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In this trial comparing two protocols designed to reduce the risk of intraoperative awareness, a protocol that used the EEG-derived bispectral index was not superior to a protocol incorporating standard monitoring of end-tidal anesthetic-gas concentration. Unintended intraoperative awareness is defined as the experience and explicit recall of sensory perceptions during surgery, 1 which can lead to post-traumatic stress disorder in as many as 70% of those who experience it. 2 In patients at high risk for intraoperative awareness, the incidence of awareness may approach 1%. 3 – 5 An estimated 20,000 to 40,000 patients experience awareness yearly in the United States alone. 1 Some cases of awareness might occur as a result of inadequate anesthetic dosing 6 and therefore constitute potentially preventable medical errors. 7 A potent inhaled anesthetic agent is incorporated in the majority of general anesthetics, and concentrations of exhaled . . .

In adult patients with newly diagnosed or recurrent diffuse glioma, more extensive resection is associated with longer progression-free and overall survival. Intraoperative mapping techniques are used to safely increase the extent of resection by locating, monitoring, and preserving the function of potentially infiltrated brain during surgery. However, there is no consensus on the indications for intraoperative mapping, the optimal functional tests to be used intraoperatively, or intraoperative decision making. Furthermore, there are no consensus standardised neurological, language, and functional outcome assessments that should be applied pre-operatively and post-operatively. The Personalized Interventions and Outcomes in Neurosurgical Oncology Research (PIONEER) Consortium and the Response Assessment in Neuro-Oncology (RANO) resect group are collaborative, multidisciplinary efforts that aim to standardise and enhance research and clinical practices in surgical neuro-oncology. Here, both working groups review the evidence and provide recommendations in an effort to improve standardisation in intraoperative stimulation mapping, electrophysiological monitoring, and intraoperative decision making during glioma resections in adults. The Policy Review offers an intraoperative framework to reduce heterogeneity and improve the quality of clinical and scientific practice. In addition to standardising practices and improving individual patient outcomes, this Policy Review provides a foundation for better consistency between institutions and facilitates multicentre collaboration in surgical neuro-oncology. Ultimately, reducing heterogeneity might accelerate the development of personalised surgical care by enabling advanced computational modelling techniques.

Background We aimed to investigate the compression and ischemic effects of two different tourniquet pressures on tissues during surgery show a clinical difference. Methods Patients aged 18–65 years who underwent foot and ankle surgery and applied a tourniquet in a single center between September 2022 and November 2023 were included in this prospective randomized study. Accordingly, tourniquet pressures were applied as limb occlusion pressure (LOP) + 50 mmHg in group 1 (12 patients) and LOP + 100 mmHg in group 2 (12 patients). The time point at which the femoral nerve motor evoked potential (MEP) decreased by 50%, the time point at which the MEP decreased by 100% for all nerves (femoral, tibial, and deep peroneal), and the time point at which all responses returned after the tourniquet was deflated were identified as the time points for analysis. Results There were no differences in demographic data (age, body mass index, and sex) between the two groups. The mean tourniquet pressure was 191 ± 16 mmHg in Group 1 and 247 ± 21 mmHg in Group 2 ( p  < 0.001). A 50% decrease in the femoral nerve MEP value was observed at an average of 47 min in Group 1 and 34 min in Group 2 ( p  < 0.001). A complete loss of MEP responses for all nerves was observed at an average of 69 min in Group 1 and 56 min in Group 2. After the tourniquet was deflated, all MEP responses returned to baseline values at an average of 8.5 min in Group 1 and 12.6 min in Group 2 ( p  = 0.007). The results showed that lower limb nerve innervation was affected later and returned to normal earlier after deflation of the tourniquet in Group 1 (low tourniquet pressure group). Conclusions The innervations of the lower extremity nerves were affected later in the group in which low tourniquet pressure was applied (average 191 mmHg). Again, in this group (LOP + 50 mmHg), nerve conduction recovered an average of 10 min after deflation and four minutes earlier than in the high tourniquet pressure group. Level of evidence Level I, diagnostic study. Trial registration NCT05926154.

Purpose We evaluated the electromyography (EMG)-based neuromuscular monitoring detectability of our novel stimulating electrode attachment method compared to the original Nihon–Kohden (Tokyo, Japan) attachment method. Methods This single-center randomized, double-blind, controlled pilot study enrolled 32 patients aged ≥ 18 years, undergoing scheduled laparoscopic surgery. The EMG electrode NM-345Y™ was attached to one forearm using the Nihon–Kohden method (Pattern N–K) and the other forearm using our novel method (Pattern Cross). The allocation to each attachment method was determined post-randomization. In Pattern Cross, the NM-345Y™ was attached such that the line connecting the anode and cathode crosses the ulnar nerve. Patients received 0.9 mg/kg rocuronium after calibration with the forearm in 90-degree supination. Following tracheal intubation, the forearm was positioned in 0-degree pronation. Intraoperatively, 0.2 mg/kg rocuronium was administered if the train-of-four (TOF) count one persisted for 1 min on either side. Post-surgery, the forearm position was returned to 90-degree supination, and rocuronium was antagonized with sugammadex. TOF and post-tetanic count (PTC) were simultaneously measured bilaterally every 15 s and 5 min, respectively, from post-calibration to tracheal extubation. Results The time to first PTC appearance was significantly shorter by 33 min in the Pattern Cross group than in the Pattern N–K group (95% Confidence interval: 1–66, p  = 0.043). Following sugammadex administration, TOF ratios ≥ 0.9 were achieved in 72% of patients in the Pattern N–K group and 97% of those in the Pattern Cross group ( p  = 0.025). Conclusions Crossing the line connecting the anode and cathode with the ulnar nerve stabilizes EMG-based neuromuscular monitoring detectability.

Anesthesia awareness has potential psychological consequences. Use of the bispectral index (BIS) developed from a processed electroencephalogram has been reported to decrease anesthesia awareness. In this randomized, controlled trial comparing a BIS-based protocol with a protocol based on measurement of end-tidal anesthetic gases, two cases of definite anesthesia awareness occurred in each group. This study did not show a benefit of BIS monitoring in reducing the rate of anesthesia awareness. This trial compared a protocol based on the bispectral index (BIS) with a protocol based on measurement of end-tidal anesthetic gases. Two cases of definite anesthesia awareness occurred in each group. This study did not show a benefit of BIS monitoring in reducing the rate of anesthesia awareness. Anesthesia awareness, also known as unintended intraoperative awareness, is the explicit recall of sensory perceptions during general anesthesia. Anesthesia awareness is rare, 1 , 2 but the incidence may approach 1% in patients at high risk. 3 – 5 Anesthesia awareness can lead to anxiety and post-traumatic stress disorder. 6 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recommended that stringent efforts be made to prevent anesthesia awareness, 7 and the American Society of Anesthesiologists (ASA) has published guidelines on the subject. 8 According to a sentinel-event alert disseminated by the JCAHO, between 20,000 and 40,000 cases of anesthesia awareness may occur yearly in the . . .

Intraoperative facial nerve monitoring (IFNM) facilitates effective nerve preservation during ear and head and neck surgeries. Quantitative differences in the timely feasibility of IFNM during total intravenous anesthesia (TIVA) vs sevoflurane anesthesia have not been investigated. We conducted a randomized controlled trial in which 98 patients undergoing ear surgery were allocated to either the TIVA or sevoflurane group. We used quantitative neuromuscular monitoring of train-of-four (TOF) responses to assess achievements of IFNM-feasible conditions, and recorded the TOF count (TOFC) or TOF ratio of T4/T1 (TOFR). The primary outcome was the time interval between a TOFR of 0.25 and 0.75 (recovery index). The most important secondary outcome was the time to reach a TOFR of 0.25. We also recorded the quality of IFNM, intubation condition, patient-ventilator dyssynchrony, surgeon's satisfaction, and postoperative analgesic and antiemetic requirements. Ninety-two patients completed the study. The median [interquartile range] recovery index was significantly shorter in the TIVA group (9 [7-11] min) than in the sevoflurane group (34 [24-53] min), with a difference in medians of 25 min (95% confidence interval, 20 to 31; P < 0.001). Before IFNM requests, the time to TOFR of 0.25 was achieved earlier in the TIVA group (34 [29-41] min) than in the sevoflurane group (51 [43-77] min) (P < 0.001). Both groups achieved neuromuscular recovery in time for IFNM without a need for reversal agents. Intraoperative facial nerve monitoring was feasible earlier and faster under TIVA than under sevoflurane anesthesia. We suggest that TIVA may be a preferable choice over sevoflurane to meet a surgeon's request for an earlier IFNM. CRIS.nih.go.kr ( KCT0006676 ); first submitted 7 October 2021.

This correspondence is in response to Dr. David Allison’s comments to the Editor, regarding the American Society of Neurophysiological Monitoring’s (ASNM) updated intraoperative somatosensory evoked potential (SEP) monitoring position statement.

Purpose Mapping higher-order cognitive functions during awake brain surgery is important for cognitive preservation which is related to postoperative quality of life. A systematic review from 2018 about neuropsychological tests used during awake craniotomy made clear that until 2017 language was most often monitored and that the other cognitive domains were underexposed (Ruis, J Clin Exp Neuropsychol 40(10):1081–1104, 218). The field of awake craniotomy and cognitive monitoring is however developing rapidly. The aim of the current review is therefore, to investigate whether there is a change in the field towards incorporation of new tests and more complete mapping of (higher-order) cognitive functions. Methods We replicated the systematic search of the study from 2018 in PubMed and Embase from February 2017 to November 2023, yielding 5130 potentially relevant articles. We used the artificial machine learning tool ASReview for screening and included 272 papers that gave a detailed description of the neuropsychological tests used during awake craniotomy. Results Comparable to the previous study of 2018, the majority of studies (90.4%) reported tests for assessing language functions (Ruis, J Clin Exp Neuropsychol 40(10):1081–1104, 218). Nevertheless, an increasing number of studies now also describe tests for monitoring visuospatial functions, social cognition, and executive functions. Conclusions Language remains the most extensively tested cognitive domain. However, a broader range of tests are now implemented during awake craniotomy and there are (new developed) tests which received more attention. The rapid development in the field is reflected in the included studies in this review. Nevertheless, for some cognitive domains (e.g., executive functions and memory), there is still a need for developing tests that can be used during awake surgery.

BackgroundBariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography—increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension—we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (PL) throughout the respiratory cycle.MethodsAfter obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm H2O until a PL of 0 +/− 1 cm H2O was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively.ResultsTo achieve the goal of a transpulmonary pressure (PL) of 0 cm H2O at end expiration, PEEP levels of 16.7 cm H2O (95% KI 15.6–18.1) before and 23.8 cm H2O (95% KI 19.6–40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm H2O before and 20 and 25 cm H2O during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly.ConclusionPatients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.

Monitoring the nociception/antinociception balance for analgesic guidance during general anesthesia may improve the quality of anesthesia. The University Hospital of Lille (France) has developed an expert software system for automatic remifentanil administration based on the continuous monitoring of the Analgesia Nociception Index (MDoloris, France). We assessed the clinical efficacy and safety of the ANI-REMI-LOOP \"expert-system software\" during burn surgery in a monocentric randomized controlled trial. The trial was approved by the French Ethics Committee, and all patients gave written informed consent. From 2018 to 2022, 52 adults were randomized into two groups: manual remifentanil infusion (standard practice) or automatic remifentanil infusion (expert-system software) during BIS-guided propofol anesthesia at the burn center of the hospital. In the standard practice group, remifentanil administration was based on Minto's model and guided by the analgesia nociception index. In both groups, propofol was administered based on Schnider's model and guided by the BiSpectral Index (Covidien). The primary endpoint was the cumulative remifentanil dose administered during anesthesia and secondary endpoints were related to the clinical safety of automatic remifentanil administration with the incidence and duration of hypotension, bradycardia, hypertension or tachycardia related to nociception. After anesthesia, the endpoints were pain and analgesic requirements during 2 hours. A p value < 0.05 was considered statistically significant. Data are presented as median [1st to 3rd quartile]. The cumulative remifentanil dose was significantly lower in the automatic group 0.125 µg.kg-1.min-1 [0.106 to 0.149] vs. 0.152 µg.kg-1.min-1 [0.137 to 0.237], p = 0.004), and the cumulative proportion of time with hemodynamic impairment or reactivity was significantly lower in the expert-system automatic group 4.2% [2.5 to 5.7] vs. 19.4% [6.9 to 59.9], p = 0.010). There were no safety issues, and pain and analgesic requirements were similar in both groups after surgery. Automatic remifentanil administration demonstrated good clinical performances during propofol anesthesia for burn surgery. It is likely that these results can be extrapolated to any surgical setting under general anesthesia, but this needs to be tested with further randomized clinical trials.