Hyperspectral imaging for perioperative monitoring of microcirculatory tissue oxygenation and tissue water content in pancreatic surgery — an observational clinical pilot study

Background Hyperspectral imaging (HSI) could provide extended haemodynamic monitoring of perioperative tissue oxygenation and tissue water content to visualize effects of haemodynamic therapy and surgical trauma. The objective of this study was to assess the capacity of HSI to monitor skin microcirculation and possible relations to perioperative organ dysfunction in patients undergoing pancreatic surgery. Methods The hyperspectral imaging TIVITA® Tissue System was used to evaluate superficial tissue oxygenation (StO2), deeper layer tissue oxygenation (near-infrared perfusion index (NPI)), haemoglobin distribution (tissue haemoglobin index (THI)) and tissue water content (tissue water index (TWI)) in 25 patients undergoing pancreatic surgery. HSI parameters were measured before induction of anaesthesia (t1), after induction of anaesthesia (t2), postoperatively before anaesthesia emergence (t3), 6 h after emergence of anaesthesia (t4) and three times daily (08:00, 14:00, 20:00 ± 1 h) at the palm and the fingertips until the second postoperative day (t5–t10). Primary outcome was the correlation of HSI with perioperative organ dysfunction assessed with the perioperative change of SOFA score. Results Two hundred and fifty HSI measurements were performed in 25 patients. Anaesthetic induction led to a significant increase of tissue oxygenation parameters StO2 and NPI (t1–t2). StO2 and NPI decreased significantly from t2 until the end of surgery (t3). THI of the palm showed a strong correlation with haemoglobin levels preoperatively (t2:r = 0.83, p < 0.001) and 6 h postoperatively (t4: r = 0.71, p = 0.001) but not before anaesthesia emergence (t3: r = 0.35, p = 0.10). TWI of the palm and the fingertip rose significantly between pre- and postoperative measurements (t2–t3). Higher blood loss, syndecan level and duration of surgery were associated with a higher increase of TWI. The perioperative change of HSI parameters (∆t1–t3) did not correlate with the perioperative change of the SOFA score. Conclusion This is the first study using HSI skin measurements to visualize tissue oxygenation and tissue water content in patients undergoing pancreatic surgery. HSI was able to measure short-term changes of tissue oxygenation during anaesthetic induction and pre- to postoperatively. TWI indicated a perioperative increase of tissue water content. Perioperative use of HSI could be a useful extension of haemodynamic monitoring to assess the microcirculatory response during haemodynamic therapy and major surgery. Trial registration German Clinical Trial Register, DRKS00017313 on 5 June 2019

Hypertensive crisis precatheter ablation for resistant atrial fibrillation: a case of undiagnosed bilateral pheochromocytomas

A 63-year-old man with hypertension was referred for catheter ablation of persistent atrial fibrillation. He was diagnosed with paroxysmal atrial fibrillation approximately 6 years prior. Over the previous 12 months, his atrial fibrillation had become persistent despite medication optimisation for rate control and elective cardioversion. Sinus rhythm was restored briefly. The decision was made to pursue catheter ablation and isolation of the pulmonary veins. On anaesthetic induction, the patient suffered from a hypertensive crisis. The procedure was aborted, and the patient was admitted to hospital for investigations of secondary hypertension. Ultimately, the patient was diagnosed with bilateral pheochromocytomas. This case outlines the diagnostic challenges and cardiac comorbidities associated with bilateral pheochromocytomas.

301 Theatre Timing Audit (TTA): HPB and Transplant theatre timing during COVID

Introduction Severe-Acute-Respiratory-Syndrome-Coronavirus-2 is a novel, highly infectious virus that has spread throughout the world causing respiratory disease (COVID-19). COVID-19 was declared a global pandemic by the World Health Organisation in March 2020. The UK has been severely affected with around 70000 deaths recorded by December 2020. Surgical practice during this pandemic has changed, as peri-operative infections carry significant mortality and morbidity burden. Method Theatre timing from a large volume hospital specifically for HPB-Transplant dedicated theatres were assessed to evaluate the impact of the national/local COVID-19 protocols on service delivery. “Pre-COVID period” was defined by auditing times from ward-to-theatre, anaesthetic induction-to-start of procedure and end of procedure-to-transfer out of theatre for 2 consecutive weeks in October/November 2019. “COVID period-1” and “COVID period-2” were defined as two consecutive weeks during the UK government-imposed lockdown in April and November 2020, respectively. Results Under the care of the HPB-Transplant team pre-COVID 56 individuals were treated in 30 sessions. Only 16 patients (28.6% of capacity) in 12 sessions were treated in COVID period-1 and 48 patients were treated (85.7% of capacity) in 30 sessions in COVID period-2. Similar times were observed in transferring patients to theatre (p-value=0.265) and induction of anaesthesia (p-value=0.698) across the 3 periods. Significant delays were observed in transferring patients out of theatre during COVID period-1, that returned to near normal timing during COVID period-2 (16.6±12.8 Vs 39.4±10.9 Vs 17.6±10.5 min; p-value = &lt;0.00001). Conclusions Despite returning to near normal theatre timings in COVID period-2, we treat fewer patients, adversely affecting waiting lists.

Comparison of Atomised Sublingual Dexmedetomidine and Oral Midazolam as Preanaesthetic Medication in Children - A Prospective, Double Blind, Randomised Control Trial

BACKGROUND Pre-operative anxiety is common in children and its relief is an important concern for the anaesthesiologist. Oral midazolam has good sedative and anxiolytic properties. Dexmedetomidine, an alpha-2 agonist, produces sedation like natural sleep, in addition to having analgesic, anxiolytic and anaesthetic-sparing properties, making it a near ideal sedative. Alleviating this anxiety using minimally invasive and painless routes for sedative drugs is of paramount importance. The purpose of this study was to compare the sedation, child-parent separation, and mask acceptance between sublingual atomised dexmedetomidine and oral midazolam, along with the haemodynamic changes associated with these drugs. METHODS This prospective, double-blind, randomised control trial was conducted in a tertiary hospital setting. Using computer-generated randomisation, sixty paediatric patients were divided into one of two groups. Group - D received sublingual dexmedetomidine 1.5 µg/kg using a mucosal atomisation device, and Group - M, oral midazolam 0.5 mg/kg, 45 minutes before anaesthetic induction. Sedation status, child-parent separation, mask acceptance scores, haemodynamics and oxygen saturation were measured at baseline and every 15 minutes till induction. Quantitative data were compared with student’s t-test and repeated measures analysis of variance (ANOVA), and qualitative data using chi-square test. RESULTS Demographic data were comparable between the two groups. Children in Group - D were significantly more sedated (P < 0.0001), with lower heart rate at 30 and 45 minutes (P = 0.003, < 0.0001 respectively) than Group - M. However, mask acceptance score was significantly better (P = 0.007) in Group - M. Child-parent separation score was comparable. CONCLUSIONS Atomised sublingual dexmedetomidine produced significantly greater sedation and low-normal heart rate, but poorer mask acceptance than with oral midazolam. Child-parent separation was comparable. We conclude that sublingual atomised dexmedetomidine 1.5 µg/kg, is not a suitable alternative to oral midazolam 0.5 mg/kg for paediatric premedication. KEY WORDS Anaesthesia, Dexmedetomidine, Midazolam, Anti-Anxiety Agents, Premedication, Paediatric

A systematic scoping literature review on the use of child life therapy (CLT) in the perioperative setting

Background Children and their caregivers often experience anxiety related to a perioperative admission. A systematic scoping review was conducted to map the evidence for child life therapy, including the professional background of treating clinicians. Methods A scoping review was conducted using the Arksey and O’Malley methodology. Six databases: PubMed, CINAHL, PsychINFO, Cochrane Library, EMBASE and Web of Science were searched. Results After reviewing 578 titles and abstracts, and 55 full texts, 11 studies were retained. Included studies were randomised controlled trials ( n = 5), retrospective studies ( n = 3), descriptive studies ( n = 1) and clinical studies ( n = 2). Child life therapy was effective for anxiety, anaesthetic induction quality, child cooperation and parental satisfaction. Professions delivering interventions included Child Life Therapists, nurses and a multidisciplinary team. Conclusion There is emerging evidence for child life therapy which may be used to guide delivery of paediatric procedural support in perioperative settings. Further studies are needed to inform practice.

Comparison of alfaxalone versus propofol as anaesthetic induction agents in increasing the rate of survival and vigour of neonates

PICO question In routine canine caesareans, is alfaxalone a superior anaesthetic induction agent than propofol in increasing the rate of survival and vigour of neonates? Clinical bottom line Category of research question Treatment The number and type of study designs reviewed Three randomised positive clinical trials have compared the efficacy between alfaxalone and propofol in routine canine caesarean sections for increased neonatal survival and vigour Strength of evidence Weak Outcomes reported Although two studies found alfaxalone to be associated with higher Apgar scores for neonates than propofol, each study nonetheless revealed positive vigour and high survival rates from the use of either alfaxalone or propofol. The evidence is too weak to suggest that one induction agent is superior to another. The selection between the two induction agents may not be the main concern in regard to neonatal depression and 24 hour survival post-delivery, provided that the entire canine caesarean protocol is thoroughly and carefully studied Conclusion Text here How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Kombinasi Dexmedetomidine – Sevoflurane 0,5 MAC pada Bedah Mikro Reseksi Malformasi Arteri-Vena

Arterio-venous malformation (AVM) is a rare case, particularly among young patients (<40 years old). Maintaining haemodynamic stability and anticipating massive haemorrhage during micro surgery resection of AVM are fundamental for an anaesthetist. Total Intra Venous Anesthesia using propofol is still popular to control intracranial pressure as it is easily titrated and fast acting agent (both in onset and duration). Moreover, general neuruologic evaluation soon after anesthesia terminated is an integral important component of microsurgery of brain MAV. In this case report: a 20-year-old woman suddenly lost her consciousness and left-sided motors strength. Brain angiographic revealed an AVM in right frontal lobe. Microsurgery of brain AVM resection was performed. After 5-minute-preoxygenation, anaesthetic induction was performed by using propofol, fentanyl, rocuronium, and sevoflurane. The surgery went successfully using a combination of dexmedetomidine-sevoflurane 0.5MAC. Post-anaesthesia hemodynamic of this patient was in stable and without new neurologic deficit afterward.

Anaesthetic management of dogs with myxomatous mitral valve disease

Myxomatous mitral valve disease is the most commonly acquired heart disease in the dog. Affected dogs have a reduced forward stroke volume as a result of the regurgitant flow back through the compromised mitral valve leaflets. Primary care practitioners will be all too familiar with the challenges of performing a general anaesthetic on these animals and unfortunately, there is no ideal protocol for every case. Having knowledge of the haemodynamic changes that occur with myxomatous mitral valve disease, compared to structurally normal hearts, as well as a good understanding of pharmacological effects of agents used in general anaesthesia, is essential in the safe management of these cases. This article will summarise disease pathophysiology, concurrent cardiac medications and commonly used pre-anaesthetic, induction and maintenance agents available in primary care practice for use in dogs with myxomatous mitral valve disease.

The Inert Brain: Explaining Neural Inertia as Post-anaesthetic Sleep Inertia

“Neural inertia” is the brain’s tendency to resist changes in its arousal state: it is manifested as emergence from anaesthesia occurring at lower drug doses than those required for anaesthetic induction, a phenomenon observed across very different species, from invertebrates to mammals. However, the brain is also subject to another form of inertia, familiar to most people: sleep inertia, the feeling of grogginess, confusion and impaired performance that typically follows awakening. Here, we propose a novel account of neural inertia, as the result of sleep inertia taking place after the artificial sleep induced by anaesthetics. We argue that the orexinergic and noradrenergic systems may be key mechanisms for the control of these transition states, with the orexinergic system exerting a stabilising effect through the noradrenergic system. This effect may be reflected at the macroscale in terms of altered functional anticorrelations between default mode and executive control networks of the human brain. The hypothesised link between neural inertia and sleep inertia could explain why different anaesthetic drugs induce different levels of neural inertia, and why elderly individuals and narcoleptic patients are more susceptible to neural inertia. This novel hypothesis also enables us to generate several empirically testable predictions at both the behavioural and neural levels, with potential implications for clinical practice.