Intraoperative Neurophysiological Monitoring

The USCOM (Ultrasonic Cardiac Output Monitors) device is a noninvasive cardiac output monitor, which utilises transaortic or transpulmonary Doppler flow tracing and valve area estimated using patient height to determine cardiac output. We evaluated USCOM against thermodilution cardiac outputs and transoesophageal echocardiography valve area measurements in 22 ASA PS4 cardiac surgical patients. Data collection commenced following pulmonary artery catheter insertion, with cardiac output measurements repeated after sternotomy closure. Failure to obtain transaortic Doppler readings using USCOM occurred in 5% of planned measurements. USCOM transaortic analysis was not planned for 11 patients with known aortic disease. Bias at the aortic window (n = 20) was -0.79 l/min with limits of agreement from -3.66 to 2.08 l/min. At the pulmonary window, failure to obtain Doppler readings occurred in 24% of planned measurements. Bias at the pulmonary window (n=36) was -0.17 l/min with limits of agre...

Obesity is associated with important physiologic changes that can potentially affect the pharmacokinetic (PK) and pharmacodynamic (PD) profile of anesthetic drugs. We designed this study to assess the predictive performance of 5 currently available propofol PK models in morbidly obese patients and to characterize the Bispectral Index (BIS) response in this population. Twenty obese patients (body mass index >35 kg/m), aged 20 to 60 years, scheduled for laparoscopic bariatric surgery, were studied. Anesthesia was administered using propofol by target-controlled infusion and remifentanil by manually controlled infusion. BIS data and propofol infusion schemes were recorded. Arterial blood samples to measure propofol were collected during induction, maintenance, and the first 2 postoperative hours. Median performance errors (MDPEs) and median absolute performance errors (MDAPEs) were calculated to measure model performance. A PKPD model was developed using NONMEM to characterize the p...

To analyze the frequency of extralaryngeal branching (ELB) of the recurrent laryngeal nerve (RLN) in a consecutive series of patients undergoing thyroidectomy by the same group of surgeons during an extended period and to compare our findings with the data available in the literature.

Preoperative and intraoperative lymph node (LN) staging is of paramount importance for patients with non-small cell lung cancer. The Council of the European Society of Thoracic Surgery took the initiative to organize workshops on intraoperative and preoperative mediastinal LN staging. This resulted in specific guidelines. Relevant peer-reviewed publications on these subjects, the experience of the participants, and the opinion of the European Society of Thoracic Surgery members contributing online were used to reach a consensus. For primary staging, mediastinoscopy remains the gold standard for the superior mediastinal LNs. Invasive procedures can be omitted in patients with peripheral tumors and negative mediastinal and hilar nodes on positron emission tomography scan. Positron emission tomography-positive mediastinal findings should always be cytohistologically confirmed. New minimally invasive techniques that provide cytohistological diagnosis became available. Their specificity is high, but the negative predictive value is low. If they yield negative results, an invasive surgical technique remains indicated. For restaging, invasive techniques providing cytohistological information are advisable. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobespecific systematic nodal dissection is acceptable for peripheral squamous T1 tumors if hilar and interlobar nodes are negative on frozen section studies. The report from the pathologist should describe the number of LNs removed and studied, the overall number of metastatic LNs in each station, and the status of the LN capsule. We hope that the adherence to these guidelines will standardize and improve preoperative and intraoperative LN staging and pathologic evaluation of non-small cell lung cancer.

Spinal cord arteriovenous malformations (AVMs) can lead to varying degrees of neurological impairment and overall morbidity. The incidence of spinal AVMs is exceedingly rare, with purely extradural spinal AVMs being exceptionally uncommon. A 19-year-old male presented with quadriparesis and respiratory difficulty in our emergency department with no history of any previous trauma. He was diagnosed with a cervical intraspinal but extradural AVM (long segment). Digital subtraction angiography revealed multiple feeders and drainage patterns. Gross total excision of the entire AVM was achieved in a single surgical session. Postoperatively, improvements in respiratory function and sensory profiles of all four limbs were observed. With meticulous preoperative planning, staged anesthesia management, and adequate blood product preparation, complete excision can often be accomplished in one sitting, potentially avoiding the need for embolization.

The ultimate goal of epilepsy therapies is to provide seizure control for all patients while eliminating side effects. Improved specificity of intervention through on-demand approaches may overcome many of the limitations of current intervention strategies. This article reviews the progress in seizure prediction and detection, potential new therapies to provide improved specificity, and devices to achieve these ends. Specifically, we discuss (1) potential signal modalities and algorithms for seizure detection and prediction, (2) closed-loop intervention approaches, and (3) hardware for implementing these algorithms and interventions. Seizure prediction and therapies maximize efficacy, whereas minimizing side effects through improved specificity may represent the future of epilepsy treatments.

Background. Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements. Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay. We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery. Methods. This single centre, blinded, prospective controlled trial randomized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based (conventional) intraoperative fluid management. The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aiming for a CVP between 12 and 15 mm Hg. Results. The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P<0.05. The median time to resuming full diet in the Doppler guided fluid group was 6 vs 7 for controls P<0.001. Doppler patients achieved significantly higher cardiac output, stroke volume, and oxygen delivery. Twenty-nine (45.3%) control patients suffered gastrointestinal morbidity compared with nine (14.1%) in the Doppler guided fluid group P<0.001, overall morbidity was also significantly higher in the control group P=0.05. Conclusions. Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.

Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB &gt;2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p &lt; 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB &gt; 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve ca...

Vocal cord paresis or paralysis occurs due to lesion in the vagus nerve. Vocal cord paralysis can lead to dysphonia as well as dysphagia which lead the patient to frustration and emotional problems. The literature available on the etiology and the problems faced by them in Indian population is very scanty. Hence a prospective study was done on 41 Patients with vocal cord palsy who were referred to the Department of ENT for voice assessment and management from March 1st 2012 till 1st August 2012. The medical and surgical reports were examined. They were evaluated by an otorhinolaryngologist, and a Speech Language Pathologist. Diagnosis was made based on video stroboscopic findings. We also examined voice-related quality of life (V-RQOL) outcomes in these patients. In this study, endo-tracheal intubation (15/41; 36.5%) was the major cause of vocal cord palsy. The second major cause for vocal cord palsy in our study was surgical trauma (iatrogenic) which constituted 26.8% (11/41), out of which thyroidectomy contributed to 81.81% (9/11) and cardiac surgery (Coronary Artery Bypass Grafting (CABG) contributed to 18.18% (2/11). Neurological problems caused 14.63% (6/41) of the total cases. Non-surgical trauma constituted 9.75% (4/41) of the total patients. Left recurrent laryngeal nerve paralysis was found as a complication of heart disease in 7.3%(3/41). Tuberculosis of lungs and cancer of lungs accounted to be the rarest causes. Hoarseness of voice was the most common symptom with associated dysphagia in a few. The voice related quality of life of these patients was found to be poor. They were found to have problems in the social-emotional domain and physical functioning domain.

Aortic surgery results in ischemia-reperfusion injury that induces an inflammatory response and frequent complications. The magnitude of the inflammatory response in blood and bronchi may be associated with the risk of immediate complications. The purpose of the study was to evaluate bronchial microdialysis as a continuous monitoring of cytokines in bronchial epithelial lining fluid (ELF) and to determine whether bronchial ELF cytokine levels reflect the ischemia-reperfusion injury and risk for complications during open abdominal aortic aneurysm (AAA) repair. We measured cytokines in venous blood using microdialysis and in serum for comparison. Sixteen patients scheduled for elective open AAA repair were included in a prospective observational study. Microdialysis catheters were introduced into a bronchi and a cubital vein. Eighteen cytokines were measured using a Bio-Plex Magnetic Human Cytokine Panel. Samples were collected before and during crossclamping of the aorta as well as from 0 to 60 min and from 60 to 120 min of reperfusion. The ELF levels of several cytokines changed significantly during reperfusion. In particular, IL-6 increased more than 10-fold and IL-13 more than 5-fold during ischemia and reperfusion. Also, the venous levels of several inflammatory and anti-inflammatory cytokines increased and exhibited their highest concentration during reperfusion. Both bronchial and venous cytokine levels correlated with duration of the procedure, intensive care days, and preoperative kidney disease. Three patients suffered organ failure as a direct consequence of the procedure, and in these patients the bronchial ELF concentrations of 17 of 18 cytokines differed significantly from patients without such complications. Bronchial microdialysis is suited for continuous monitoring of inflammation during open AAA repair. The bronchial ELF cytokine levels may be useful in predicting immediate complications such as organ failure in patients undergoing vascular surgery.

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1988 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during monitored procedures along the neuraxis. This goal is accomplished through programs in education, advocacy of basic and clinical research, and publication of guidelines. The ASNM is committed to the development of medically sound and clinically relevant guidelines for intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative monitoring were established by a committee of nearly 30 total participants and ultimately endorsed by the Board of Directors of ASNM on January 24th 2013. That document follows.

The early signs of brain ischemia are key indicators of secondary brain injury and their recognition on time can ultimately save life. Direct recording of cerebral ischemia is possible using the method of cerebral microdialysis (CM). This paper presents results of the five-year experience in applying this method at University Department of Neurosurgery, Sarajevo University Clinical Center in Sarajevo. In this observational prospective clinical study, the treatment and outcome of 51 patients with subarachnoid hemorrhage (SAH) and traumatic intracranial hemorrhage (tICH) undergoing neurosurgery and consequently treated conservatively at Neurosurgical Intensive Care Unit (NICU) were analyzed. All patients were followed up by unified monitoring at NICU and additionally by the CM method. Between December 2006 and September 2010, CM monitoring was performed in 51 patients: 18 patients with SAH and 33 patients with tICH. In all patients, samples were obtained on 367 occasions, yielding a t...

P seudoaneurysm of the left ventricle is a rare complication of myo- cardial infarction (MI), and has a propensity to rupture and cause sudden death. Early diagnosis and surgical exploration is crucial in the management of this pathology. We describe a patient with a contained left ventricular false aneurysm rupture following an acute MI secondary to left anterior descending (LAD) artery embolism.

Minimally invasive surgeries are widely applied due to the advantages of small surgical wound, short postoperative recovery period, and low surgical infection rate. In minimally invasive surgery, vascular clips play a significant role in hemostasis and managing the direction of blood flow, ensuring the success of surgical procedures. The mechanical structure and manufacturing materials of vascular clips have an important influence on its clinical application effect. In this paper, we classify and summarize the mechanical structure and manufacturing materials of the currently available vascular clips worldwide, and then analyze the hemostatic coating materials of vascular clips. Besides, we also summarize the shortcomings of the existing vascular clips and propose a coat-absorbable vascular clip with future research potential.

Neuropathic pain results from injury to the central or peripheral nervous system and can prove itself refractory to classical medical treatment by anticonvulsants and antidepressants. In such cases, motor cortex stimulation is among the neurostimulation techniques available for its symptomatic control. This technique is based on surgical implantation of electrodes over the motor cortical representation of the painful area. Image-guided navigation is used for precise identification of the motor cortex intraoperatively, but proper placement of the electrodes is usually ensured by electrophysiologic mapping. This article details the intraoperative electrophysiologic procedure that we currently use for refining electrode placement in the epidural space, including the recording of somatosensory and motor-evoked potentials (MEPs). Various procedures have been reported and some groups are using direct cortical mapping and subdural electrode placement rather than epidural. Our method is one of several proposed techniques and is mostly based on intraoperative MEP mapping in response to monopolar (anodal) epidural stimulation of the cortex. The limit of this approach is that MEPs cannot be recorded in patients with total or severe motor deficit. We have shown that intraoperative mapping of the cortical region corresponding to the painful area by recording MEPs could help select contacts to be activated for chronic stimulation. Therefore, the patients in whom intraoperative MEP mapping is possible could benefit from this technique, at least if we consider that it improves the accuracy of electrode placement and that motor cortex stimulation efficacy critically depends on this placement.

Intraoperative mapping and monitoring techniques for eloquent area tumors are routinely used world wide. Very few data are available regarding mapping and monitoring methods and preferences, intraoperative seizures occurrence and perioperative antiepileptic drug management. A questionnaire was sent to 20 European

Negative contralateral groin exploration for childhood hernias raises the question of whether contralateral groin exploration is necessary or not. To find out whether a contralateral processus vaginalis was patent, we performed laparoscopy with a flexible scope. After carbon dioxide insufflation, a flexible laparoscope was inserted through the opened hernia sac and the contralateral processus vaginalis orifice was examined. We considered a patent processus vaginalis as a potential hernia. The study involved 20 children: 16 boys and 4 girls. The symptomatic side was explored in a conventional manner and laparoscopy was performed through the opened hernia sac. A contralateral processus vaginalis was found in 6 children: 4 boys and 2 girls. These results were confirmed by exploring the opposite groin. We did not explore if the laparoscopic examination was within normal limits. There was one false-positive result in a female patient. Intraoperative non-puncture laparoscopy utilizing a f...

A number of conditions can lead to acute liver failure. Determining the cause has important prognostic implications that guide decisions regarding the likelihood of spontaneous recovery, or conversely, the need for transplantation. Neurological deterioration is associated with intracranial hypertension, which requires meticulous management. The decision to employ invasive intracranial pressure monitoring is controversial because of associated risks and the lack of controlled studies. Recent literature addressing the use of intracranial pressure monitoring is reviewed. Even tertiary care units that specialize in liver disease treat acute liver failure patients infrequently. Knowledge of the latest guidelines and treatment protocols can lead to improved patient care.

Postoperative cognitive dysfunction (POCD) is a common postoperative complication in elder patients, elevating the risk of dementia, impacting patient prognosis, and adding to the socioeconomic burden. Electroencephalography (EEG) enables the recording of brain electrical activity and reflects the state of consciousness. Changes in the electrogram may signal diverse pathological and physiological states. Currently, EEG and its associated monitoring devices are extensively utilized in clinical practice. This paper presents a thorough review of the use of EEG in POCD research, aiming to establish a more substantial foundation for the prediction and prevention of POCD.

espite the new advancements in antiepileptic drug development, thousands of people with epilepsy will remain intractable to medication. For a considerable proportion of these people, epilepsy surgery is a consideration for better control of their seizures. Resective surgery is now standard practice for patients with medicationrefractory epilepsy. Temporal lobectomy continues to be the most common surgery performed. Once patients fail 2 to 3 optimal trials of antiepileptic medication, further drug therapy offers a minimal number of patients freedom from seizures. In contrast, temporal lobectomy in carefully selected patients may result in seizure-free outcomes in more than 70% to 90% of patients with intractable seizures. As technology and drug availability increases in the new millennium, it is important for the primary care physician to be aware of epilepsy surgery as a means to treat patients with antiepileptic drug-refractory epilepsy.

Background Context. Electroencephalography (EEG) is one of the oldest and most commonly utilized modalities for intraoperative neuromonitoring. Historically, interest in the EEG patterns associated with anesthesia is as old as the discovery of the EEG itself. The evolution of its intraoperative use was also expanded to include monitoring for assessing cortical perfusion and oxygenation during a variety of vascular, cardiac, and neurosurgical procedures. Furthermore, a number of quantitative or computer-processed algorithms have also been developed to aid in its visual representation and interpretation. The primary clinical outcomes for which modern EEG technology has made significant intraoperative contributions include: 1) recognizing and/or preventing perioperative ischemic insults, and 2) monitoring of brain function for anesthetic drug administration in order to determine depth of anesthesia (and level of consciousness), including the tailoring of drug levels to achieve a predefined neural effect (e. g., burst suppression). While the accelerated development of microprocessor technologies has fostered an extraordinarily rapid growth in the use of intraoperative EEG, there is still no universal adoption of a monitoring technique(s) or of criteria for its neural end-point(s) by anesthesiologists, surgeons, neurologists, and neurophysiologists. One of the most important limitations to routine intraoperative use of EEG may be the lack of standardization of methods, alarm criteria, and recommendations related to its application. Lastly, refinements in technology and signal processing can be expected to advance the usefulness of the intraoperative EEG for both anesthetic and surgical management of patients. Objective. This paper is the position statement of the American Society of Neurophysiological Monitoring. It is the practice guideline for the intraoperative use of raw (analog and digital) and quantitative EEG. Methods. The following recommendations are based on trends in the current scientific and clinical literature and meetings, guidelines published by other organizations, expert opinion, and public review by the members of the American Society of Neurophysiological Monitoring. This document may not include all possible methodologies and interpretative criteria, nor do the authors and their sponsor intentionally exclude any new alternatives. Results. The use of the techniques reviewed in these guidelines may reduce perioperative neurological morbidity and mortality Conclusions. This position paper summarizes commonly used protocols for recording and interpreting the intraoperative use of EEG. Furthermore, the American Society of Neurophysiological Monitoring recognizes this as primarily an educational service.

C omputer-assisted frameless stereotactic image guidance allows precise preoperative planning and intraoperative localisation of the image. It has been developed and tested in the laboratory. We evaluated the efficacy, clinical results and complications of placement of a pedicle screw in the lumbar spine using this technique. A total of 62 patients (28 men, 34 women) had lumbar decompression and spinal fusion with segmental pedicle screws. Postoperative CT scans were taken of 35 patients to investigate the placement of 330 screws. None showed penetration of the medial or inferior wall of a pedicle. Registration was carried out 66 times. The number of fiducial points used on each registration averaged 5.8 (4 to 7) The mean registration error was 0.75 mm (0.32 to 1.72). This technique provides a safe and reliable guide for placement of transpedicular screws in the lumbar spine.

In early-stage breast cancer, the primary treatment option for the majority of women is breast-conserving surgery (BCS). There is a clear need for more accurate techniques to assess resection margins intraoperatively, as on average 20% of patients require further surgery to achieve clear margins. Cerenkov luminescence imaging (CLI) combines optical and molecular imaging by detecting light emitted by (18)F-fluorodeoxyglucose ((18)F-FDG). Its high-resolution and small size imaging equipment makes CLI a promising technology for intraoperative margin assessment. A first-in-human study was conducted to evaluate the feasibility of (18)F-FDG CLI for intraoperative assessment of tumor margins in BCS. Twenty-two patients with invasive breast cancer received 5 MBq/kg (18)F-FDG 45-60 min prior to surgery. Sentinel lymph node biopsy (SLNB) was performed using an increased technetium-99m ((99m)Tc)-nanocolloid activity of 150 MBq to facilitate nodal detection against the gamma-probe background si...

Objective Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion The model described here seems useful to understand some of the pathophysiological characteristics of acute IH.

Here we present a case of a destitute 61-year-old male who developed sudden onset of acute flaccid paraplegia of his lower extremities, impaired sensation of pain and temperature, acute urinary retention and loss of voluntary sphincter tone following an injection of heroin. He has a past medical history significant for coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, peripheral artery disease, chronic kidney disease and substance abuse disorder. We diagnosed him with heroin induced infarction with primary hypercoagulable state.

Pulmonary and systemic organ injury produced by oxidative stress including lipid peroxidation is a fundamental tenet of ischemia-reperfusion injury, inflammatory response to cardiac surgery, and cardiopulmonary bypass (CPB) but is not routinely measured in a surgically relevant time frame. To initiate a paradigm shift toward noninvasive and real-time monitoring of endogenous lipid peroxidation, we have explored pulmonary excretion and dynamism of exhaled breath ethylene during cardiac surgery to test the hypothesis that surgical technique and ischemia-reperfusion triggers lipid peroxidation. We have employed laser photoacoustic spectroscopy to measure real-time trace concentrations of ethylene from the patient breath and from the CPB machine. Patients undergoing aortic or mitral valve surgery-requiring CPB (n = 15) or off-pump coronary artery bypass surgery (OPCAB) (n = 7) were studied. Skin and tissue incision by diathermy caused striking (&gt; 30-fold) increases in exhaled ethylen...

Anaemia, hypoproteinaemia and acidic pH in renal failure patients can alter the pharmacokinetics and pharmacodynamics of anaesthetic agents, resulting in altered dose requirements. We evaluated the induction dose of propofol in adult patients with end-stage renal disease by titrating the hypnotic effect by means of a clinical parameter as well as using a more objective assessment of hypnosis, the Bispectral Index (BIS) monitor. The dose was compared with that for patients with normal renal function. Propofol doses that provided the clinical end-point of hypnosis (syringe drop method), as well as the end-point of a mean (SD) BIS value of 50 ( ), were evaluated in 27 end-stage renal disease and 27 normal renal function patients. Propofol was administered at 0.2mg/kg every 15 seconds until these end-points were achieved. End-stage renal disease patients required significantly higher propofol doses to achieve the clinical end-point of hypnosis (1.42 (0.24) mg/kg versus 0.89 (0.2) mg/kg in normal renal function patients, P<0.05 unpaired "t" test). Propofol dose required to achieve a BIS of 50 ( ) was also higher in end-stage renal disease patients (2.03 (0.4) mg/kg versus 1.39 (0.43) mg/kg in normal renal function patients, P<0.05). There was a significant negative correlation of propofol dose with preoperative haemoglobin concentration. A hyperdynamic circulation in renal failure patients with anaemia may be responsible for the higher propofol dose requirement in this group.

Anaemia, hypoproteinaemia and acidic pH in renal failure patients can alter the pharmacokinetics and pharmaco-dynamics of anaesthetic agents, resulting in altered dose requirements. We evaluated the induction dose of propofol in adult patients with end-stage renal disease by titrating the hypnotic effect by means of a clinical parameter as well as using a more objective assessment of hypnosis, the Bispectral Index (BIS) monitor. The dose was compared with that for patients with normal renal function. Propofol doses that provided the clinical end-point of hypnosis (syringe drop method), as well as the end-point of a mean (SD) BIS value of 50 (5), were evaluated in 27 end-stage renal disease and 27 normal renal function patients. Propofol was administered at 0.2mg/kg every 15 seconds until these end-points were achieved. End-stage renal disease patients required significantly higher propofol doses to achieve the clinical end-point of hypnosis (1.42 (0.24) mg/kg versus 0.89 (0.2) mg/kg...

Airway injury is one of the common complications after endotracheal intubation under general anesthesia. According to the US Closed Claims Database, the larynx is the most common site of airway injury during endotracheal intubation, accounting for one-third of all airway injuries. Common laryngeal injuries include traumatic granuloma, hematoma, and vocal cord paralysis, but only 20% of cases are related to intubation difficulties [1]. Granuloma or hematoma can often be detected using visual equipment for a definitive diagnosis. Vocal fold paralysis is not easily identified during extubation and often causes upper respiratory tract obstruction or even aspiration pneumonia [2,3]. In severe cases, it can be life-threatening. Vocal fold paralysis is mainly manifested as a disorder of vocal fold adduction or abduction. In patients with complete vocal fold paralysis, the vocal fold is often fixed in the paramedian position. The causes of vocal fold paralysis can be roughly divided into three categories: recurrent laryngeal nerve injury, cricoarytenoid joint dislocation, and glottic edema [4]. This article reviews the literature on vocal cord paralysis after surgery in a patient with preoperative recurrent laryngeal nerve injury, analyzes the causes of its occurrence, and explores the diagnosis and prevention procedures for similar cases.

Successful performance of cryosurgery relies heavily on a quick, efficient, safe and economic imaging way to monitor the surgical advancement and then to evaluate the curative effect. However, there is currently a lack of such an imaging modality. As for the commonly adopted imaging devices such as X-CT, MRI and PET, in addition their high cost and complexity in operation, they often induce additional scathe to the patients due to their potential radiation effects. Besides, in cryosurgery, the most important parameter -temperature -can not be directly detected by these methods. Considering the above factors, infrared thermography (IRT), a rather useful yet often neglected functional imaging technique in clinics, is proposed in this paper as an efficient tool for the quick evaluation and administration of a cryosurgical treatment of tumors. Based on skin surface temperature mapping, the degree of damage to the target tissue site caused by different freezing/heating protocols, as well as the states of blood circulation and metabolic heat generation within the treated region can possibly be identified. Further, through recording the temperature variation feature at the skin surface before and after cryosurgery, IRT would help to quickly evaluate the curative effect, which is very beneficial for later treatment planning. By detecting the surface infrared image and analyzing its digital values, the patient's invisible focus and abnormal physiological states, e.g. inflammations or pneumothorax, often accompanied by cryosurgical output yet difficult to determine via conventional imaging, could also possibly be diagnosed. To test the above concepts, both typical animal and clinical experiments were performed to demonstrate the feasibility and advantages of IRT-guided cryosurgery. This study may help push forward a novel, low-cost and non-contact way for an efficient performance of cryosurgery.

Severe traumatic injury (sTBI) continues to be a common source of morbidity and mortality. While there have been several advances in understanding the pathophysiology of this injury, the clinical outcome has remained grim. These trauma patients often require multidisciplinary care and are admitted to a surgical service line, depending on hospital policy. A retrospective chart review spanning 2019-2022 was completed using the electronic health record of the neurosurgery service. We identified 140 patients with a Glasgow Coma Scale (GCS) of eight or less, ages 18-99, who were admitted to a level-one trauma center in Southern California. Seventy patients were admitted under the neurosurgery service, while the other half were admitted to the surgical intensive care unit (SICU) service after initial assessment in the emergency department by both services to evaluate for multisystem injury. Between both groups, the injury severity scores that evaluated patients' overall injuries were not significantly different. The results demonstrate a significant difference in GCS change, modified Rankin Scale (mRS) change, and Glasgow Outcome Scale (GOS) change between the two groups. Furthermore, the mortality rate differed between neurosurgical care and other service care by 27% and 51%, respectively, despite similar Injury Severity Scores (ISS) (p=0.0026). Therefore, this data demonstrates that a well-trained neurosurgeon with critical care experience can safely manage a severe traumatic brain injury patient with an isolated head injury as a primary service while in the intensive care unit. Since injury severity scores did not differ between these two service lines, we further theorize that this is likely due to a deep understanding of the nuances of neurosurgical pathophysiology and Brain Trauma Foundation (BTF) guidelines.

Objective-MRI-negative (MRI-) pharmacoresistant focal epilepsy (PFE) patients are most challenging for epilepsy surgical management. This study utilizes a voxel-based MRI postprocessing technique, implemented using a morphometric analysis program (MAP), aiming to facilitate detection of subtle focal cortical dysplasia (FCD) in MRI-patients. Furthermore, the study examines the concordance between MAP-identified regions and localization from magnetic source imaging (MSI). Methods-Included in this retrospective study were 25 MRI-surgical patients. MAP was performed on T1-weighted MRI, with comparison to a normal database. The pertinence of MAP+ areas was confirmed by MSI, surgical outcome and pathology. Analyses of MAP and MSI were performed blindly from patients' clinical information and independently from each other. Results-The detection rate of subtle changes by MAP was 48% (12/25). Once MAP+ areas were resected, patients were more likely to be seizure-free (p = 0.02). There were no false positives in the 25 age-matched normal controls. Seven patients had a concordant MSI correlate. Patients in whom a concordant area was identified by both MAP and MSI had a significantly higher chance of achieving a seizure-free outcome following complete resection of this area (p = 0.008). In the 9 resected MAP+ areas, pathology revealed FCD type IA in 7 and type IIB in 2.

This study aims to assess neurosurgeons' knowledge, attitude, and practices regarding the techniques of neuromonitoring used in spine surgeries, and the limitations that prevent them from implementing these techniques in care optimization. It also aims to determine which interventions are most effective at avoiding postoperative complications following IONM alerts. Results: Among the participating neurosurgeons, 16.7% confirmed adopting IONM regularly, while the majority (58.3%) rarely used spinal cord monitoring. One neurosurgeon, however, stated that he never used any monitoring. More than 80% of neurosurgeons thought IONM modalities were useful for spinal procedures. Discussion: IONM of the spinal cord is changing dramatically as a result of the recent technological advancements and the development of a wide range neurophysiological techniques to improve patient outcomes. This contribution in enhancing the safety of spinal procedures and limiting potential iatrogenic neurologic injuries has made IONM more popular among neurosurgeons. Additionally, more than 80% of neurosurgeons considered IONM modalities to be useful for spinal procedures. IONM is a highly useful neuromonitoring technique to identify the signs of potential postoperative neurologic deficits and avoid possible subsequent sequelae. Physicians should have enough knowledge regarding the proposed surgery, and the preferred types of IONM to be employed, and understand the influence of drugs and anesthetic techniques on evoked potentials in order to choose the most appropriate neuromonitoring approach.

The interdisciplinary group of experts has compiled a clinical guidance for manifest dabigatraninduced haemorrhage and envisaged invasive interventions on patients under dabigatran. It recommends an escalation of treatment measures as summarized in a pocket guide (see electronic supplementary material online and insert in the print issue). Thrombin time • Ccarin clotting time • Patient blood management • Haemodialysis • Prothrombincomplex concentrate • Recombinant factor VIIa Management bei Dabigatran-induzierter Blutung -Expertenempfehlung Zusammenfassung Die interdisziplinäre Expertengruppe hat einen klinischen Leitfaden für das Vorgehen bei manifester Dabigatran-induzierter Blutung und bei anstehenden invasiven Eingriffen bei Patienten unter Dabigatran zusammengestellt. Es wird ein eskalierendes Vorgehen vorgeschlagen und in einer Karte für die Manteltasche zusammengefasst (siehe "Electronic supplementary material" online und Beilage in der Print-Ausgabe). Schlüsselwörter Thrombinzeit • Ecarin clotting time • Patient Blood Management • Hämodialyse • Prothrombinkomplexkonzentrat • rekombinanter Faktor VIIa

There is a critical need for development of real time physiological biomarkers for birth asphyxia that constitutes a major global public health burden. Our recent study (Scientific Reports, V10:9183, 2020) established a novel non-invasive neurovascular coupling (NVC) assessment in newborns using dynamic wavelet transform coherence (WTC) analysis irrespective of different aEEG algorithms. As an extended study, the current paper examines whether the variability in processed EEG and amplitude-EEG (aEEG) outputs would impact the determination of NVC in newborns with encephalopathy. Concurrent processed EEG tracings and regional near infrared spectroscopy (NIRS)-based cerebral tissue oxygen saturation (SctO2) readings during a period of twenty hours in their first day of life were selected and processed in this study. After bandpass-filtered in 2–15 Hz, rectified, and down-sampled at 0.21 Hz, the processed EEG tracings along with NIRS-SctO2 (0.21 Hz) were used to perform WTC analysis, fo...

Purpose The aims of this study were to determine the utility of transesophageal echocardiography (TEE) for identifying spinal canal structures and epidural catheter position and to assess the effect of catheter position on intraoperative hemodynamics and quality of postoperative analgesia. Methods Twenty-six adult patients undergoing thoracic surgery were included in this prospective, observational study. An epidural catheter was inserted 7.5 cm or more into the thoracic epidural space using a midline approach and a loss-of-resistance technique. A pediatric TEE probe was inserted after induction of general anesthesia. It was used to identify the spinal canal structures, the catheter tip position in the epidural space, and the spread of injected local anesthetic. Intraoperative hemodynamics, postoperative visual analogue scale (VAS) pain scores,

This study pertains to a six-channel acoustic monitoring system for use in patient monitoring during or after surgery. The base hardware consists of a USB data acquisition system, a custom-built six-channel amplification system, and a series of microphones of various designs. The software is based on the MATLAB platform with data acquisition drivers installed. The displayed information includes: time domain signals, frequency domain signals, and tools to aid in the detection of endobronchial intubation. We hypothesize that the above mentioned arrangement may be helpful to the anesthesiologist in recognizing clinical conditions like wheezing, bronchospasm, endobronchial intubation, and apnea. The study also evaluated various types of microphone designs used to transduce breath sounds. The system also features selectable band-pass filtering using MATLAB algorithms as well as a collection of recordings obtained with the system to establish what respiratory acoustic signals look like un...

Endoscopic drainage is an accepted method of treatment in the case of medially located subperiosteal orbital abscess (SPOA) because endoscopy enables almost uncompromised visualization of the medial orbital wall . However, endoscopic drainage of superiorly or inferiorly located SPOAs or intraconal abscesses raises more controversies as transnasal access to this region is rather limited . n e u r o l o g i a i n e u r o c h i r u r g i a p o l s k a 4 8 ( 2 0 1 4 ) 3 1 5 -3 2 1 a r t i c l e i n f o Article history:

Transapical transcatheter aortic valve implantation (TA-TAVI) is increasingly used to treat aortic valve stenosis in high-risk patients. Mixed venous oxygen saturation (SvO(2)) is still the &#x27;gold standard&#x27; for the determination of the systemic oxygen delivery to consumption ratio in cardiac surgery patients. Recent data suggest that regional cerebral oxygen saturation (rScO(2)) determined by near-infrared spectroscopy is closely related to SvO(2). The present study compares rScO(2) and SvO(2) in patients undergoing TA-TAVI. n = 20 cardiac surgery patients scheduled for TA-TAVI were enrolled in this prospective observational study. SvO(2) and rScO(2) were determined at predefined time points during the procedure. Correlation and Bland-Altman analysis of the complete data set showed a correlation coefficient of r(2 )= 0.7 between rScO(2) and SvO(2) (P &lt; 0.0001), a mean difference (bias) of 5.8 with limits of agreement (1.96 SD) of -6.8 to 18.3% and a percentage error of 1...

BACKGROUND: Respiratory variations in arterial pulse pressure (⌬PP) are accurate predictors of fluid responsiveness in mechanically ventilated patients. The aim of our study was to assess the ability of a novel algorithm for automatic estimation of stroke volume variation (SVV) to predict fluid responsiveness in mechanically ventilated patients. METHODS: We studied 25 patients referred for coronary artery bypass grafting. SVV was continuously displayed by the Vigileo/FloTrac system. All patients were under general anesthesia, mechanical ventilation and were also monitored with a pulmonary artery catheter. SVV and ⌬PP were recorded simultaneously before and after an intravascular volume expansion (VE) (500 mL hetastarch). Responders to VE were defined as patients whose cardiac index obtained using thermodilution increased by more than 15% after VE. RESULTS: Agreement between ⌬PP and SVV over the 50 pairs of collected data was Ϫ1.3% Ϯ 2.8% (mean bias Ϯ sd). Seventeen patients were responders to VE. A threshold ⌬PP value of 10% allowed discrimination of responders to VE with a sensitivity of 88% and a specificity of 87%. A threshold SVV value of 10% allowed discrimination of responders to VE with a sensitivity of 82% and a specificity of 88%. CONCLUSION: SVV predicts fluid responsiveness with an acceptable sensitivity and specificity and is also a potential surrogate for continuous monitoring of ⌬PP.

Background: Hypotension is commonly encountered in association with anaesthesia and surgery. Uncorrected and sustained it puts the brain, heart, kidneys, and the fetus in pregnancy at risk of permanent or even fatal damage. Its recognition and correction is time critical, especially in patients with pre-existing disease that compromises organ perfusion. Objectives: To examine the role of a previously described core algorithm ''COVER ABCD-A SWIFT CHECK'', supplemented by a specific sub-algorithm for hypotension, in the management of hypotension when it occurs in association with anaesthesia. Methods: Reports of hypotension during anaesthesia were extracted and studied from the first incidents reported to the Australian Incident Monitoring Study (AIMS). The potential performance of the COVER ABCD algorithm and the sub-algorithm for hypotension was compared with the actual management as reported by the anaesthetist involved. Results: There were 438 reports that mentioned hypotension, cardiovascular collapse, or cardiac arrest. In 17% of reports more than one cause was attributed and 550 causative events were identified overall. The most common causes identified were drugs (26%), regional anaesthesia (14%), and hypovolaemia (9%). Concomitant changes were reported in heart rate or rhythm in 39% and oxygen saturation or ventilation in 21% of reports. Cardiac arrest was documented in 25% of reports. As hypotension was frequently associated with abnormalities of other vital signs, it could not always be adequately addressed by a single algorithm. The sub-algorithm for hypotension is adequate when hypotension occurs in association with sinus tachycardia. However, when it occurs in association with bradycardia, non-sinus tachycardia, desaturation or signs of anaphylaxis or other problems, the sub-algorithm for hypotension recommends cross referencing to other relevant sub-algorithms. It was considered that, correctly applied, the core algorithm COVER ABCD would have diagnosed 18% of cases and led to resolution in two thirds of these. It was further estimated that completion of this followed by the specific sub-algorithm for hypotension would have led to earlier recognition of the problem and/or better management in 6% of cases compared with actual management reported. Conclusion: Pattern recognition in most cases enables anaesthetists to determine the cause and manage hypotension. However, an algorithm based approach is likely to improve the management of a small proportion of atypical but potentially life threatening cases. While an algorithm based approach will facilitate crisis management, the frequency of co-existing abnormalities in other vital signs means that all cases of hypotension cannot be dealt with using a single algorithm. Diagnosis, in particular, may potentially be assisted by cross referencing to the specific sub-algorithms for these.