Intraoperative Changes Research Articles

Haemodynamic Effects and Quality of Intrathecal Block in Lateral Decubitus Position using 25G Whitacre versus 25G Quincke Spinal Needles- A Cohort Study

Introduction: Various attempts have been made to manipulate the needle designs to counter the adverse effects (hypotension, postdural puncture headache) of spinal anaesthesia. This includes the modification of the tip, the location of the orifice, and the length and material of the needle. Aim: To access if a Whitacre needle is a better substitute than the classical commonly used, Quincke spinal needle along with intraoperative haemodynamic changes and quality of intrathecal block. Materials and Methods: The present stud was a hospital-based cohort study which included 100 patients in the age group of 20-50 years, who belonged to American Society of Anaesthesiologists (ASA) Grade of I and II, and were operated on for lower abdominal and lower limb surgeries under spinal anaesthesia. They were assigned into two groups A and B, wherein group A, 25G Whitacre and in Group B, 25G Quincke needles were used respectively. The primary outcome measures were the differences in the incidence of hypotension, bradycardia, and quality of sensory and motor blockade in the two groups. The t-test and Chi-square test were used. Statistical calculations were done using Statistical Package for the Social Science (SPSS) 21.0 version. Results: There was a noteworthy drop in the blood pressures (Systolic blood pressure (SBP), Diastolic blood pressure (DBP), Mean Arterial Pressure (MAP), where the readings were - group A 117.59 mmHg, group B 117.39 mmHg, group A 73.58 mmHg, group B 73.15 mmHg, group A 88.25 mmHg, group B 87.90 mmHg. But the variance between the two needle groups was statistically insignificant (p>0.05). There was no statistically significant difference between the two needles group to the quality of intrathecal block. Sensory block onset in group A (83.08±12.26 seconds), group B (81.42±17.81 seconds) with p-value 0.410. The mean bromage score in group A (2.90±0.30), group B (2.88±0.33). Conclusion: Both the needles provided excellent sensory and motor blockade and haemodynamic steadiness.

Application of Mivacurium in Fast-Track Anesthesia for Transthoracic Device Closure of Ventricular Septal Defects in Children.

IntroductionThe objective of this study was to investigate the effect of mivacurium in the application of fast-track anesthesia for transthoracic device closure of ventricular septal defects (VSDs) in children.MethodsThe data of 108 children who underwent transthoracic device closure of VSDs from December 2018 to June 2020 were recorded and analyzed. All children were divided into group M (mivacurium group, n=55) and group C (cisatracurium group, n=53) according to the different muscle relaxant drug used.ResultsNo statistically significant differences in general preoperative data, intraoperative hemodynamic changes, or the incidence of adverse reactions were noted between the two groups (P>0.05). However, the intubation condition rating of children in group M was better than that in group C. The onset time, duration of clinical action and recovery index of the muscle relaxant, postoperative mechanical ventilation duration, and length of intensive care unit stay in group M were significantly lower than those in group C (P<0.05).ConclusionIt is safe and feasible to use mivacurium as a muscle relaxant in children undergoing fast-track cardiac anesthesia during transthoracic device closure of VSDs.

Preemptive analgesic effect of ultrasonography-guided transversus abdominis plane block performed by adding dexamethasone to bupivacaine

The objective of this study was to evaluate the preemptive analgesic effect of ultrasound-guided transversus abdominis plane block performed with bupivacaine or adding dexamethasone on bupivacaine in laparoscopic cholecystectomy. This retrospective study was conducted on a total of 84 patients who underwent ultrasound-guided TAP block in laparoscopic cholecystectomy. Patients were divided into two groups: Group Bupivacaine (Group B) and Group Bupivacaine+Dexamethasone (Group B+D). Intraoperative hemodynamic changes, intraoperative remifentanil consumption, postoperative visual analog scale scores, tramadol consumption in 24 hours postoperatively, and postoperative first analgesic time were obtained from the records and compared between the groups. There were no statistically significant differences between both groups in terms of intraoperative heart rate, mean arterial pressure, oxygen saturation, and end-tidal CO2 values. Postoperative visual analog scale scores, doses of remifentanil and total tramadol, and time of receiving the first analgesic were similar. Dexamethasone can be added to the bupivacaine for the TAP block without major side effects. Adding dexamethasone to bupivacaine in transverse abdominis plane block performed in laparoscopic cholecystectomy procedures did not create a significant difference in VAS score. We think that the use of dexamethasone does not have an additional analgesic effect. However, our results should be supported by further studies.

Effects of intraoperative hemodynamic instability on postoperative adverse outcomes in patients with cardiovascular comorbidities undergoing noncardiac surgery − an observational study

Background and aims Cardiovascular diseases, especially coronary artery disease, have become an epidemic in India. There are a significant number of asymptomatic cases that are not diagnosed until an invasive intervention is required. The presence of such cardiac comorbidities may in turn lead to intraoperative hemodynamic changes in patients undergoing noncardiac surgery under general or regional anesthesia. This prospective observational study was designed to register and compare the incidence of intraoperative cardiovascular events of variation in heart rate and blood pressure in relation to postoperative adverse outcomes in patients with cardiac comorbidities undergoing noncardiac surgery. The statistical analysis was performed by SPSS 23.0 version.Patients and methods A total of 200 patients of American Society of Anesthesiologists grades II, III, and IV having known cardiovascular comorbidities posted for elective noncardiac surgical procedures under general/regional anesthesia were closely monitored for any intraoperative hemodynamic disturbances, namely, variations in heart rate and blood pressure. After the completion of surgery, the patients were followed up during the immediate postoperative period for up to 72 h for documenting any postoperative adverse outcomes.Results In this study, preexisting hypertensive heart disease and intraoperative hypotension emerged as independent predictors for postoperative adverse outcomes, whereas the most common postoperative adverse outcome was acute kidney injury.Conclusion Meticulous risk stratification of patients preoperatively may help guide decisions on adequate perioperative management, thus reducing untoward adverse events.

Influence of protective lung ventilation on arterial-to-end tidal carbon dioxide gradient during one lung ventilation: A prospective observational study

Background: One lung ventilation (OLV) results in a ventilation-perfusion (V/Q) mismatch. Protective lung ventilation (PLV) reduces postoperative pulmonary complications following OLV. However, PLV predisposes to areas of atelectasis in the ventilated lung and worsens the V/Q mismatch. Aim of Study: To evaluate the gradient between arterial carbon dioxide tension (PaCO2) and partial pressure of end-tidal carbon dioxide gas (ETCO2) during OLV using PLV. The second objective was to see if a high gradient could be predicted based on preoperative pulmonary function tests (PFTs), American Society of Anesthesiologists Physical Status (ASA-PS) or intraoperative haemodynamic changes. Patients and Methods: The PaCO2 and ETCO2 during two lung ventilation (TLV) and OLV were noted with patient in the lateral position. The PaCO2-ETCO2 gradients during TLV and OLV were calculated. The mean values of PaCO2, ETCO2 and PaCO2-ETCO2 gradient were compared for OLV and TLV. For gradients above 8 mm Hg, PFT, ASA-PS grade and blood pressure were assessed to identify any clinical association. Results: Sixty patients were enrolled in the study. The mean values of PaCO2 were 38.17 and 44.02 mm Hg during TLV and OLV respectively. The mean values of ETCO2 were 31.31 and 34.53 mm Hg during TLV and OLV respectively. The mean PaCO2-ETCO2 gradient was 6.74 and 9.71 mm Hg during TLV and OLV respectively. These values were significantly lower during TLV than OLV. Conclusion: ETCO2 does not correspond with PaCO2 during OLV using PLV. It is not possible to predict which patients will show a higher PaCO2-ETCO2 gradient. This study could not find any clinical association between the preoperative PFT, ASA-PS grade or intraoperative haemodynamics when PaCO2-ETCO2 gradient was greater than 8 mm Hg.

Association between intra-operative hemodynamic changes and corrective procedures during posterior spinal fusion in adolescent patients with scoliosis: A case-control study.

Previous reports indicated that a decrease in intra-operative cardiac output and mean arterial pressure occurs due to thoracic cage deformities when patients with scoliosis are placed in the prone position. The aims of this study were to investigate the occurrence of hypotension during posterior spinal fusion in adolescent patients with scoliosis, and the association between hypotension, surgical procedures, changes of thoracic cage morphology.This retrospective, single-center, case-control study included 106 patients who underwent surgeries for spinal deformity at our institute between June 2014 and March 2020. The inclusion criteria were: age ≤19 years at the time of surgery, lowest instrumented vertebra over L5, posterior spinal fusion as the first surgery for scoliosis, and no severe cardiac or pulmonary disease pre-operatively. Finally, 49 patients met the criteria, and were divided to 3 groups as follows: thoracic constructive curve using a 6.0-mm cobalt-chromium alloy circular rod (T-C group; n = 28); thoracolumbar/lumbar constructive curve using a 6.0-mm cobalt-chromium alloy circular rod (L-C group; n = 8); and thoracic constructive curve using a 5.5-mm cobalt-chromium alloy beam-like rod (T-B group; n = 13). The beam-like rod is characteristic as the rod is mounted to screw heads without cantilever force. Intra-operative changes in circulation associated with corrective procedures, perioperative data, and sagittal depth and sternum deviation of thoracic cage were compared between the 3 groups.The T-C group had a higher rate of hypotension alarm than did the other groups (7 vs 0 vs 0; P = .047). Corrective procedures included rodding 4 times, rod rotation maneuver once, and direct vertebral rotation twice. Blood pressure was increased by pausing the correction procedures, increasing infusion, and administering vasopressors. The T-C and T-B groups had greater sternum deviation parameters than the L-C group, both before and after surgery. All parameters associated with sagittal depth and sternum deviation decreased significantly after surgery in the T-C and the T-B groups.In corrective surgery for constructive thoracic scoliosis, the corrective procedures requiring the application of compression force in the forward direction should be closely monitored in view of their possible influence on circulatory conditions.

Intraoperative Glove Change During Cesarean Birth: A Pre- and Post-Interventional Trial

Intraoperative Glove Change During Cesarean Birth: A Pre- and Post-Interventional Trial

Surgical Causes of Significant Intraoperative Neuromonitoring Signal Changes in Three-Column Spinal Surgery.

Study DesignRetrospective case series.PurposeTo evaluate the risks and causes of neurologic complications in three-column spinal surgery by analyzing intraoperative neurophysiological monitoring (IONM) data. Overview of LiteratureThree-column spinal surgery, which may be required to correct complex spinal deformities or resection of spinal tumors, is known to carry a high risk of neurologic complications. However, few studies reported a specific surgical procedure related to a significant IONM signal change during surgery.MethodsMultimodality IONM data, including somatosensory-evoked potentials (SSEP) and motor-evoked potentials (MEP), were reviewed in 64 patients who underwent three-column spinal surgery from 2011 to 2015. Surgical procedures included posterior vertebral column resection, pedicle subtraction osteotomy, total en bloc spondylectomy, piecemeal spondylectomy, and corpectomy with laminectomy (n=27) in three cervical, 34 thoracic, and 31 lumbar procedures.ResultsSignificant IONM signal changes occurred in 11 of 64 (17.1%) patients. SSEP and MEP were changed in 11 patients. Postoperative neurologic deterioration occurred in 54.5% (6 of 11) of the patients, and two of them were permanent. There was no postoperative neurologic deterioration in patients without significant signal change. Suspected causes of IONM data changes are as follows: adhesion/tethering, translation, contusion, and perfusion.ConclusionsBased on the results of this study, to enhance neurologic safety in three-column spinal surgery, surgeons should pay attention to protect the spinal cord from mechanical insult, especially when the spinal column was totally destabilized during surgery, and not to compromise perfusion to the spinal cord in close cooperation with a neurologist and anesthesiologist.

Simultaneous Anterior and Posterior Release in Lateral Decubitus Position for Rigid Adult Spinal Deformity: A Technical Note and 2 Case Reports

Correction surgery for rigid adult spinal deformity usually involves a complex 360° osteotomy, multiple intraoperative position changes, and staged surgery. Moreover, there is a lack of consensus regarding the surgical strategy for this pathology. We report the technical advantages of a simultaneous anterior and posterior release only in the lateral decubitus position to reduce surgical invasiveness in two case reports. A 76-year-old woman and an 80-year-old woman presented with significant spinal imbalance and segmental fusion in the anterior and posterior columns around the apex of the lumbar spinal curvature. We conducted this procedure for these patients at the first stage of spinal corrective surgery to achieve 360° osteotomy. A long posterior fusion surgery was performed after 1 week. The mean values of the central sacral vertical line, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt improved substantially postoperatively: central sacral vertical line, from 51.0 to 7.5 mm; pelvic incidence minus lumbar lordosis, from 27.5° to 0.5°, sagittal vertical axis, from 107.6 to 14 mm; pelvic tilt, from 34.0° to 13.0°. The mean surgical time and blood loss in the first- and second-stage operations were 242.1 minutes and 702 mL and 315.5 minutes and 549 mL, respectively, and no perioperative complications occurred. Simultaneous 360° segmental release in the lateral decubitus position without repositioning can make it possible to acquire satisfactory correction and reduce surgical invasiveness compared with the conventional procedure for adult spinal deformity.

Role of Novel Kidney Biomarkers in Patients With Cirrhosis and After Liver Transplantation.

Acute kidney injury (AKI) and chronic kidney disease (CKD) are important drivers of morbidity and mortality in patients with cirrhosis before and after liver transplantation (LT). In this review, we examine the role of novel kidney biomarkers for early recognition of kidney injury. Studies are limited by lack of reference standards, heterogeneous definitions of outcomes and biomarker cutoffs, and inconsistent diagnostic performance. Overall, a change in biomarker is more relevant than an absolute cutoff. Cystatin C and urinary neutrophil gelatinase-associated lipocalin (uNGAL) are the most studied candidate biomarkers and identify AKI or progression of AKI earlier than serum creatinine (sCr). Kidney injury molecule 1 and liver-type fatty acid-binding protein (L-FABP) also show potential. NGAL and interleukin 18 may play a role in differentiating acute tubular necrosis from other forms of AKI. Combining novel biomarkers with the Model for End-Stage Liver Disease score may assist prognosis. Persistent elevations in select markers (eg, NGAL) can portend irreversible injury. Several pretransplantation markers (including sCr) predict posttransplantation kidney dysfunction. Pretransplantation assessment of clinical factors (eg, age, diabetes) and novel markers (osteopontin and tissue inhibitor of metalloproteinases 1 [TIMP-1]) may predict renal kidney recovery after LT. Intraoperative changes in biomarkers predict early post-LT AKI. Prediction of CKD remains difficult, although a combination of biomarkers (eg, beta-2 microglobulin, CD40) is promising. Novel biomarkers have yet to replace sCr in guideline-based evaluation and management of kidney dysfunction in patients with cirrhosis. We propose a theoretical framework for practical incorporation of these biomarkers that considers patient characteristics (risk for irreversible injury), markers of functional and structural change, and assessment of the AKI-CKD continuum to identify patients at the highest risk for progressive kidney disease before and after LT.

The place of lymph dissection in the treatment of cancer and the choice of surgical tactics (review article)

Over the past years, due to increase of detection of patients with early-stage stomach cancer and colorectal cancer, and improvement of survival rate, the efforts have been made to gradually develop the concept of sentinel lymph nodes detection in order to improve postoperative quality of life. The article presents the review of the literature on the feasibility of sentinel lymph nodes intraoperative diagnosis the choice of surgical treatment of patients with tumors of the stomach and colon. Analytical work demonstrates that the real time intraoperative visualization of lymph sineses using fluorescent imaging of indocyanine green during laparoscopic surgery for stomach or colorectal cancer is possible and it is a useful method of the lymph nodes mapping, therefore it can lead to intraoperative changes at lymphadenectomy as well as to reduce the surgical injury. It indicates the need in further research and improvement of approach.

Correlation between Electrophysiological Change and Facial Function in Parotid Surgery Patients.

This observational study investigated intraoperative electrophysiological changes and their correlation with postoperative facial expressions in parotidectomy patients with visual confirmation of facial nerve (FN) continuity. Maximal electromyography(EMG) amplitudes of the facial muscles corresponding to temporal, zygomatic, buccal and mandibular branches were compared before/after FN dissection, and facial function at four facial regions were evaluated before/after parotidectomy in 112 patients. Comparisons of 448 pairs of EMG signals revealed at least one signal decrease after FN dissection in 75 (67%) patients. Regional facial weakness was only found in 13 of 16 signals with >50% amplitude decreases. All facial dysfunctions completely recovered within 6 months. EMG amplitude decreases often occur after FN dissection. An amplitude decrease >50% in an FN branch is associated with a high incidence of dysfunction in the corresponding facial region. This study tries to establish a standard facial nerve monitoring (FNM) procedure and a proper facial function grading system for parotid surgery that will be useful for the future study of FNM in parotid surgery.

Perioperative changes of FGF23 in patients undergoing surgery for primary hyperparathyroidism

BackgroundFibroblast growth factor 23 (FGF23) is a key regulator of urine phosphate excretion. The aim of the study was to investigate the perioperative (intraoperative and postoperative) changes of plasma intact and C-terminal FGF23 (iFGF23, cFGF23) concentrations in patients with primary hyperparathyroidism (pHPT) submitted to surgery.Materials and methodsThe study involved 38 adult patients with pHPT caused by adenoma. Parathyroid hormone (PTH) levels were investigated intraoperatively (just before the incision and 10 min after adenoma excision). cFGF23, iFGF23, phosphate, estimated glomerular filtration rate (eGFR), and procollagen type 1 N-terminal propetide (P1NP) were measured intraoperatively and postoperatively (next day after the surgery).ResultsPTH levels decreased intraoperatively (13.10 pmol/L vs 4.17 pmol/L, P< 0.0001). FGF23 levels measured intraoperatively were at the upper level of reference interval. cFGF23 decreased postoperatively compared with the values measured just before the incision (cFGF23: 89.17 RU/mL vs 22.23 RU/mL, P< 0.0001). iFGF23 decreased as well, but the postoperative values were low. Postoperative inorganic phosphate values increased (1.03 mmol/L vs 0.8 mmol/L, P= 0.0025). We proved significant negative correlation of perioperative FGF23 with inorganic phosphate (cFGF23: Spearman’s r = −0.253, P= 0.0065; iFGF23: Spearman’s r = −0.245, P= 0.0085). We also found that FGF23 values just before incision correlated with eGFR (cystatin C) (cFGF23: Spearman’s r = −0.499, P= 0.0014; iFGF23: Spearman’s r = −0.413, P= 0.01).ConclusionIntraoperative iFGF23 and cFGF23 did not change despite PTH decreased significantly. cFGF23 and iFGF23 significantly decreased 1 day after parathyroidectomy and are associated with increase of inorganic phosphate in pHPT patients. cFGF23 and iFGF23 just before incision correlated with eGFR (cystatin C). Similar results found in both iFGF23 and cFGF23 suggest that each could substitute the other.

Accuracy of image-free navigation in intraoperative leg length change from total hip arthroplasty using evaluations from 2D and 3D measurements

BackgroundLeg length discrepancy is one of the most common problems after total hip arthroplasty (THA). The aim of this study was to investigate the accuracy of image-free navigation in intraoperative leg length change (LLC) using evaluations from anteroposterior radiographs (2D measurement) and 3D bone models using CT data (3D measurement).MethodsOne hundred THAs with cementless cups and stems were performed using an image-free navigation system in our hospital. We evaluated the accuracy of image-free navigation based on LLC from 2D and 3D measurements. Furthermore, we also investigated error in absolute value and correlations between 2D and 3D measurements in LLC.ResultsThe accuracy of image-free navigation based on 2D measurement was 94% within 5 mm and 76% within 3 mm. The accuracy of image-free navigation based on 3D measurement was 92% within 5 mm and 81% within 3 mm. The error in absolute value in LLC between 2D and 3D measurements was 1.7 ± 1.4 mm (range, 0 to 6 mm). A strong correlation was observed between 2D and 3D measurements in the LLC.ConclusionsIn the present study, good accuracy of image-free navigation in intraoperative LLC was confirmed for both evaluation methods from 2D and 3D measurements. In addition, the error in absolute value in the LLC between 2D and 3D measurements was very small, and we observed a strong correlation between 2D and 3D measurements. Based on these results, evaluation of LLC from radiographs was considered sufficient if radiographs can be taken accurately.

Comparison of three neuraxial anesthesia approaches in parturient women with obesity and pregnancy-induced hypertension who underwent cesarean section.

ObjectiveTo compare the effectiveness of different approaches of neuraxial anesthesia in parturient women with obesity and pregnancy-induced hypertension (PIH) who undergo cesarean section (CS).MethodsWe retrospectively analyzed data from 108 parturient women with obesity and PIH who underwent CS. All women were divided into the following three groups according to the neuraxial anesthesia approach: spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal–epidural anesthesia (CSE). Clinical variables were compared.ResultsThe mean age of the patients was 27.3 ± 2.2 years. Women in the CSE group had a longer duration from puncture to surgery, smaller intraoperative change in mean arterial pressure, higher Apgar scores at 1 and 5 minutes, shorter surgery time, lower rates of nausea and vomiting, and lower rate of intraoperative hypotension compared with those in the SA and EA groups.ConclusionCSE takes longer to administer in parturient women with obesity and PIH who undergo CS compared with those who have SA or EA. However, CSE has several advantages over SA or EA, including a shorter surgery time, more stable intraoperative mean arterial pressure, lower rates of nausea, vomiting, and intraoperative hypotension, and better Apgar scores at 1 and 5 minutes.

Intraoperative Neuromonitoring: Electroencephalography

Intraoperative neuromonitoring using electroencephalography (EEG) enables anaesthesiologists to monitor the depth of anaesthesia. It is intended to reduce the occurrence of intraoperative wakefulness, postoperative delirium and postoperative cognitive deficits and to shorten process times in the operating room. This article shows how to interpret the raw EEG, spectrograms and processed indices for different age groups and anaesthetics and summarizes the resulting clinical benefits. While propofol and volatile anesthetics produce characteristic frontal EEG signatures with a high activity of coherent α- and δ-waves, ketamine triggers an increase in rapid γ-waves, which leads to incorrectly high indices (BIS, PSI, NI) despite deep anaesthetic levels.In children, frontal α-waves do not appear until the age of approx. 6 months and valid indices (BIS, PSI, NI) can only be derived starting at an age of approx. 12 months. Furthermore, children of preschool and elementary school age often show epileptiform discharges in the EEG during induction of anaesthesia, what is linked to emergence delirium. In adults, the intraoperative frontal α-power decreases significantly with increasing age and older patients tend to have an increased occurrence of burst suppression patterns during anaesthesia. Clinical benefits of EEG-based neuromonitoring comprise reduced doses of anaesthesia, shorter wake-up times after surgery and a lower incidence of intraoperative awareness during total intravenous anaesthesia. Moreover, anaesthesia guided by processed EEG indices can reduce the incidence of postoperative delirium and postoperative cognitive deficits in older patients. In-depth knowledge about intraoperative EEG changes that go beyond the interpretation of processed indices could lead to a further reduction in intra- and postoperative complications in the future.

Supine harvest of vascularised scapular bone grafts–Anatomical study and clinical application

BackgroundWe report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach. MethodsTwenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper. ResultsThere are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm. ConclusionsSupine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.

Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial

BackgroundMyocardial injury after noncardiac surgery frequently occurs and may influence survival. The aims of this study were to examine the association between myocardial injury after noncardiac surgery and patient and procedural factors as well as its impact on postoperative clinical outcome. MethodsA retrospective analysis was conducted from data collected in adults enrolled in a randomized trial in elective major open abdominal surgery. Preoperative patient characteristics, intraoperative hemodynamic changes, and postoperative adverse events were analyzed, and Kaplan-Meier curves were built for postoperative survival probability. After adjustment for baseline patient and procedural characteristics, the effect of myocardial injury after noncardiac surgery on postoperative outcomes was analyzed in a propensity score matched cohort. ResultsAmong 394 patients, myocardial injury after noncardiac surgery was reported in 109 (27.7%) and was associated with a higher cardiovascular risk profile, prolonged surgery (333 ± 111 min vs 295 ± 134 min, P = .010), greater need for transfusions (41.3% vs 19.3%, P < .001), higher incidence of major adverse cardiac events (22.9% vs 6.7%, P < .001), pulmonary complications (31.2% vs 17.9%, P = .004) , acute kidney injury (30.3% vs 18.2%, P = .009), and systemic inflammatory syndrome (28.4% vs 13.0%, P < .001). After propensity score matching, the operative time and the need for blood transfusion remained higher among myocardial injury after noncardiac surgery patients who experienced more frequent major adverse cardiac events and acute kidney injury. In both the entire and matched cohorts, survival up to 30 months after surgery was determined mainly by the presence of cancer. ConclusionThe burden of cardiovascular disease and operative stress surgery is predictive of myocardial injury after noncardiac surgery and, in turn, with a higher incidence of cardiac adverse events, whereas the presence of cancer is associated with poor survival in patients undergoing major open abdominal surgery. Further studies are needed to determine whether myocardial injury after noncardiac surgery can be prevented by better control of the patient’s cardiovascular condition and implementation of less invasive of surgical procedures.

Management of neurophysiological monitoring changes during carotid endarterectomy exposure

BackgroundCarotid endarterectomy (CEA) is a safe and effective operation in the management of carotid stenosis. Intraoperative neurophysiologic monitoring (IONM) changes during carotid clamping has been well studied, but there is scant evidence detailing IONM changes during carotid exposure. ObjectiveWe analyzed our experience with IONM changes during CEA exposure to determine whether multimodal IONM changes during exposure predict outcomes and how best to manage this challenging clinical scenario. MethodsWe reviewed all CEAs performed at our medical center between January 2015 and June 2020 and identified patients with multimodal IONM changes during exposure of the carotid artery. Our primary outcomes were perioperative stroke and functional outcomes. Functional outcomes were measured by modified Rankin scale (mRS), with good functional outcome defined at mRS scores 0–3. We also reviewed our intraoperative IONM change management strategies. ResultsFive patients (4 males, 1 female) with an average age of 67 ± 12 years had intraoperative IONM changes during carotid exposure. Among these, three patients were discharged with good functional outcome, and four patients had a good functional outcome at last follow-up. Two patients had perioperative stroke, half of which resulted in significant disability. One patient was transferred to the neuroendovascular suite intraoperatively for evaluation for thromboembolism followed by angioplasty and stenting with distal protection. ConclusionIntraoperative IONM changes during carotid exposure predict outcomes in CEA. We propose that transition to the neuroendovascular suite following significant IONM changes during carotid exposure may be a useful strategy for management of this challenging clinical scenario. This approach provides the opportunity to evaluate and treat thromboembolism and still complete carotid revascularization when appropriate. This algorithm may be particularly useful in the era of dual trained vascular neurosurgeons.

A descriptive study of the relationship between preoperative body temperature and intraoperative core temperature change in adults under general anaesthesia

Background: Despite numerous guidelines on perioperative temperature management, perioperative hypothermia remains common. Prewarming to prevent redistribution hypothermia is supported by evidence, but not widely practised. We investigate the measurement of preoperative mean body temperature as a potential tool for individualising the practice of prewarming. Methods: We hypothesised that patients who experience intraoperative hypothermia have a lower preoperative mean body temperature. A longitudinal study was conducted in adult patients presenting for ophthalmological surgery under general anaesthesia, to describe the relationship between the incidence of hypothermia within the first hour of anaesthesia and preoperative mean body temperature. Results: Sixty-five patients were enrolled. Twelve participants (18%) presented to the operating theatre hypothermic (core temperature < 36.0 °C). A further 28 (43%) became hypothermic during the procedure. All hypothermia events occurred within 60 minutes after induction of anaesthesia, and half of the events occurred within 19 minutes. The difference in preoperative mean body temperature between those with and without intraoperative hypothermia was only -0.2 °C (95% CI -0.4, 0.1). This is neither clinically relevant nor statistically noteworthy. In Cox proportional hazards analysis, BMI and ASA status compounded the observed association between preoperative mean body temperature and the incidence of intraoperative hypothermia. A higher BMI and ASA are associated with a lower incidence of hypothermia. Conclusion: We conclude that intraoperative hypothermia is common and occurs early after induction of anaesthesia. We observed no useful difference in preoperative mean body temperature to help distinguish between patients who become hypothermic and those who do not. Without a useful risk prediction tool, a generic approach to prewarming remains appropriate. Preoperative screening for pre-existing hypothermia should be practised, even in cases considered as low risk.