqueda de la técnica indirecta de elección de la medida de la presión intraabdominal

ObjectiveTo study the effects on the renal system in a porcine model of intraabdominal hypertension, and to determine the indirect technique of choice for determination of the intraabdominal pressure.Material and methods30 pigs were used divided in two groups according with increased intraabdominal pressure values (20 mm Hg and 30 mm Hg). In both groups pressures were registered 8 times, summing up to 3 hours, with a CO₂ insufflator. Three different measures of the intraabdominal pressure were taken: a direct transperitoneal measure, using a catheter of Jackson-Pratt connected to a pressure transducer, and two indirect measures, a transvesical by means of a Foley to manometer system, and a transgastric by introducing in the stomach a catheter connected to a pressure monitor with electronic hardware. Mean arterial pressure was calculated, along with the cardiac index, production of urine and serum creatinine.ResultsThere was a greater correlation between the transvesical and the transperitoneal intraabdominal pressures (R² = 0,95). Average transgastric intraabdominal pressure was inferior to the transperitoneal indicator in all taken measurements. The average arterial pressure descended in both groups, with earlier significant differences observed at 30 mm Hg (p < 0,020). Urine production was lower at 30 mm Hg compared with the 20 mm Hg group (9,63 ± 1,57 versus 3.26 ml ± 1,73). Serum creatinine increased in both groups being pathological at 30 mm Hg after 1 h 20 min, with existing differences between early pressures (p < 0,027).ConclusionsThis study revealed marked renal affectation with higher severity at 30 mmHg pressures. The transvesical technique showed a greater correlation with the direct measurement technique used, defining this as the method of choice for determination of intraabdominal pressure.     

Kinemyography (KMG) versus Electromyography (EMG) neuromuscular monitoring in pediatric patients receiving cisatracurium during general anesthesia

Aim of the workTo compare KMG versus EMG neuromuscular monitoring in pediatric patients receiving cisatracurium during general anesthesia.MethodsAfter approval of the protocol by Ethics Committee 24 pediatric patients of both sexes aged 2–6 years, with a maximum weight 20 kg, were included in the study. Monitoring equipments (Datex-Ohmeda A/S 5?) were attached to the patient. The electromyogram was attached to one hand, while, KMG was attached to the other hand for simultaneous monitoring. Induction of anesthesia with fentanyl 2 μg/kg and propofol 2 mg/kg followed by endotracheal intubation. Anesthesia was maintained by end-tidal isoflurane 1.2%. Ventilation was kept by 50% oxygen in air and was adjusted to maintain end-tidal CO₂ in the range of 35–40 mm Hg. After a stable baseline period of at least 3 min, the 24 patients were received 0.1 mg/kg cisatracurium twice the 95% effective dose (2 × ED₉₅). The following parameters were collected and compared; (1) lag time (time from start of muscle relaxant administration until the first measurable neuromuscular block (NMB), (2) onset time (time from start of muscle relaxant administration until maximal NMB), (3) assessing the recovery period by; train of four (TOF) 0.25, 0.50, 0.75 and 0.90 (time to reach a TOF ratio of 25%, 50%, 75% and 90%, respectively). No top-up doses of muscle relaxants were given.ResultsThere was no statistical difference between both studied groups as regard the demographic data of the patients, the lag time, the onset time, TOF 0.25, 0.5, 0.75 and 0.9 ratios using either EMG or KMG. In addition, there is excellent degree of agreement between EMG and KMG in measuring TOF ratio during both induction and recovery of muscle relaxants.ConclusionsKMG showed an excellent degree of agreement with EMG for determination of onset and recovery of NMB in children.     

Optimal blood pressure decreases acute kidney injury after gastrointestinal surgery in elderly hypertensive patients: A randomized study: Optimal blood pressure reduces acute kidney injury

Study objectiveTo determine the appropriate mean arterial pressure (MAP) control level for elderly patients with hypertension during the perioperative period.DesignA prospective, randomized study.SettingThree teaching hospitals in China.PatientsSix hundred seventy-eight elderly patients with chronic hypertension undergoing major gastrointestinal surgery.InterventionsPatients were randomly allocated to three groups and the target MAP level was strictly controlled to one of three levels: level I (65–79 mm Hg), level II (80–95 mm Hg), or level III (96–110 mm Hg).MeasurementsThe primary outcome was acute kidney injury (AKI) (50% or 0.3 mg·dL^− 1increase in creatinine level) during the first 7 postoperative days. The secondary outcomes were perioperative adverse complications. Moreover, vasoactive agents were observed during surgery.Main resultsThe overall incidence of postoperative AKI was 10.9% (71/648). AKI occurred significantly less often in patients with level II MAP control (6.3%;13/206) than in patients with level I (13.5%; 31/230) and level III (12.9%; 27/210) (P < 0.001) MAP control. Level II was associated with lower incidences of hospital-acquired pneumonia (6.7%; 14/206; P = 0.014) and admission to the intensive care unit (ICU) (4.4%; 9/206; P = 0.015) and with shorter length of stay in the ICU (P = 0.025) when compared with level I and level III. Use of norepinephrine, phenylephrine, and nitroglycerin was significantly higher for patients with level III MAP control than for patients with level I and level II MAP control (P = 0.001).ConclusionsFor elderly hypertensive patients, controlling intraoperative MAP levels to 80 to 95 mm Hg can reduce postoperative AKI after major abdominal surgery.     

Perioperative haemodynamic changes in patients undergoing laparoscopic adrenalectomy for phaeochromocytomas and other adrenal tumours

BackgroundPerioperative haemodynamic changes are well recognised sequelae of adrenalectomy for phaeochromocytomas. The aim of this study was to compare haemodynamic changes in patients undergoing laparoscopic adrenalectomy (LA) for phaeochromocytomas and other adrenal tumours.MethodPatients were identified from a prospective database (Jan 1999–Feb 2008). All patients were managed by a multi-disciplinary team. Haemodynamic variables were: pulse, blood pressure and the requirement of antihypertensive or vasopressor therapies in the perioperative period.ResultsOver the nine-year period, 34 consecutive patients underwent laparoscopic phaeochromocytoma resection (one patient had delayed contralateral LA) and 104 consecutive patients underwent LA for other tumours (two patients had delayed contralateral LA). 5 out of 35 resections in the phaeochromocytoma group experienced severe hypertension (systolic blood pressure (SBP) >200 mm Hg) compared to two out of 106 resections in the non phaeochromocytoma group (p = 0.010). No patient in either group had a transient or persistent (>10 min) SBP >220 mm Hg. Intraoperative antihypertensive use was significantly increased in the phaeochromocytoma group (p < 0.005). There were no significant differences between groups for persistent hypotension (SBP <80 mm Hg), heart rate >120/min and recovery room haemodynamic parameters.ConclusionLA for phaeochromocytoma can be accomplished with low perioperative haemodynamic complications when compared to LA for other adrenal tumours.     

Impact of pulmonary hypertension on survival in patients with cystic fibrosis undergoing lung transplantation: An analysis of the UNOS registry

BackgroundPulmonary hypertension (PH) is a comorbidity reported in patients with cystic fibrosis (CF) with research limited to single-center studies.MethodsTo assess the impact of PH in patients with CF who received a lung transplant (LTx), the United Network for Organ Sharing was queried from 1987 to 2012, restricting analysis to transplant patients 6–55 years old between 1/1/2005 and 7/6/2011.ResultsOf 23,951 lung transplants, 1177 met inclusion criteria with 831 having mean pulmonary artery pressure (mPAP) data available. For the entire cohort, mean age was 30.3 (SD = 9.2, range 12–55), and mean mPAP was 26.5 (SD = 7.8, range 5–66) mm Hg. A total of 470 (57%) had PH defined as mPAP ≥ 25 mm Hg. Comparing PH to non-PH groups, mean forced expiratory volume in one second (FEV₁) was 24.4 (SD = 13.8) vs. 26 (SD = 13.9) % of predicted, mean supplemental oxygen requirement at rest was 4.5 (SD = 4.1) vs. 3.7 (SD = 3.0) liters per minute, and mean lung allocation score was 49 (SD = 16) vs. 43 (SD = 12), respectively. For the PH group, median survival was 84.4 months compared to 67.1 months for the non-PH group (log-rank p-value = 0.326). The adjusted hazard ratio for PH vs. non-PH was 0.862 (95% CI: 0.653–1.138; p = 0.293), thus indicating no statistically significant effect of PH on survival.ConclusionsA high prevalence of PH was found in CF patients prior to LTx. Based on our models despite PH being prevalent, there is no strong evidence suggesting that it significantly alters the risk of death in CF patients after LTx.     

Role of sugammadex in accelerating postoperative discharge: A meta-analysis

Study objectiveSugammadex has been introduced for reversal of neuromuscular blockade (NMB) induced by rocuronium (or vecuronium). Although its efficacy and safety have been established, data are conflicting as to whether it accelerates discharge to the surgical ward compared with neostigmine, which is traditionally used for reversing NMB. The object of this systematic review and meta-analysis was to review the research comparing sugammadex and neostigmine in the context of patient discharge after general anesthesia.DesignSystematic review and meta-analysis.SettingUniversity medical hospital.PatientsFive-hundred eighteen patients from six studies were included.MethodsA comprehensive search was conducted using PubMed, Web of Science, Google Scholar, and Cochrane Library electronic databases to identify randomized controlled trials written in English. Two reviewers independently selected the studies, extracted data regarding postoperative discharge, and assessed the trials' methodological quality and evidence level. Postoperative discharge time was determined from the operating room (OR) to the postanesthesia care unit (PACU) and from the PACU to the surgical ward. This study was conducted using PRISMA methodology.MeasurementsTime to discharge after NMB reversal with sugammadex or neostigmine.Main resultsCompared with neostigmine, sugammadex was associated with a significantly faster discharge from the OR to the PACU (mean difference [MD] = 22.14 min, 95% CI (14.62, 29.67), P < 0.0001, I² = 0%) and from the PACU to the surgical ward (MD = 16.95 min, 95% CI (0.23, 33.67), P = 0.0469, I² = 98.4%). Similarly, discharge-readiness was shorter for sugammadex than for neostigmine from the OR to the PACU (MD = 5.58 min, 95% CI (3.03, 8.14), P ≤ 0.0001, I² = 0%). However, discharge-readiness was similar in both groups for patients moving from the PACU to the surgical ward (MD = − 1.10 min, 95% CI (− 5.69, 3.50), P = 0.6394, I² = 25.3%).ConclusionsResults from this meta-analysis suggest that sugammadex accelerates postoperative discharge of patients after general anesthesia compared with neostigmine.     

Giant gallstone performed by emergency laparoscopic cholecystectomy

INTRODUCTIONGallstone disease is very common, but the gallstone bigger than 5 cm in diameter is very rare. It is very challenging to be removed by laparoscopic cholecystectomy (LC) and poses extra difficulty in emergency.PRESENTATION OF CASEA 70-year-old man complained of abdominal pain in the right upper quadrant with fever of 38 °C for two days. Abdominal ultrasound indicated acute cholecystitis and a single, extremely large gallstone (95 mm × 60 mm × 45 mm). Emergency laparoscopic cholecystectomy was performed successfully.DISCUSSIONGallstone over 5 cm in diameter is very rare. LC will be very difficult for these cases, especially for the emergency cases. Emergency laparoscopic cholecystectomy can be successfully performed with clear exposure of the anatomy of the Calot's triangle. To the best of our knowledge, such giant gallstone has been rarely reported.CONCLUSIONWe have proven that for the rare giant gallstone about 10 cm in size, LC is a feasible option if the anatomy of the Calot's triangle can be clearly exposed; otherwise, open cholecystectomy is a safe choice.     

Association of genetic polymorphisms of angiopoietin-like 4 with severity of posttransplant proteinuria in kidney allograft recipients

BackgroundProteinuria is a hallmark of glomerular injury, and persistent proteinuria is associated with graft failure in kidney transplant patients. Recently, it is known that the level of circulating angiopoietin-like 4 (ANGPTL4) is elevated in the patients with human nephrotic syndrome, in which ANGPTL4 is responsible for relieving proteinuria.PurposeThe purpose of this study is to determine effects of clinical factors and genetic polymorphism of ANGPTL4 on proteinuria after kidney transplantation.MethodsA total of 282 patients out of 400 renal transplant patients between 2008 and 2012 at St. Vincent Medical Center, CA were studied in a retrospective study design. The level of proteinuria was measured by random urine protein to creatinine ratio, and divided into two groups (Group 1: UPC < 500 mg/day, Group 2: ≥ 500 mg/day). Single nucleotide polymorphisms of ANGPTL4 genes (rs1044250, rs2278236, rs116843064, rs11672433, rs4076317) were determined by real time PCR with sequence specific primers.ResultsAmong various clinical factors, only delayed graft function, mTOR inhibitor use and fish oil use were significantly associated with posttransplant proteinuria. Statistical differences were found in genetic polymorphisms of ANGPTL4 (rs1044250, rs2278236) in regards to proteinuria among tested patients. rs1044250 (C/T, T228M, missense mutation) alleles showed multiple significant differences (Group 1 vs. Group 2: C vs. T: OR = 1.893, CI = 1.322–2.710, p < 0.001). Similar trends were found in rs2278236 (A/G) alleles with statistical significances (Group 1 vs. Group 2: A vs. G: OR = 0.620, CI = 0.443–0.867, p = 0.005). With multiple logistic regression, rs1044250 was still a significant risk factor of moderate/severe proteinuria (p = 0.021).ConclusionsThis study suggests that the presence of C allele of rs1044250 and G allele of rs2278236 in ANGPTL4 gene is associated with higher risk of moderate/severe proteinuria in renal transplant patients.     

Sugammadex efficacy for reversal of rocuronium- and vecuronium-induced neuromuscular blockade: A pooled analysis of 26 studies

Study objectiveTo summarize and compare efficacy of sugammadex with neostigmine or placebo for reversal of rocuronium- or vecuronium-induced neuromuscular blockade (NMB), and to demonstrate consistency of sugammadex results across various patient populations.DesignPooled analysis on data from 26 multicenter, randomized, Phase II and III studies.SettingOperating room.Patients1855 adults undergoing surgery under general anesthesia and receiving rocuronium or vecuronium for NMB.InterventionsSugammadex (2.0 mg/kg at second twitch reappearance [T₂; moderate NMB], 4.0 mg/kg at 1–2 post-tetanic counts [PTC; deep NMB] or 16.0 mg/kg at 3 min after rocuronium 1.2 mg/kg), neostigmine or placebo.MeasurementsTime to recovery of the train-of-four (TOF) ratio to 0.9.Main resultsGeometric mean (95% CI) times to recovery to TOF ratio of 0.9 were 1.9 (1.8–2.0) min following sugammadex 2.0 mg/kg and 10.6 (9.8–11.6) min following neostigmine administration at T₂ after rocuronium, and 2.9 (2.5–3.4) min and 17.4 (13.4–22.6) min, respectively, after vecuronium. Recovery times were 2.2 (2.1–2.3) min following sugammadex 4.0 mg/kg and 19.0 (14.8–24.6) min following neostigmine administered at a target of 1–2 PTC after rocuronium, and 3.8 (3.0–5.0) min and 67.6 (56.3–81.2) min after vecuronium. Sugammadex administered 3 min after rocuronium 1.2 mg/kg resulted in rapid recovery (1.7 [1.5–2.0] min). Modest increases in mean recovery time were associated with vecuronium use (+ 1.6 min [78%; (61%–98%)] versus rocuronium), mild-to-moderate renal impairment (+ 0.4 min [20%; (9%–32%)] versus normal renal function) and geographic location (+ 1.0 min [38%; (25%–52%)] in subjects in USA/Canada versus Europe/Japan).ConclusionsSugammadex administered at recommended doses provides rapid and predictable reversal of rocuronium and vecuronium-induced moderate and deep NMB, and effective reversal 3 min after rocuronium 1.2 mg/kg. Robust recovery was seen across various patient factors, providing further confirmation of labeled dose recommendations.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery

BackgroundDuring spinal anesthesia for cesarean delivery phenylephrine is the vasopressor of choice but can cause bradycardia. Norepinephrine has both β- and α-adrenergic activity suitable for maintaining blood pressure with less bradycardia. We hypothesized that norepinephrine would be superior to phenylephrine, requiring fewer rescue bolus interventions to maintain blood pressure.MethodsEighty-five parturients having spinal anesthesia for elective cesarean delivery were randomized to Group P (phenylephrine 0.1 μg/kg/min) or Group N (norepinephrine 0.05 μg/kg/min) fixed-rate infusions. Rescue bolus interventions of phenylephrine 100 μg for hypotension, or ephedrine 5 mg for bradycardia with hypotension, were given as required to maintain systolic blood pressure. Maternal hemodynamic variables were measured non-invasively.ResultsThere was no difference between groups in the proportion of patients who required rescue vasopressor boluses (Group P: 65.8% [n=25] vs. Group N: 48.8% [n=21], P=0.12). The proportion of patients who received ⩾1 bolus of phenylephrine was similar between groups (Group P: 52.6% [n=20] vs. Group N: 46.5% [n=20], P=0.58). However, more patients received ⩾1 bolus of ephedrine in the phenylephrine group (Group P: 23.7% [n=9] vs. Group N: 2.3% [n=1], P <0.01). The incidence of emesis was greater in the phenylephrine group (Group P: 26.3% vs. Group P: 16.3%, P <0.001). Hemodynamic parameters including heart rate, the incidence of bradycardia, blood pressure, cardiac output, cardiac index, stroke volume, and systemic vascular resistance and neonatal outcome were similar between groups (all P <0.05).ConclusionNorepinephrine fixed-rate infusion has efficacy for preventing hypotension and can be considered as an alternative to phenylephrine.     

Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto

ObjectivesTo analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment.Patients and methodPatients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators.Results166 patients: Group A: 2002 – 3 n=50, B: 2004 – 5 n=53 and C: 2006 – 7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2±4.5 vs. 13±6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029).ConclusionsSeveral indicators have significantly improved in a relatively short period of time due to self-evaluations of the process.     

Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials

Background and objectiveSugammadex has been introduced for reversal of rocuronium (or vecuronium)–induced neuromuscular blockade (NMB). Although its efficacy has been established, data are conflicting whether it is safer than neostigmine traditionally used for reversing NMB.DesignMeta-analysis of data about effectiveness and safety of sugammadex compared to neostigmine for reversing NMB in adults was performed using the PRISMA methodology.SettingUniversity medical hospital.MethodsA comprehensive search was conducted using PubMed, Web of Science, and Cochrane Library electronic databases to identify English-language randomized controlled trials. Two reviewers independently selected the trials; extracted data on reversal times, incomplete reversals of NMB, and adverse events (AEs); and assessed the trials' methodological quality and evidence level. Only AEs that were related to study drug by a blinded safety assessor were considered for meta-analysis.PatientsA total of 1384 patients from 13 articles were included in this meta-analysis.Main resultsCompared to neostigmine, sugammadex was faster in reversing NMB (P < .0001) and more likely to be associated with higher train-of-four ratio values at extubation (mean difference, 0.18; 95% confidence interval [CI], 0.14-0.22; P < .0001) and lower risk of postoperative residual curarization after extubation (odds ratio [OR], 0.05; 95% CI, 0.01-0.43; P = .0068). Compared to neostigmine, sugammadex was associated with a significantly lower likelihood of global AEs (OR, 0.47; 95% CI, 0.34-0.66; P < .0001), respiratory AEs (OR, 0.36; 95% CI, 0.14-0.95; P = .0386), cardiovascular AEs (OR, 0.23; 95% CI, 0.08-0.61; P = .0036), and postoperative weakness (OR, 0.45; 95% CI, 0.21-0.97; P = .0409). Sugammadex and neostigmine were associated with a similar likelihood of postoperative nausea and vomiting (OR, 1.23; 95% CI, 0.70-2.15; P = .4719), pain (OR, 1.06; 95% CI, 0.15-7.36; P = .9559), neurologic AEs (OR, 1.47; 95% CI, 0.52-4.17; P = .4699), general AEs (OR, 0.75; 95% CI, 0.47-1.21; P = .2448), and changes in laboratory tests' values (OR, 0.57; 95% CI, 0.18-1.78; P = .3368).ConclusionsResults from this meta-analysis suggest that sugammadex is superior to neostigmine, as it reverses NMB faster and more reliably, with a lower risk of AEs.     

Early assessment of glucose abnormalities during continuous glucose monitoring associated with lung function impairment in cystic fibrosis patients

BackgroundCystic fibrosis-related diabetes (CFRD) is correlated with a decline in lung function. Under certain circumstances, oral glucose tolerance test (OGTT) screening, used to diagnose CFRD, fails to reveal early glucose tolerance abnormalities. In this situation, continuous glucose monitoring (CGM) could be a useful tool for evaluating early abnormalities of glucose tolerance in CF patients. We aimed to study the CGM glucose profile in CF patients with normal OGTT screening results and to evaluate lung function and nutritional status according to the CGM glucose profile.MethodsWe assessed glycemic control, the CGM glucose profile, nutritional status, lung function antibiotic courses and colonization (P. aeruginosa and S. aureus) in CF patients, aged 10 years and over, with normal screening OGTT results (blood glucose at T120 min < 7.8 mmol/l). Two groups were identified according to the max CGM glucose value: Group 1 < 11 mmol/l and Group 2 ≥ 11 mmol/l.ResultsAmong the 38 patients with normal OGTT, 12 (31.6%) were in Group 2. Compared to Group 1, Group 2 patients exhibited a significant impairment in lung function: FEV₁, 68.2 ± 25.6% vs. 87.3 ± 17%, p = 0.01 and FVC, 86.1% ± 19.4% vs. 99.3% ± 13.4%, p = 0.021, as well as a higher rate of colonization by P. aeruginosa: 83.3% vs. 44%, p = 0.024. Nevertheless, there were no differences in nutritional status (BMI standard deviation score: p = 0.079; prealbumin: p = 0.364).ConclusionsCGM reveals early abnormalities of glucose tolerance that remain undiagnosed by OGTT screening and are associated with worse lung function and a higher prevalence of P. aeruginosa colonization in patients with CF.Clinical trial registration number: NCT00476281.     

Efeito de diferentes doses de esmolol sobre a resposta hemodinâmica,BIS e resposta de movimento durante a intubação orotraqueal: estudo prospectivo,randômico e duplo‐cego

ObjectiveA prospective, randomized and double‐blind study was planned to identify the optimum dose of esmolol infusion to suppress the increase in bispectral index values and the movement and hemodynamic responses to tracheal intubation.Materials and methods120 patients were randomly allocated to one of three groups in a double‐blind fashion. 2.5 mg kg⁻¹ propofol was administered for anesthesia induction. After loss of consciousness, and before administration of 0.6 mg kg⁻¹ rocuronium, a tourniquet was applied to one arm and inflated to 50 mm Hg greater than systolic pressure. The patients were divided into 3 groups; 1 mg kg⁻¹ h⁻¹ esmolol was given as the loading dose and in Group Es50 50 μg kg⁻¹ min⁻¹, in Group Es150 150 μg kg⁻¹ min⁻¹, and in Group Es250 250 μg kg⁻¹ min⁻¹ esmolol infusion was started. Five minutes after the esmolol has been begun, the trachea was intubated; gross movement within the first minute after orotracheal intubation was recorded.ResultsIncidence of movement response and the ΔBIS max values were comparable in Group Es250 and Group Es150, but these values were significantly higher in Group Es50 than in the other two groups. In all three groups in the 1 st minute after tracheal intubation heart rate and mean arterial pressure were significantly higher compared to values from before intubation (p < 0.05). In the study period there was no significant difference between the groups in terms of heart rate and mean arterial pressure.ConclusionIn clinical practise we believe that after 1 mg kg⁻¹ loading dose, 150 μg kg⁻¹ min⁻¹ iv esmolol dose is sufficient to suppress responses to tracheal intubation without increasing side effects.     

Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery

BackgroundDexamethasone has anti-inflammatory properties that can affect postoperative analgesia when added to caudal bupivacaine.MethodsSeventy-two geriatric patients scheduled for elective total hip replacement under ultrasound guided caudal anesthesia were randomized blindly into two groups: Group BD received caudal isobaric bupivacaine 0.25% (20 ml) and dexamethasone 8 mg (2 ml) and Group BS received caudal isobaric bupivacaine 0.25% (20 ml) and normal saline (2 ml). Postoperative analgesia was assessed by recording time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively as a primary outcome. Secondary outcomes were the time taken to the onset of sensory analgesia at T10, time to the onset of complete motor block, VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12 and 24 h, and postoperative adverse events.ResultsGroup BD had a significantly longer time to first rescue analgesia [402 (63) vs 213 (53)] min and significantly lower doses of paracetamol [3389 (728) vs 2833 (697)] mg meperidine hydrochloride [78 (30) vs 142 (28)] mg than Group BS. VAS scores were significantly lower in Group BD than Group BS both at rest and on movement respectively at 4, 6, 8, 12 and 24 h.ConclusionAdding dexamethasone with isobaric bupivacaine caudal anesthesia prolongs the duration of postoperative analgesia and decreased postoperative analgesic requirement in geriatric patients undergoing total hip replacement surgery in comparison isobaric bupivacaine alone.     

Morphological imaging and CT histogram analysis to differentiate pancreatic neuroendocrine tumor grade 3 from neuroendocrine carcinoma

PurposeTo compare morphological imaging features and CT texture histogram parameters between grade 3 pancreatic neuroendocrine tumors (G3-NET) and neuroendocrine carcinomas (NEC).Materials and methodsPatients with pathologically proven G3-NET and NEC, according to the 2017 World Health Organization classification who had CT and MRI examinations between 2006-2017 were retrospectively included. CT and MRI examinations were reviewed by two radiologists in consensus and analyzed with respect to tumor size, enhancement patterns, hemorrhagic content, liver metastases and lymphadenopathies. Texture histogram analysis of tumors was performed on arterial and portal phase CT images. images. Morphological imaging features and CT texture histogram parameters of G3-NETs and NECs were compared.ResultsThirty-seven patients (21 men, 16 women; mean age, 56 ± 13 [SD] years [range: 28-82 years]) with 37 tumors (mean diameter, 60 ± 46 [SD] mm) were included (CT available for all, MRI for 16/37, 43%). Twenty-three patients (23/37; 62%) had NEC and 14 patients (14/37; 38%) had G3-NET. NECs were larger than G3-NETs (mean, 70 ± 51 [SD] mm [range: 18 - 196 mm] vs. 42 ± 24 [SD] mm [range: 8 - 94 mm], respectively; P = 0.039), with more tumor necrosis (75% vs. 33%, respectively; P = 0.030) and lower attenuation on precontrast (30 ± 4 [SD] HU [range: 25-39 HU] vs. 37 ± 6 [SD] [range: 25-45 HU], respectively; P = 0.002) and on portal venous phase CT images (75 ± 18 [SD] HU [range: 43 - 108 HU] vs. 92 ± 19 [SD] HU [range: 46 - 117 HU], respectively; P = 0.014). Hemorrhagic content on MRI was only observed in NEC (P = 0.007). The mean ADC value was lower in NEC ([1.1 ± 0.1 (SD)] × 10⁻³ mm²/s [range: (0.91 - 1.3) × 10⁻³ mm²/s] vs. [1.4 ± 0.2 (SD)] × 10⁻³ mm²/s [range: (1.1 - 1.6) × 10⁻³ mm²/s]; P = 0.005). CT histogram analysis showed that NEC were more heterogeneous on portal venous phase images (Entropy-0: 4.7 ± 0.2 [SD] [range: 4.2-5.1] vs. 4.5 ± 0.4 [SD] [range: 3.7-4.9]; P = 0.023).ConclusionPancreatic NECs are larger, more frequently hypoattenuating and more heterogeneous with hemorrhagic content than G3-NET on CT and MRI.     

Evaluation of neurosurgical training of French military surgeons prior to their deployment

BackgroundA specific training course was formalized in 2007 in order to facilitate the management of cranio-encephalic injuries by French military general surgeons during deployment, within the Advanced Course for Deployment Surgery (ACDS). The objective is to evaluate the neurosurgical pre-deployment training course attended by the military surgeons.MethodsFrom June 2019 to September 2019, we conducted a cross-sectional survey in the form of a digital self-completed questionnaire, addressed to all graduated military surgeons working in the French Military Training Hospitals. The survey included: (1) a knowledge assessment; and (2) a self-assessment of the training course. The participating surgeons were classified into two groups according to their participation (group 1) or not (group 2) in the neurosurgical module. The main outcome was the score received on the knowledge assessment.ResultsAmong the 145 military surgeons currently in service, 76 participated in our study (53%), of which 49 were classified in group 1 (64%) and 27 in group 2 (36%). Group 1 surgeons had a significantly higher score than Group 2 at the knowledge assessment (mean 21.0 ± 7.1 vs. 17.8 ± 6.0, P = 0.041). The most successful questions were related to TBI diagnosis and surgical technique, while the least successful questions dealt with “beyond emergency care” and surgical indications.ConclusionThe French pre-deployment neurosurgical training course provides a strong neurosurgical background, sufficient to perform life-saving procedures in a modern conflict situation. However, neurosurgical specialized advice should be solicited whenever possible to assist the in-theatre surgeon in surgical decisions.