The ability of bispectral index to detect intra‐operative wakefulness during total intravenous anaesthesia compared with the isolated forearm technique

It has been suggested that monitoring during total intravenous anaesthesia should include aspects of brain function. The current study used a manually adjusted target‐controlled infusion of propofol for anaesthesia, guided to a bispectral index range of 55–60. Intra‐operative responsiveness, as assessed by the isolated forearm technique, was compared with whether the bispectral index predicted/identified a patient's appropriate hand movements in responses to commands. Twenty‐two women underwent major gynaecological surgery with total intravenous anaesthesia, propofol, remifentanil and atracurium. Sixteen women responded, on 80 occasions, with appropriate hand movements to commands during surgery, of which the bispectral index detected 47 (sensitivity 59%). The bispectral index suggested consciousness 220 times in the absence of movement responses (specificity 85%). The positive predictive value of a bispectral index response was 18%. While two women had vague recall about squeezing fingers, none had recall of surgery. For patients who responded more than once during surgery the bispectral index value associated with a response was not constant. Although there was no difference in the median (IQR [range]) effect site propofol concentration between intra‐operative responses (2.0 (1.5–2.3 [1.2–4.0]) μg.ml^?1) and eye opening after surgery (2.1 (1.7–2.8 [1.5–3.9]) μg.ml^?1), the median (IQR [range]) bispectral index value at eye opening after surgery was significantly higher than that associated with responses during surgery: 75 (70–78 [51–93]) vs 61 (52–67 [37–80]) respectively, (p < 0.001). The manual control of propofol intravenous anaesthesia to target a bispectral index range of 55–60 may result in an unacceptable number of patients who are conscious during surgery (albeit without recall).     

Impact of right‐handedness on anaesthetic sensitivity,intra‐operative awareness and postoperative mortality

Anatomical, neurological and behavioural research has suggested differences between the brains of right‐ and non‐right‐handed individuals, including differences in brain structure, electroencephalogram patterns, explicit memory and sleep architecture. Some studies have also found decreased longevity in left‐handed individuals. We therefore aimed to determine whether handedness independently affects the relationship between volatile anaesthetic concentration and the bispectral index, the incidence of definite or possible intra‐operative awareness with explicit recall, or postoperative mortality. We studied 5585 patients in this secondary analysis of data collected in a multicentre clinical trial. There were 4992 (89.4%) right‐handed and 593 (10.6%) non‐right‐handed patients. Handedness was not associated with (a) an alteration in anaesthetic sensitivity in terms of the relationship between the bispectral index and volatile anaesthetic concentration (estimated effect on the regression relationship ?0.52 parallel shift; 95% CI ?1.27 to 0.23, p = 0.17); (b) the incidence of intra‐operative awareness with 26/4992 (0.52%) right‐handed vs 1/593 (0.17%) non‐right‐handed (difference = 0.35%; 95% CI ?0.45 to 0.63%; p = 0.35); or (c) postoperative mortality rates (90‐day relative risk for non‐right‐handedness 1.19, 95% CI 0.76–1.86; p = 0.45). Thus, no change in anaesthetic management is indicated for non‐right‐handed patients.     

Effect of penehyclidine hydrochloride on the incidence of intra‐operative awareness in Chinese patients undergoing breast cancer surgery during general anaesthesia

Intra‐operative awareness can lead to serious adverse psychological consequences. We conducted a prospective, randomised, double‐blinded trial in 920 patients undergoing breast cancer surgery under bispectral index‐guided total intravenous anaesthesia to evaluate the effect of penehyclidine hydrochloride on intra‐operative awareness. Patients were randomly divided to receive 0.01 mg.kg^?1 penehyclidine hydrochloride or saline intravenously 30 min before surgery. The pre‐administration, pre‐operative anxiety levels were assessed using a 100‐mm visual analogue scale. Intra‐operative awareness was defined as recall of intra‐operative events using a modified Brice interview administered 2–6 h postoperatively, and in the next 24–48 h. A committee of three experts, blinded to the study conditions, independently scrutinised all reported recollections. We found no differences in depth of anaesthesia and patients' pre‐operative anxiety levels between the two groups. The incidence of awareness with penehyclidine hydrochloride (0/456 patients; 0%) was significantly lower than with saline (5/452; 1.1%), p = 0.030. We conclude that penehyclidine hydrochloride reduced the incidence of intra‐operative awareness in patients undergoing breast cancer surgery during general anaesthesia.     

The effect of intra‐operative passive movement therapy on non‐surgical site pain after breast reconstructive surgery: a preliminary study

Pain distant to an operative site is under‐reported but sometimes more severe than pain from the surgical site. Intra‐operative passive movement could possibly reduce this pain. This preliminary study was designed to assess the practicalities of conducting a randomised controlled trial of this therapy in anaesthetised patients. The study design was pragmatic. Forty‐two patients undergoing breast reconstruction were randomly assigned to receive either intra‐operative passive movement or standard care. Twenty‐four hours after surgery, median (IQR [range]) morphine consumption was 33 (11–42 [0–176]) mg in the passive movement group compared with 74 (15–118 [0–238]) mg with standard care (p = 0.126), while participants reported median (IQR [range]) visual analogue scores in areas distant from the surgical site of 0 (0–4 [0–34]) mm in the passive movement group compared with 10 (2–30 [0–57]) mm in those receiving standard care (p = 0.002). A full trial of intra‐operative passive movement therapy to reduce postoperative is feasible and warranted.     

A randomised prospective trial of intra‐operative oesophageal Doppler‐guided fluid administration in major gynaecological surgery

Intra‐operative oesophageal Doppler monitor‐guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra‐operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra‐operative fluid management using an oesophageal Doppler‐guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra‐operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5–8 [4–25]) days in the oesophageal Doppler monitor group compared with 7 (5–9 [4–42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra‐operative oesophageal Doppler‐guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.     

A comparison of airway dimensions,measured by acoustic reflectometry and ultrasound before and after general anaesthesia

Changes in airway dimensions can occur during general anaesthesia and surgery for a variety of reasons. This study explored factors associated with postoperative changes in airway dimensions. Patient airway volume was measured by acoustic reflectometory and neck muscle diameter by ultrasound echography in the pre‐ and post‐anaesthetic periods in a total of 281 patients. Neck circumference was also assessed during these periods. A significant decrease in median (IQR [range]) total airway volume (from 63.8 (51.8–75.7 [14.7–103]) ml to 45.9 (33.5–57.2 [6.4–96.3]) ml, p < 0.0001), and a significant increase in muscle diameter (from 4.3 (3.3–5.6 [2.2–9.0]) mm to 5.8 (4.7–7.3 [2.8–1.3]) mm, p < 0.0001) and neck circumference (from 34.0 (32.5–37.0 [29.5–49.0]) cm to 35.0 (33.5–38.0 [30.5–50.5]) cm, p < 0.0001) were observed. It may be possible that changes in airway volume and neck circumference were influenced by surgical duration or peri‐operative fluid management (ρ) = ?0.31 (95% CI ?0.24 to ?0.01), p = 0.0301, ?0.17 (?0.23 to ?0.06), p = 0.0038, 0.23 (0.12–0.34), p < 0.0001, and 0.16 (0.05–0.27), p = 0.0062, respectively). The intra‐oral space can significantly decrease and neck thickness increase after general anaesthesia, and might increase the risk of difficult laryngoscopy and intubation if airway management is required after extubation following general anaesthesia.     

Postoperative morphine concentration in infants with or without biliary atresia and its association with hepatic blood flow

We measured pre‐operative hepatic blood flow and postoperative morphine concentration in infants with or without biliary atresia. Thirty‐four infants (0–3 months) with biliary atresia undergoing portoenterostomy (Kasai operation) were included and hepatic blood flow was assessed by magnetic resonance imaging before surgery in 12 of them. Sixteen subjects (0–3 months) without liver disease undergoing abdominal or pelvic surgery acted as controls and six of them had hepatic blood flow assessed. Intravenous morphine (8 μg.kg^?1.h^?1) was administered to all patients postoperatively. The median (IQR [range]) relative hepatic blood flow was 3.51 (2.72–3.88 [1.68–4.43]) with and 3.15 (2.66–4.42 [2.30–5.01]) without biliary atresia (p = 0.851). The median (IQR [range]) morphine concentration after 24 h infusion was 5.9 (4.5–16.4 [2.9–42.2]) ng.ml^?1 and 6.4 (3.2–12.0 [1.9–48.6]) ng.ml^?1, respectively (p = 0.460). An inverse regression relation was found between the morphine concentration and the hepatic perfusion index (R² = 0.519, p = 0.001). Compensatory increases in hepatic arterial blood flow maintain the total hepatic blood flow in infants with biliary atresia.     

The combined effects of midazolam and propofol sedation on muscle power

We performed a randomised, crossover study to investigate the effects of intravenous sedation on grip strength and bite force. Twenty male volunteers received a bolus intravenous injection of midazolam (0.02 mg.kg^?1) together with a 30‐min propofol infusion designed to achieve an effect‐site concentration of 1.0 μg.ml^?1. Observed variables included bispectral index, observer's assessment of alertness/sedation, correct answer rate of Stroop colour‐word test, grip strength and bite force. Grip strength decreased from a median (IQR [range]) of 483 (443–517 [380–586]) N to 358 (280–405 [108–580]) N (p < 0.001) during sedation and recovered following flumazenil administration, while bite force increased from 818 (593–1026 [405–1406]) N to 1377 (1243–1585 [836–2357]) N (p < 0.001) during sedation. Although bite force gradually returned to baseline following flumazenil administration, it remained increased throughout the experimental period. We conclude that bite force increased during intravenous sedation and that this may have clinical implications.     

A randomised controlled trial comparing two popliteal nerve catheter tip positions for postoperative analgesia after day‐case hallux valgus repair

We compared the effect of two different positions of a sciatic nerve catheter within the popliteal fossa on local anaesthetic consumption and postoperative analgesia in patients undergoing day‐case hallux valgus repair. Eighty‐four patients were randomly allocated to receive a sciatic nerve catheter either between the tibial and peroneal components (sciatic group) or medial to the tibial nerve (tibial group). The primary endpoint was postoperative local anaesthetic consumption, while secondary endpoints were pain scores, number of occasions where sleep was disturbed by pain and incidence of insensate limb and foot drop at 24 h and 48 h postoperatively. Postoperative median (IQR [range]) local anaesthetic consumption was 126 (106–146 [98–180]) ml in the sciatic group versus 125 (114–158 [98–200]) ml in the tibial group (p = 0.103). Insensate limb occurred in 14 patients in the sciatic group versus one patient in the tibial group (p < 0.001), while foot drop was reported by six patients in the sciatic group and none in the tibial group (p = 0.012). Sciatic nerve catheter placement medial to the tibial nerve may be a superior analgesic technique for day‐case foot surgery.     

Analgesic efficacy of pre‐operative stellate ganglion block on postoperative pain relief: a randomised controlled trial

We undertook a randomised, double‐blind, placebo‐controlled study to compare the analgesic efficacy of pre‐operative stellate ganglion block on postoperative pain relief after upper limb orthopaedic surgery. Patients were administered a 3‐ml injection during ultrasound‐guided stellate ganglion block; 15 patients received lidocaine 2% and 15 patients received 0.9% saline. Following the block, all patients received standardised general anaesthesia. Postoperative analgesia included regular intravenous diclofenac, paracetamol and patient‐controlled analgesia with tramadol for 24 h. Patients were observed at 0, 2, 4, 6, 8, 12 and 24 h after surgery for tramadol consumption, cardiovascular variables and visual analogue scale pain scores at rest and on movement. The mean (SD) hourly tramadol consumption was significantly reduced in the lidocaine group compared with the saline group at 4 h (8.0 (10.1) mg vs 28.0 (12.6) mg, respectively; p = 0.001), 6 h (5.3 (10.8) mg vs 17.3 (12.7) mg, respectively; p = 0.013) and 8 h (5.3 (11.8) mg vs 21.3 (9.1) mg, respectively; p = 0.001). The cumulative 24‐h tramadol consumption was 97.3 (16.6) mg in the lidocaine group and 150.6 (26.0) mg in the saline group (p = 0.001). There were significant differences in the pain visual analogue scale at rest at two time points; at 4 h the median (IQR [range]) visual analogue scale scores were 4 (4–6 [2–8]) in the lidocaine group and 5 (4–6 [2–7]) in the saline group (p = 0.03), and at 6 h visual analogue scale scores were 3 (3–4 [3–6]) and 4 (4–6 [2–7]), respectively (p = 0.04). Pain visual analogue scale on movement was lower in the lidocaine group at all time intervals compared with the saline group, but this did not reach statistical significance. The present study has demonstrated a postoperative tramadol‐sparing and analgesic effect of pre‐operative stellate ganglion block in patients undergoing upper limb orthopaedic surgery under general anaesthesia.     

HIV,vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri‐operative cardiac morbidity are poorly described in HIV‐positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV‐positive. When compared with HIV‐negative patients, the HIV‐positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0–5 [0–2]) vs 0 (0–2 [0–0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV‐positive and ‐negative patients had similar outcomes in: 30‐day mortality (p = 0.78); three‐day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV‐positive patients have fewer cardiovascular risk factors, they have similar peri‐operative major adverse cardiac events to HIV‐negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.     

Fibrinogen concentrate vs. fresh frozen plasma for the management of coagulopathy during thoraco-abdominal aortic aneurysm surgery: a pilot randomised controlled trial

Major vascular surgery is frequently associated with significant blood loss and coagulopathy. Existing evidence suggests hypofibrinogenaemia develops earlier than other haemostatic deficiencies during major blood loss. The purpose of this study was to assess whether the use of an infusion of fibrinogen concentrate to prevent and treat hypofibrinogenaemia during surgery resulted in satisfactory haemostasis, removing or reducing the need for blood component transfusion. Twenty patients undergoing elective extent-4 thoraco-abdominal aortic aneurysm repair were randomly allocated to receive either fresh frozen plasma or fibrinogen concentrate to treat hypofibrinogenaemia during surgery. Coagulation was assessed during and after surgery by point-of-care and laboratory testing, respectively, and treatment was guided by pre-defined transfusion triggers. Despite blood losses of up to 11,800 ml in the patients who received the fibrinogen concentrate, none required fresh frozen plasma during surgery, and only two required platelet transfusions. The median (IQR [range]) allogeneic blood component administration during surgery and in the first 24 h postoperatively was 22.5 (14–28 [2–41]) units in patients allocated to fresh frozen plasma vs. 4.5 (3–11[0–17]) in patients allocated to fibrinogen concentrate (p = 0.011). All patients in both groups were assessed by the surgeon to have satisfactory haemostasis at the end of surgery. Mean (SD) postoperative fibrinogen concentrations were similar in patients allocated to fresh frozen plasma and fibrinogen concentrate (1.6 (0.3) g.l⁻¹ vs. 1.6 (0.2) g.l⁻¹; p = 0.36) but the mean (SD) international normalised ratio and activated partial thromboplastin time ratio were lower in patients allocated to fresh frozen plasma (1.1 (0.1) vs. 1.8 (0.3); p < 0.0001 and 1.1 (0.2) vs. 1.7 (0.5); p = 0.032, respectively). Fibrinogen concentrate may be used as an alternative to fresh frozen plasma in the treatment of coagulopathy during thoraco-abdominal aortic aneurysm repair.     

Changes in cardiac index and blood pressure on positioning children prone for scoliosis surgery

In this prospective observational study we investigated the changes in cardiac index and mean arterial pressure in children when positioned prone for scoliosis correction surgery. Thirty children (ASA 1–2, aged 13–18 years) undergoing primary, idiopathic scoliosis repair were recruited. The cardiac index and mean arterial blood pressure (median (IQR [range])) were 2.7 (2.3–3.1 [1.4–3.7]) l.min^?1.m^?2 and 73 (66–80 [54–91]) mmHg, respectively, at baseline; 2.9 (2.5–3.2 [1.7–4.4]) l.min^?1.m^?2 and 73 (63–81 [51–96]) mmHg following a 5‐ml.kg^?1 fluid bolus; and 2.5 (2.2–2.7 [1.4–4.8]) l.min^?1.m^?2 and 69 (62–73 [46–85]) mmHg immediately after turning prone. Turning prone resulted in a median reduction in cardiac index of 0.5 l.min^?1.m^?2 (95% CI 0.3–0.7 l.min^?1.m^?2, p = 0.001), or 18.5%, with a large degree of inter‐subject variability (+ 10.3% to ? 40.9%). The changes in mean arterial blood pressure were not significant. Strategies to predict, prevent and treat decreases in cardiac index need to be developed.     

A randomised controlled trial comparing the GlideScope® and the Macintosh laryngoscope for double‐lumen endobronchial intubation

Double‐lumen endobronchial tubes are the most common method of achieving lung isolation and one‐lung ventilation during thoracic anaesthesia and surgery. We compared the clinical performance of the Macintosh laryngoscope and the GlideScope^® during endobronchial intubation with a double‐lumen tube. Seventy patients with no predictors for difficult laryngoscopy were allocated randomly to the Macintosh laryngoscope or GlideScope. The time taken for endobronchial intubation with the Macintosh laryngoscope was significantly shorter compared with that taken for the GlideScope, median (IQR [range]) 33 (22–52 [11–438]) s vs 70 (39–129 [21–242]) s, respectively, p = 0.0013. There was no statistical difference in the rate of success at the first attempt (91% vs 83%, respectively). On a numerical rating scale (scored from 0 to 10), the 30 anaesthetists who took part in the study rated endobronchial intubation overall as easier using the Macintosh compared with the GlideScope, 2 (1–3 [0–8]) vs 3 (2–6 [0–10]), respectively, p = 0.003. Postoperative voice changes were also less common in the Macintosh group (8 (22%) vs 17 (58%), p = 0.045). Anaesthetists found the GlideScope more difficult to use than the Macintosh laryngoscope and endobronchial intubation took longer; therefore, we cannot recommend its routine use with double‐lumen tubes in patients who are predicted to have a normal airway.     

ORIGINAL ARTICLE: Analgesic efficacy of intracapsular and intra‐articular local anaesthesia for knee arthroplasty

The optimal site for wound delivery of local anaesthetic after total knee arthroplasty is undetermined. Sixty patients having total knee arthroplasty received intra‐operative infiltration analgesia with ropivacaine 0.2% and were then were randomly assigned to receive either intracapsular or intra‐articular catheters with 20 ml ropivacaine 0.5% given at 6 h and again at 24 h, postoperatively. Analgesic efficacy was assessed for 3 h after each injection, using a visual analogue score, where 0 = no pain and 100 = worst pain. There was no statistically significant difference between groups. Maximum pain relief (median (IQR [range])) at rest observed in the 3 h after the 6 and 24 h postoperative injections was 17 (7–31 [0–80]) and 10 (4–27 [0–50]) p = 0.27 for 6–9 h; and 17 (7–33 [0–100]) and 13 (3–25 [0–72]) p = 0.28 for 24–27 h, for intracapsular and intra‐articular, respectively. Intracapsular local anaesthetic has similar analgesic efficacy to intra‐articular after total knee arthroplasty.     

Comparison of the Baska® mask with the single‐use laryngeal mask airway in low‐risk female patients undergoing ambulatory surgery

We compared the Baska^® mask with the single‐use classic laryngeal mask airway (cLMA) in 150 females at low risk for difficult tracheal intubation in a randomised, controlled clinical trial. We found that median (IQR [range]) seal pressure was significantly higher with the Baska mask compared with the cLMA (40 (34–40 [16–40]) vs 22 (18–25 [14–40]) cmH₂O, respectively, p < 0.001), indicating a better seal. In contrast, the first time success rate for insertion of the Baska mask was lower than that seen with the cLMA (52/71 (73%) vs 77/99 (98%), respectively, p < 0.001). There were no differences in overall device insertion success rates (78/79 (99%) vs 68/71 (96%), respectively, p = 0.54). The Baska mask proved more difficult to insert, requiring more insertion attempts, taking longer to insert and had higher median (IQR [range]) insertion difficulty scores (1.6 (0.8–2.2 [0.1–5.6]) vs 0.5 (0.3–1.4 [0.1–4.0]), respectively, p < 0.001). There was also an increased rate of minor blood staining of the Baska mask after removal, but there were no differences in other complication rates, such as laryngospasm, or in the severity of throat discomfort. In conclusion, in clinical situations where the seal with the glottic aperture takes priority over ease of insertion, the Baska mask may provide a useful alternative to the cLMA.     

Effects of ropivacaine concentration on the spread of sensory block produced by continuous thoracic paravertebral block: a prospective,randomised, controlled,double‐blind study

Factors affecting the distribution of continuous thoracic paravertebral block have never been examined. We designed this prospective, double‐blind study to check whether continuous thoracic paravertebral block with a higher ropivacaine concentration would provide a wider segmental sensory block spread. Sixty consecutive patients undergoing pulmonary lobectomy or segmentectomy were randomly allocated to receive continuous paravertebral infusion of either 0.2% or 0.5% ropivacaine (6 ml.h^?1). The primary outcome was the number of anaesthetised dermatomes as determined by loss of cold sensation 24 h after surgery. Twenty‐seven patients per group were included in the final analysis. The median (IQR [range]) number of anaesthetised dermatomes 24 h after surgery was 4 (3–6 [1–9]) with ropivacaine 0.2% and 4 (3–6 [2–11]) with ropivacaine 0.5% (p = 0.66). Contrary to our expectation, the segmental spread of sensory block produced by continuous thoracic paravertebral block does not depend on ropivacaine concentration.     

The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg⁻¹ morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy.     

A comparison of intra-operative blood loss and acid-base balance between vasopressor and inotrope strategy during living donor liver transplantation: a randomised, controlled study

Administration of vasopressors or inotropes during liver transplant surgery is almost universal, as this procedure is often accompanied by massive haemorrhage, acid–base imbalance, and cardiovascular instability. However, the actual agents that should be used and the choice between a vasopressor and an inotrope strategy are not clear from existing published evidence. In this prospective, randomised, controlled and single‐blinded study, we compared the effects of a vasopressor strategy on intra‐operative blood loss and acid–base status with those of an inotrope strategy during living donor liver transplantation. Seventy‐six adult liver recipients with decompensated cirrhosis were randomly assigned to receive a continuous infusion of either phenylephrine at a dose of 0.3–0.4 μg.kg^?1.min^?1 or dopamine and/or dobutamine at 2–8 μg.kg^?1.min^?1 during surgery. Vascular resistance was higher over time in the phenylephrine group than in the dopamine/dobutamine group. Estimated blood loss was significantly lower in the phenylephrine group than in the dopamine/dobutamine group (mean (SD) 4.5 (1.8) l vs 6.1 (3.4) l, respectively, p = 0.011). Patients in the phenylephrine group had lower lactate levels in the late pre‐anhepatic and the early anhepatic phase and needed less bicarbonate administration than those in the dopamine/dobutamine group (median (IQR [range]) 40 (0–100 [0–160]) mEq vs 70 (40–163 [0–260]) mEq, respectively, p = 0.018). Postoperative clinical outcomes and laboratory‐measured hepatic and renal function did not differ between the groups. Increased vascular resistance and reduction of portal blood flow by intra‐operative phenylephrine infusion is assumed to decrease the amount of intra‐operative bleeding and thereby ameliorate the progression of lactic acidosis during liver transplant surgery.     

Reversal of neuromuscular blockade with sugammadex during continuous administration of anaesthetic agents: a double-blind randomised crossover study using the bispectral index

Sugammadex, a specific reversal agent for steroidal neuromuscular blocking drugs, has on occasion been reported to be associated with clinical signs of awakening. We performed a study to systematically search for an increase in bispectral index values and signs of awakening in patients maintained under general anaesthesia following sugammadex administration. Patients, scheduled to receive general anaesthesia with neuromuscular blockade, were included in this double-blind randomised crossover study. After surgery was completed, and while the train-of-four ratio was zero, intravenous anaesthesia was continued with the aim of maintaining the bispectral index in the range of 40–60. Patients then received either sugammadex 4 mg.kg⁻¹ or saline. In cases of incomplete reversal of neuromuscular blockade after 5 min, patients received the other drug. Bispectral index and train-of-four monitoring were recorded every minute and clinical signs of awakening noted. Fifty-one patients completed the study. Median (IQR [range]) bispectral index values increased after sugammadex administration from 49 (43–53 [38–64]) to 63 (53–80 [45–97]) (p < 0.01) with an increase of ≥ 20 in 22 patients; 14 (27%) patients had clinical signs of awakening. Saline had no effect on bispectral index values, clinical signs of awakening or degree of neuromuscular blockade. This study confirms that reversal of neuromuscular blockade with sugammadex may be associated with clinical signs of awakening despite maintenance of anaesthesia. Intravenous anaesthesia should be maintained until complete recovery of muscle function is achieved, especially when sugammadex is administered.