Intraoperative Monitoring Research Articles

246. EFFECT OF INTRAOPERATIVE NERVE MONITORING DURING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Recurrent laryngeal nerve (RLN) lymphadenectomy is a crucial step during esophagectomy. However, it is technically demanding and associated with a significant risk of RLN injury. Despite several studies demonstrating the feasibility of intraoperative nerve monitoring (IONM) during esophageal surgery, routine utilization of IONM during minimally invasive esophagectomy has not become common, and there is limited evidence to provide robust guidance. Here, we describe our experience with IONM during minimally invasive McKeown esophagectomy. Methods Data from 115 consecutive patients who underwent bilateral RLN lymphadenectomy during thoracoscopic McKeown esophagectomy for esophageal squamous cell carcinoma (ESCC) by a single surgeon between July 2017 and November 2023 were reviewed. The cohort was divided into three groups: Group 1 (initial 23 cases without IONM), Group 2 (middle 46 cases without IONM), and Group 3 (late 46 cases with IONM). We compared the number of resected lymph nodes and the incidence of vocal cord palsy (VCP) among the three groups. Results The mean number of resected right-side RLN lymph nodes was 1.21, 2.30, and 3.28 in Groups 1, 2, and 3, respectively. A significant difference was noted between Groups 2 and 3 (p = 0.03, Kruskal-Wallis test). The mean number of resected left-side RLN lymph nodes was 1.13, 2.70, and 2.67 in Groups 1, 2, and 3, respectively. A significant difference was noted between Groups 1 and 2 (p = 0.009), but not between Groups 2 and 3. The incidence of VCP was 8.7%, 8.7%, and 10.9% in Groups 1, 2, and 3, respectively. Compared to Group 2, the utilization of IONM in Group 3 did not reduce the postoperative VCP rate (OR: 1.280, 95% CI: 0.321-5.107). Conclusions With increasing experience, the number of resected RLN lymph nodes significantly increased. However, the utilization of IONM did not further improve left-side RLN lymphadenectomy or reduce the VCP rate.

222. LONG-TERM SURVIVAL OF ROBOT-ASSISTED ESOPHAGECTOMY AND ITS UTILITY IN TREATING CT4B ESOPHAGEAL CANCER

Abstract (Background) Robot-assisted esophagectomy (RAMIE) has lately been introduced to many hospitals after its insurance approval. However, long-term outcome of RAMIE or its utility in treating cT3br-T4 esophageal cancer remains unclear. (Methods) A total of 188 esophageal cancer patients who underwent RAMIE between 2017 and 2022 were eligible in the present study. Among them, 20 cases with cT3br-T4 were reviewed to evaluate short-term outcome. Also, a comparison between RAMIE (n=66) and VATS (n=277) group with 2-year and longer follow-up time was made to evaluate their long-term outcomes. (Results) Background factors; age=71 (42-86), gender (M/F)= 145/43, tumor location (Ut/Mt/Lt, Ae)= 25/84/79, cT1/2/3/4= 36/31/101/20, cN0/1/2/3= 65/82/34/7, cM0/1= 155/33, and preoperative treatment (none/chemo/CRT/both)= 39/139/10. Surgical outcomes; operation time = 508 (273-833) min, console time=244 (108-479) min, estimated blood loss= 130 (0-2090) ml, overall postoperative morbidity (CD classification≧grade2) = 53.2% (pneumonia= 29.3%, atelectasis=9.0%, palsy of recurrent laryngeal nerve=10.1%, surgical site infection=5.9%, chylothorax=5.9%, and anastomotic leakage=5.9%). Postoperative hospital stay was 21 (12-385) days. The palsy rate of recurrent laryngeal nerve decreased from 9.1 to 0.7% after introducing intraoperative continuous nerve monitoring (NIM). In terms of RAMIE for cT3br-T4 cases (n=20), no convert to open or intraoperative complications were observed while all cases achieved R0 resection. Regarding survival comparison between the RAMIE (n=66) and the VATS (n=277) group, disease-free and overall survival were 74.8 vs 70.9% (P=0.4582), 76.4 vs 78.5% (p=0.7626), respectively. (Conclusion) NIM system reduced the palsy of recurrent laryngeal nerve during RAMIE while the comparable survival was identified between the two groups. Given its advantage, RAMIE seems to be particularly useful in treating cT3br-T4 cases. Our surgical videos of cT3br-T4 cases will be also presented in the meeting.

Effect of optimizing cerebral oxygen saturation on postoperative delirium in older patients undergoing one-lung ventilation for thoracoscopic surgery.

This randomized controlled trial investigated whether the regional cerebral oxygenation saturation (rScO2)-guided lung-protective ventilation strategy could improve brain oxygen and reduce the incidence of postoperative delirium (POD) in patients older than 65 years. This randomized controlled trial enrolled 120 patients undergoing thoracic surgery who received one-lung ventilation (OLV). Patients were randomly assigned to the lung-protective ventilation group (PV group) or rScO2-oriented lung-protective ventilation group (TPV group). rScO2 was recorded during the surgery, and the occurrence of POD was assessed. The incidence of POD 3 days after surgery-the primary outcome-was significantly lower in the TPV group (23.3% versus 8.5%). Meanwhile, the levels of POD-related biological indicators (S100β, neuron-specific enolase, tumor necrosis factor-α) were lower in the TPV group. Considering the secondary outcomes, both groups exhibited a lower oxygenation index after OLV, whereas partial pressure of carbon dioxide and mean arterial pressure were significantly increased in the TPV group. In addition, minimum rScO2 during surgery and mean rScO2 were higher in the TPV group than in the PV group. Continuous intraoperative monitoring of brain tissue oxygenation and active intervention measures guided by cerebral oxygen saturation are critical for improving brain metabolism and reducing the risk of POD.

559. SURGICAL PROCEDURE AND CLINICAL OUTCOME OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background We started performing esophagectomy by a laparoscopic transhiatal approach in 2009, and 577 patients had undergone to date. Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a technique for total mediastinal lymph node dissection (390 patients). Methods The upper and middle mediastinal lymph node dissection including lymph nodes along the left recurrent laryngeal nerve, using a left cervical approach, was performed with a single-port mediastinoscopic technique. This approach with pneumomediastinum by AirSeal System improved the visibility and handling in the deep mediastinum around the aortic arch. We recently performed intraoperative monitoring of the recurrent laryngeal nerve using Nerve Integrity Monitor system. For dissection of upper and middle mediastinal lymph nodes, the left recurrent laryngeal nerve was sometimes compressed by the shaft of the sealing device or the retractor. We used continuous monitoring with the Automatic Periodic Stimulation electrode for the left recurrent laryngeal nerve, and immediately recognized dangerous procedures. Frequency of recurrent laryngeal nerve palsy was dramatically reduced to half by the introduction of Nerve Integrity Monitor system. Furthermore, to understand the anatomy of bilateral bronchial arteries, we performed 3-dimensional computed tomography angiography preoperatively, which was crucial to avoid intraoperative bleeding. Results The outcome of patients performed transmediastinal radical esophagectomy was compared with those performed the right thoracotomy by using propensity score matching. The operative time, the operative bleeding, and postoperative respiratory complications were significantly decreased by transmediastinal radical esophagectomy. Conclusion Our surgical procedure resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications. https://intconferenceservices-my.sharepoint.com/:v:/g/personal/barbarav_icsevents_com/ER9oAGbon3xJvdMGlJ2EUbIBgaq_8XDlKNA-wzVH3-7Hcg?nav=eyJyZWZlcnJhbEluZm8iOnsicmVmZXJyYWxBcHAiOiJPbmVEcml2ZUZvckJ1c2luZXNzIiwicmVmZXJyYWxBcHBQbGF0Zm9ybSI6IldlYiIsInJlZmVycmFsTW9kZSI6InZpZXciLCJyZWZlcnJhbFZpZXciOiJNeUZpbGVzTGlua0NvcHkifX0&e=KbAfDr

Hyperglycemia in Orthopaedic Trauma Patients: Implications, Management, and Future Directions

Physiologic stress-induced hyperglycemia (SIH) significantly impacts patient outcomes in both non-diabetic and diabetic individuals following orthopaedic trauma. This review synthesizes current literature on SIH's effects, highlighting its association with increased surgical site infections (SSI), extended hospital stays, wound complications, nonunion, need for revision surgery, and mortality. Non-diabetic patients with SIH face worse outcomes compared to euglycemic patients, including a higher risk of deep infections and systemic complications. Diabetic patients experience exacerbated hyperglycemia during trauma, leading to poor wound healing and heightened infection risk. Effective glycemic control, through preoperative optimization, intraoperative monitoring, and postoperative management, is crucial for improving outcomes. Special considerations are discussed for the geriatric population, who are particularly vulnerable to SIH-induced morbidity and mortality. Future directions emphasize developing tailored glycemia management algorithms, utilizing continuous monitoring systems, and fostering multidisciplinary collaboration to optimize care for orthopaedic trauma patients.

How i do it: individualized bypass strategy with tentative clamping method.

Cerebral Revascularization (CR) remained an indispensable arm in the neurosurgical arsenal, especially managing symptomatic hemisphere with misery perfusion (SHMP). We described an a mid-aged gentleman diagnosed with progressive middle cerebral steno-occlusion following carotid endarterectomy by employing individualized arterial reconstruction with tentative clamping method (TCM) under supervision of intraoperative monitoring. An operative video was also accompanied to demonstrate further details. The optimal treatment strategy for SHMP should be tailored by individuals. The risk of postoperative adverse sequel can be minimized and improved neuro-cognitive status was accomplished with an aid of TCM for such prophylactic procedure. NA.

Factors of postoperative recurrent laryngeal nerve paralysis and recovery of vocal cord movement in thyroid surgery

ObjectivePostoperative recurrent laryngeal nerve paralysis is one of the complications of thyroid surgery, and the prevention and management of paralysis is an important issue for surgeons. In this study, in order to gain further understanding of recurrent laryngeal nerve paralysis after thyroid surgery, we analyzed and examined the usefulness of nerve stimulators for recurrent laryngeal nerve paralysis and the factors that may cause recurrent laryngeal nerve paralysis. Furthermore, in cases where transient recurrent laryngeal nerve paralysis occurred, we analyzed and examined the timing of improvement in vocal cord movement for each intraoperative finding and intraoperative operation that caused the paralysis. MethodsAt the Department of Otorhinolaryngology Head and Neck Surgery, Sapporo Medical University Hospital, between January 2012 and December 2021, the subjects were 543 thyroid surgery cases (692 nerves) without preoperative paralysis or cancer nerve invasion performed. The relationship between postoperative transient and permanent paralysis of the recurrent laryngeal nerve was evaluated using univariate and multivariate analysis. The factors evaluated were gender, age, BMI, total thyroidectomy, benignity, malignancy, Graves’ disease, using IIONM (intermittent intraoperative nerve monitoring), using CIONM (continuous intraoperative nerve monitoring), malignant tumor T3b or higher, with lateral neck dissection, and years of experience of the surgeon. Furthermore, by targeting 87 nerves with transient paralysis, surgical operations were divided into three groups: minor injury, major injury, and adhesion, and their relationship with the timing of postoperative vocal fold movement improvement was evaluated. ResultsPermanent paralysis of the recurrent laryngeal nerve occurred in 12 nerves (1.7 %), and transient paralysis occurred in 100 nerves (14.5 %). Univariate analysis showed no association with each factor, but multivariate analysis showed that transient paralysis was significantly lower in men and in patients using IIONM. The improvement time for vocal cord paralysis was 2.8 months in the minor injury group, 4.5 months in the major injury group, and 3.2 months in the adhesion group, indicating a statistically significant difference between the minor injury group and the major injury group. ConclusionThis study suggests that the use of IIONM and gentle manipulation of women may prevent recurrent laryngeal nerve paralysis during thyroid surgery. In addition, understanding the period of nerve recovery for each operation for postoperative transient recurrent laryngeal nerve paralysis may contribute to patient explanations and determining the timing of therapeutic intervention for speech improvement surgery.

Minimally Invasive Anterolateral Cervical Cordotomy for Intractable Cancer Pain Using Microtubular Retractors: A Single Institution Case Series.

As advancements in cancer treatments have allowed patients with a high burden of disease to live longer, the number of patients who present with debilitating refractory pain has increased. Anterolateral cordotomy has long been used for the treatment of intractable unilateral cancer pain using either an imaging-guided percutaneous approach or an open surgical approach. In this report, we describe a novel minimally invasive modification to the open surgical approach. It combines the benefits of both approaches by providing direct visualization for lesioning without the collateral tissue damage of an open approach. This retrospective study evaluated medical records, operative reports, and imaging studies of patients who underwent a minimally invasive cordotomy at a single institute between 2018 and 2022. The surgical technique involved a microscope-assisted C2 hemilaminectomy using microtubular retractors followed by dural opening and anterolateral cordotomy under direct visualization and with intraoperative neurophysiological monitoring. Eleven patients were included in the study. None were converted to an open approach, and no wound-related postoperative complications were observed. A clinically significant decrease in pain was observed after the procedure, and 10 of the 11 patients (91%) were ambulatory by the time of analysis. Compared with image-guided percutaneous cordotomy, anterolateral cervical cordotomy with microtubular retractors potentially improves the safety of the procedure through direct visualization while being less invasive than a conventional open approach. Our preliminary experience with this technique demonstrates the feasibility of the approach, as it was both safe and effective.

Enhancing boundary detection of radiofrequency ablation lesions through photoacoustic mapping

Atrial fibrillation (A-fib) is the most common type of heart arrhythmia, typically treated with radiofrequency catheter ablation to isolate the heart from abnormal electrical signals. Monitoring the formation of ablation-induced lesions is crucial for preventing recurrences and complications arising from excessive or insufficient ablation. Existing imaging modalities lack real-time feedback, and their intraoperative usage is in its early stages. A critical need exists for an imaging-based lesion indexing (LSI) method that directly reflects tissue necrosis formation. Previous studies have indicated that spectroscopic photoacoustic (sPA) imaging can differentiate ablated tissues from their non-ablated counterparts based on PA spectrum variation. In this paper, we introduce a method for detecting ablation lesion boundaries using sPA imaging. This approach utilizes ablation LSI, which quantifies the ratio between the signal from ablated tissue and the total tissue signal. We enhance boundary detection accuracy by adapting a regression model-based compensation. Additionally, the method was cross-validated with clinically used intraoperative monitoring parameters. The proposed method was validated with ex vivo porcine cardiac tissues with necrotic lesions created by different ablation durations. The PA-measured lesion size was compared with gross pathology. Statistical analysis demonstrates a strong correlation (R > 0.90) between the PA-detected lesion size and gross pathology. The PA-detected lesion size also exhibits a moderate to strong correlation (R > 0.75) with local impedance changes recorded during procedures. These results suggest that the introduced PA imaging-based LSI has great potential to be incorporated into the clinical workflow, guiding ablation procedures intraoperatively.

LATEST ADVANCES IN FACIAL NERVE INTRAOPERATIVE MONITORING FOR VESTIBULAR SCHWANNOMA - UP TO DATE 2024

Introduction: Vestibular schwannoma, a benign tumor of the eighth cranial nerve, can be treated with radiosurgery, microsurgery, or observation. This study aims to present advances in intraoperative monitoring techniques for preserving facial nerve function during acoustic neuroma surgeries. By sharing the latest evidence, we hope to influence clinical practices for the benefit of patients. Methodology: Thus, we conducted a comprehensive literature review using the Scopus database, we searched for articles published from 2018 to 2023 using the keywords "facial paralysis," "acoustic neuroma," and "intraoperative monitoring." Results: The use of electromyographic parameters in the pre, intra, and post-resection monitoring of vestibular schwannoma provides valuable indicators of both the functional state of the facial nerve and the tumor adherence. This information plays a crucial role in making safe decisions regarding the extent of tumor resection while minimizing the risk of facial nerve damage during surgery. Supramaximal stimulation of the facial nerve in proximity to the tumor is of utmost importance to preserve facial function. However, the presence of a separate intermediate nerve poses challenges in accurately detecting false positives. Therefore, monitoring the facial nerve during surgery becomes essential to prevent potential injuries and to predict both short- and long-term outcomes. Conclusion: Intraoperative electrophysiological facial nerve monitoring is a crucial strategy to reduce postoperative facial paralysis. While the best technique is still under debate, several options exist to enhance monitoring efficacy and patient safety. By staying informed, clinicians can make better decisions to improve patient outcomes.

The Transtemporal Isthmus Approach for Insular Glioma Surgery.

Maximal and safe removal of insular gliomas by a transinsular cortex approach is challenging. In this article, a new transtemporal isthmus approach to resect insular gliomas is presented. We retrospectively examined 53 patients with insular glioma who underwent resection through the temporal isthmus approach using magnetic resonance imaging and functional neuronavigation guidance and intraoperative electrophysiological monitoring. Extent of resection was determined using intraoperative magnetic resonance imaging. Fifty-three patients were included for analysis, 30 men and 23 women. The median (range) age was 45 (26-70) years. Tumor laterality was left in 22 patients and right in 31. All tumors involved at least zone III or IV (Berger-Sanai classification system), including zones I-IV were involved in 29 (54.7%) and zones III and IV in 17 (32.0%). Among the 37 low-grade gliomas, preoperative median (IQR) volume was 45.7 (31.8, 60.3) cm 3 , and gross total resection was achieved in 24 (64.9%). Among the 16 high-grade gliomas, preoperative median (IQR) volume was 45.3 (40.1, 54.0) cm 3 , and gross total resection was achieved in 14 (87.5%). The median (IQR) extent of resection of the whole group was 100% (89%-100%). The median (IQR) postoperative Karnofsky performance score 3 months after surgery was 90 (80-90). Mean temporal isthmus width was significantly higher in the affected side (involving tumor) than the contralateral one (21.6 vs 11.3 mm; 95% CI: 9.3 to 11.3, P < .01). Muscle strength was grade 4 or higher, and speech was nearly normal in all patients 3 months after surgery. Insular glioma surgery using the transtemporal isthmus approach can achieve safe and maximum resection. A widened temporal isthmus provides a surgical pathway for transisthmic resection of insular tumor.

Permanent unilateral visual loss and orbital compartment syndrome following unilateral frontal craniotomy: illustrative case.

Vision loss following supine craniotomy is an unexpected and devastating complication for the patient and the operating team. Postoperative vision loss (POVL) is commonly associated with cardiac, spinal, neck, and prone head surgeries, as they share common risk factors, such as a prone position, intraoperative hypotension, a longer anesthesia duration, and the use of vasopressors. Herein, the authors report a case of irreversible vision loss following a frontal craniotomy in the supine position together with a review of the literature. All published cases in the literature since the first reported case in 1970 are summarized. Possible etiologies and proposed preventive measures are discussed. Different pathologies, such as vascular, intra-axial, and extra-axial lesions, are associated with POVL and have similar clinical courses and nonrecovery rates, which raises the question of whether POVL begins during the exposure part of these surgeries. Preventive measures could include avoiding direct ocular pressure during flap reflection, the use of elastic bands or fishhooks to avoid stretching the orbital contents and impairing venous outflow, and a careful review of the venous drainage of frontal tumors, which could help avoid unnecessary large venous thrombi or waxing. The role of intraoperative visual neurophysiological monitoring in predicting POVL requires further exploration. https://thejns.org/doi/10.3171/CASE2434.

P164. Rapid response during spinal deformity surgery can successfully save spinal cord function using intraoperative monitoring.

P164. Rapid response during spinal deformity surgery can successfully save spinal cord function using intraoperative monitoring.

Transesophageal echocardiography: Revolutionizing perioperative cardiac care.

Cardiovascular diseases (CVDs) are a major challenge in global health. Despite significant advances in treatment and management, the incidence and mortality rates of CVDs have been rising in recent years, particularly in the United States. With continuous advancements in medical technology, perioperative transesophageal echocardiography (TEE) has become a key technology in cardiac surgery, enhancing surgical success rates and patient safety. The application of TEE spans preoperative planning, intraoperative monitoring, and postoperative evaluation, especially in complex procedures such as mitral valve repair and aortic valve replacement, where it plays an indispensable role. Simultaneously, the introduction of artificial intelligence (AI) brings new prospects for TEE image analysis and diagnostic support, significantly improving diagnostic accuracy and real-time decision-making capabilities. However, the application of TEE technology faces challenges such as high costs, uneven technological diffusion, and the high skill requirements for medical personnel. Therefore, establishing standardized training protocols and strengthening multidisciplinary collaboration are crucial. This paper reviews the application of TEE in cardiac surgery and its path toward educational and practical standardization from a global perspective, emphasizing its importance in improving the postoperative quality of life for patients and exploring future directions in technological innovation and educational optimization.

Reconstructive Surgery of the Head and Neck in Organ Transplant Recipients: A Case Report and a Review of the Literature.

The number of solid organ transplant recipients (SOTRs) is growing as a consequence of an increase in transplantations and longer survival; these patients, thus, frequently suffer various comorbidities and are subjected to the detrimental effects of immunosuppressive agents, which expose them to a higher risk of developing malignancies. These drugs also complicate the surgical treatment of neoplasms, as they can hinder wound healing, especially when associated with other unfavorable factors (e.g., previous radiotherapy, diabetes, etc.). We herein present our experience with a 74-year-old SOTR who underwent a radical extended parotidectomy and reconstruction with a submental island flap for a persistent cutaneous squamous carcinoma after radiotherapy; his complicated clinical course was characterized by incredibly slow wound healing. The current literature was reviewed to provide a succinct overview of the main difficulties of head and neck surgery in SOTRs. In particular, the immunosuppressive regimen can be tapered considering the individual risk and other elements should be carefully assessed, possibly prior to surgery, to prevent cumulative harm. New developments, including intraoperative monitoring of flap vascularization through indocyanine green fluorescence video-angiography and the prophylactic application of negative pressure wound therapy, when feasible, may be particularly beneficial for high-risk patients.

Intraoperative assessment of microimplantation-induced acute brain inflammation with titanium oxynitride-based plasmonic biosensor

Implantable devices for brain-machine interfaces and managing neurological disorders have experienced rapid growth in recent years. Although functional implants offer significant benefits, issues related to transient trauma and long-term biocompatibility and safety are of significant concern. Acute inflammatory reaction in the brain tissue caused by microimplants is known to be an issue but remains poorly studied. This study presents the use of titanium oxynitride (TiNO) nanofilm with defined surface plasmon resonance (SPR) properties for point-of-care characterizing of acute inflammatory responses during robot-controlled micro-neuro-implantation. By leveraging surface-enriched oxynitride, TiNO nanofilms can be biomolecular-functionalized through silanization. This label-free TiNO-SPR biosensor exhibits a high sensitivity toward the inflammatory cytokine interleukin-6 with a detection limit down to 6.3 fg ml−1 and a short assay time of 25 min. Additionally, intraoperative monitoring of acute inflammatory responses during microelectrode implantation in the mice brain has been accomplished using the TiNO-SPR biosensors. Through intraoperative cerebrospinal fluid sampling and point-of-care plasmonic biosensing, the rhythm of acute inflammatory responses induced by the robot-controlled brain microelectrodes implantation has been successfully depicted, offering insights into intraoperative safety assessment of invasive brain-machine interfaces.

Effect of propofol infusion vs ketamine plus dexmedetomidine infusion on the amplitude of motor evoked potential in pediatric patients undergoing tethered spinal cord surgeries; a randomized, double blind controlled study

Background &amp; objective: The use of intraoperative neurophysiologic monitoring (IOM) has increased over the past two decades for the detection and prevention of iatrogenic neurologic injuries. Motor evoked potentials (MEP) are extremely sensitive to changes in physiological variables and inhalational agents reduce MEPs in a dose dependent manner. So IV anesthetics (propofol or ketamine) and opioids (fentanyl or remifentanil), are frequently used in spinal surgeries under MEPs monitoring. We compared the effects of propofol and fentanyl to those of ketamine, dexmedetomidine, and fentanyl in terms of minimizing their effects on MEP amplitude and hemodynamic stability during surgery Methodology: This double blind, randomized, prospective study was conducted on 46 children, who were randomly allocated into 2 groups Ketamine–dexmedetomidine group: (n = 23) Maintenance throughout the procedure, by infusing Dexmedetomidine (0.4 -0.6 μg/.kg /.hr) ketamine, (1 -2m/.kg/.hr.) and giving bolus of fentanyl, (1-2μg/.kg/ ). Propofol-group:(n = 23) Maintenance throughout the procedure, By infusing propofol (100 ug L/kg/min) and giving bolus of fentanyl, (1-2μg/.kg/ ), with keeping mean arterial blood pressure changes within 25% of the baseline in both groups. Results: Right and left quadriceps muscle measurements were insignificantly different between both groups at base line and were significantly higher in Group KD than Group P at skin incision, surgical manipulation and surgical closure. Right and left adductor hallucis muscle measurements were insignificantly different between both groups at base line and were significantly higher in Group KD than Group P at 5 mins, 10 mins, 15 mins, skin incision, surgical manipulation and surgical closure (P value &lt;0.001). Intraoperative fentanyl consumption was significantly lower in Group KD than Group P. Conclusion: The combination of dexmedetomidine and ketamine infusion is efficacious, safe, and has minimal effect on evoked potentials compared with the propofol-based TIVA group during spine pediatrics surgery. In addition, this combination increases the reliability and accuracy of MEP monitoring with hemodynamic stability and adequate post-operative pain relief. Using dexmedetomidine and ketamine infusions during pediatric spine surgery might successfully replace the typical propofol-based TIVA, although more studies are required . Registration: ClinicalTrials.gov registration number NCT05591001. Keywords: Motor evoked potential, dexmedetomidine, ketamine, propofol. Citation: Saleh AH, Hammad SH, Hassan PF. Effect of propofol infusion vs ketamine plus dexmedetomidine infusion on the amplitude of motor evoked potential in pediatric patients undergoing tethered spinal cord surgeries; a randomized, double blind controlled study. Anaesth. pain intensive care 2024;28(4):692−699; DOI: 10.35975/apic.v28i4.2218 Received: May 08, 2023; Reviewed: February 02, 2024; Accepted: July 03, 2924

Bispectral Index Monitoring Effect on Delirium Occurrence and Nursing Quality Improvement in Post-anesthesia Care Unit Patients Recovering From General Anesthesia: A Randomized Controlled Trial.

The effect of intraoperative anesthesia depth monitoring on deliriumoccurrenceand improvement of nursing quality in the post-anesthesia care unit (PACU) remains unclear.We aimed to explore the effect of intraoperative anesthesia bispectral index (BIS) monitoring on delirium occurrence and improvement of nursing quality in the PACU for patients recovering from general anesthesia. This randomized controlled trial included 120 patients, aged 20-80 years, classified as grades I-III according to the American Society of Anesthesiologists. The BIS-guided group (group B) underwent intraoperative monitoring of BIS anesthesia depth (maintained within the anesthetic range (40-60)).The depth of anesthesia was not monitored in the non-BIS-guided group (group C). The patient's vital signs were recorded at the beginning of the operation (T0), upon entering the PACU (T1), 15 min after extubation (T2), and after leaving the PACU (T3). Delirium score, emergence period (extubation and PACU observation times), and adverse events in the PACU were monitored. The nursing activity score (NAS) was used to evaluate the quality of care. Group B exhibited significantly lower heart rate and mean arterial pressure at T1 and T2, shorter time to extubation and PACU observation time, and a significantly lower incidence of adverse events than group C. Group B had significantly lower Ricker sedation-agitation scores and a lower incidence of delirium than group C.The NAS was significantly lower for group B than for group C. Patients aged 60-80 years in group C experienced agitation, requiring 30% more frequent assistance from one or two nurses than those in group B. Intraoperative BIS monitoring can reduce the incidence of adverse events in the PACU, diminish the incidence of delirium during the recovery period in elderly patients, lessen the nursing workload, improve nursing quality, and promote patient rehabilitation, thus meriting clinical application.

Neuraxial Analgesia for Scoliosis Correction: A Case Series in a Specialised Children's Centre.

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist due to the extensive nature of the surgery, the co-morbidities of the patients and the constraints on aesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Patients undergoing scoliosis surgery are considered to suffer severe pain, which may lead to a negative impact on patient psychology and physical well-being. By using effective postoperative pain regimens to enhance recovery after surgery, pain can be significantly reduced, leading to patient satisfaction, facilitating early mobilisation, promoting oral intake, lowering postoperative pain and shortening the length of hospital stay. Thus, the primary objectives of this study were to assess the postoperative pain management andfirst rescue analgesic medications, by using preservative-free morphine 50 mcg/kg and dexmedetomidine 4 mcg along with normal saline 0.5 ml kg caudally, as well as to look for thesecondary objectivesside effects, including respiratory depression, nausea, vomiting and pruritis, timing of postoperative ambulation and length of hospital stay. Methods: In this study, we retrospectively included children under 14 years of age and above three years who underwent scoliosis surgery under a caudal epidural-general anaesthesia using caudal morphine and the dexmedetomidine technique in the period from January to May 2023 at the National Guard Health Affairs Hospital (NGHA), Riyadh. We collected the data of seven cases using the electronic chart system of the Best Care database to extract the specific cases that meet the inclusion criteria for the study, which are idiopathic scoliosis patients, aged 3-14 years, and primary correction procedures. Results: The pain-free duration was between seven hours and 48 hours (about two days). There were four female cases (57.14%), and three cases were male (42.85%). The patients' American Society of Anesthesiologists (ASA) status were II to III. In all the cases, there was no documentation of any episodes of postoperative nausea and vomiting (PONV), respiratory distress or pruritus, except for one case where the patient had an episode of PONV. Conclusion: In this study, our aim was to present our experience with dexmedetomidine as an efficient medication when coadministered with morphine to be used in the operating room. We found a high level of reliability in prolonging analgesia time and delaying the usage of rescue medication. We encourage more studies on caudal dexmedetomidine for patients undergoing scoliosis surgery.

The predictive value of intraoperative bulbocavernosus reflex monitoring for postoperative voiding function in patients with conus medullaris and cauda equina tumors: a retrospective single center study

BACKGROUND CONTEXTSurgical resection is the preferred treatment in most conus medullaris and cauda equina tumor (CMCET) cases. However, total resection is usually challenging to obtain and has a strong possibility of causing various complications if forcibly attempted. Intraoperative neurophysiological monitoring (IONM) has become a necessary adjunctive tool for CMCET resection. PURPOSEThe current study aimed to evaluate the application value of bulbocavernosus reflex (BCR) monitoring in CMCET surgery. STUDY DESIGNA retrospective clinical study. PATIENT SAMPLEThe medical records of patients who underwent CMCET resection by the same neurosurgical team at our hospital from September 2020 to June 2022 were retrospectively reviewed. IONM was conducted in all surgeries. According to inclusion criteria and exclusion criteria, ultimately, 105 patients were enrolled in the study. OUTCOME MEASURESThe voiding function was assessed before surgery, 1 month after, and 6 months after surgery using the Neurogenic Bladder Symptom Score (NBSS). If the NBSS obtained 1 month after surgery exceeds 9 points than that before surgery, it can be considered that the patient suffered new-onset postoperative voiding dysfunctions (PVDs). Moreover, if the NBSS could restored (less than 9 points higher than before the surgery) at 6 months after surgery, it was defined as a short-term PVD. Otherwise, it was defined as a long-term PVD. METHODSThe amplitude reduction ratios (ARRs) of bilateral BCR waveforms were calculated and compared between patients with PVDs and those without. The receiver operating characteristic curve analysis was subsequently applied to determine the cut-off value of the maximal and minimal ARRs for predicting PVDs. RESULTSThe maximal and minimal ARRs were significantly correlated with short-term and long-term PVDs (p<.001 for all comparisons, Mann-Whitney U test). The threshold values of maximal ARR for predicting short-term and long-term PVD were 68.80% (AUC=0.996, p<.001) and 72.10% (AUC=0.996, p<.001), respectively. While those of minimal ARR were 50.20% (AUC=0.976, p<.001) and 53.70% AUC=0.999, p<.001). CONCLUSIONSThe amplitude reduction of intraoperative bilateral BCR waveforms showed high predictive value for PVDs.