Cerebral oximetry is normally placed on the upper forehead to monitor the frontal lobe cerebral tissue oxygen saturation (SctO
2
). We present a case in which the SctO
2
was simultaneously monitored ...at both frontal and parietal regions during internal carotid artery (ICA) stenting. Our case involves a 79-year-old man who presented after a sudden fall and was later diagnosed with a watershed ischemic stroke in the distal fields perfused by the left middle cerebral artery. He had diffuse atherosclerotic occlusive lesions in the carotid and cerebral arterial systems including an 85 % stenotic lesion in the left distal cervical ICA. The brain territory perfused by the left ICA was devoid of collateral flow from anterior and posterior communicating arteries due to an abnormal circle of Willis. During stenting, the SctO
2
monitored at both frontal and parietal regions tracked the procedure-induced acute flow change. However, the baseline SctO
2
values of frontal and parietal regions differed. The SctO
2
–MAP correlation was more consistent on the stroked hemisphere than the non-stroked hemisphere. This case showed that SctO
2
can be reliably monitored at the parietal region, which is primarily perfused by the ICA. SctO
2
of the stroked brain is more pressure dependent than the non-stroked brain.
Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, ...hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.
The phase equilibria in the Mg-rich region of the Mg–Nd–Sr ternary system at 300 and 350 °C were established using equilibrated-sample method. Powder X-ray diffraction (XRD) technique and scanning ...electron microscopy (SEM) equipped with energy-dispersive spectroscopy (EDS) were used for phase composition determination. Four three-phase equilibria and four two-phase equilibria have been experimentally determined at both isothermal sections of 300 and 350 °C. The phase equilibria relationships in the Mg-rich side were studied. The major invariant reaction temperatures of vertical sections with 80 at. % Mg and 10 at. % Sr were determined with differential scanning calorimetry (DSC) test. Moreover, thermodynamic modeling of Mg–Nd–Sr ternary system has been carried out by CALPHAD method based on the present key experimental results. The liquid solution was described using the modified quasi-chemical model in the pair approximation (MQMPA). The compound energy formalism (CEF) was used for the solid phases. The present obtained thermodynamic database of Mg–Nd–Sr ternary system will provide an important support for the Mg-based biodegradable implant development.
Previous studies on the association between renal tissue desaturation and acute kidney injury (AKI) in infant cardiac surgery are limited by small sample sizes and inconsistent results. This ...prospective study aimed to determine the association between renal desaturation and AKI in infants undergoing surgical repair of an isolated ventricular septal defect (VSD).
Infants undergoing VSD repair involving cardiopulmonary bypass participated in this prospective cohort study. The exposure of interest was renal tissue desaturation, defined as at least 20% decrease in saturation from baseline for at least 60 consecutive seconds. Intraoperative care was not guided by renal oxygenation, as the anaesthesiologists were blinded to the monitor. The outcome was AKI arising within postoperative Days 1–3. The primary analysis was based on propensity score-matched infants with and without intraoperative renal desaturation.
Intraoperative renal desaturation was detected in 38 of 242 infants using near-infrared spectroscopy. This group of infants was matched with 114 infants without intraoperative renal saturation after propensity score matching. Acute kidney injury occurred in 47% (18/38) and 27% (31/114) of infants with or without renal desaturation, respectively. Infants with renal desaturation had higher odds of developing AKI than infants without renal desaturation based on conditional logistic regression (odds ratio 2.79; 95% confidence interval: 1.21–6.44; P=0.016). The cumulative time of renal desaturation correlated moderately with the ratio of postoperative peak creatinine to preoperative baseline creatinine (r=0.51; P<0.001).
Intraoperative renal desaturation is associated with increased odds of developing AKI after surgical repair of an isolated VSD involving cardiopulmonary bypass in infants.
NCT03941015.
Purpose
The association between conflicts of interest (COI) and study results or article conclusions in goal-directed hemodynamic therapy (GDHT) research is unknown.
Methods
Randomized controlled ...trials comparing GDHT with usual care were identified. COI were classified as industry sponsorship, author conflict, device loaner, none, or not reported. The association between COI and study results (complications and mortality) was assessed using both stratified meta-analysis and mixed effects meta-regression. The association between COI and an article’s conclusion (graded as GDHT-favorable, neutral, or unfavorable) was investigated using logistic regression.
Results
Of the 82 eligible articles, 43 (53%) had self-reported COI, and 50 (61%) favored GDHT. GDHT significantly reduced complications on the basis of the meta-analysis of studies with any type of COI, studies declaring no COI, industry-sponsored studies, and studies with author conflict but not on studies with a device loaner. However, no significant relationship between COI and the relative risk (GDHT vs. usual care) of developing complications was found on the basis of meta-regression (
p
= 0.25). No significant effect of GDHT was found on mortality. COI had a significant overall effect (
p
= 0.016) on the odds of having a GDHT-favorable vs. neutral conclusion based on 81 studies. Eighty-four percent of the industry-sponsored studies had a GDHT-favorable conclusion, while only 27% of the studies with a device loaner had the same conclusion grade.
Conclusions
The available evidence does not suggest a close relationship between COI and study results in GDHT research. However, a potential association may exist between COI and an article’s conclusion in GDHT research.
The coronavirus disease 2019, named COVID-19 officially by the World Health Organization (Geneva, Switzerland) on February 12, 2020, has spread at unprecedented speed. After the first outbreak in ...Wuhan, China, Chinese anesthesiologists encountered increasing numbers of infected patients since December 2019. Because the main route of transmission is via respiratory droplets and close contact, anesthesia providers are at a high risk when responding to the devastating mass emergency. So far, actions have been taken including but not limited to nationwide actions and online education regarding special procedures of airway management, oxygen therapy, ventilation support, hemodynamic management, sedation, and analgesia. As the epidemic situation has lasted for months (thus far), special platforms have also been set up to provide free mental health care to all anesthesia providers participating in acute and critical caring for COVID-19 patients. The current article documents the actions taken, lesson learned, and future work needed.
Why is pulse oximetry a standard monitor, whereas tissue oximeter is not? Is this a double-standard treatment?
There appears to be a lack of enthusiasm for a continual investigation into whether the ...use of pulse oximetry leads to reduced morbidity and mortality in acute care although there is no robust evidence attesting to its outcome benefits. In contrast, research investigating the outcome effectiveness of tissue oximetry-guided care is consistently ongoing. A recent randomized controlled trial involving 800 patients who underwent laparoscopic hysterectomy found that, although muscular tissue oxygen saturation-guided care did not reduce the overall occurrence of postoperative nausea and vomiting for all patients, it did reduce the occurrence of these symptoms in patients who had a body mass index ≥25. It was also observed that muscular tissue oxygen saturation increases when blood pressure falls following the administration of nicardipine. These studies highlight the persistence of interest in understanding the value of tissue oximetry in patient care.
Pulse oximetry and tissue oximetry are treated differently although neither monitor has robust evidence attesting to its outcome benefits. This difference may root in the difference in the physiology they monitor, the cost, the ease of use/interpretation/intervention and the relevance to patient safety and care quality. Pulse oxygen saturation represents a vital sign, whereas tissue oxygen saturation is likely a quality sign; however, further research endeavors are required to fully understand how to best use tissue oximetry.
The relationship between muscular tissue oxygen saturation (SmtO
2
) during surgery and postoperative nausea and vomiting (PONV) remains to be determined. Patients undergoing robotic hysterectomy ...participated in this prospective cohort study. SmtO
2
of the brachioradialis muscle in the forearm was continuously monitored during surgery. Thresholds based on relative changes or absolute values were systematically assigned. The relationship between thresholds and PONV was investigated based on threshold analysis (i.e., exceeding or not exceeding a threshold), area under the curve analysis (i.e., the size of the area enclosed by the SmtO
2
trace and threshold), and multivariable analysis by accounting for recognized PONV risk factors. PONV occurred in 35 of 106 patients (33%). Based on the multivariable analysis, the SmtO
2
threshold of 20% above baseline correlated with less PONV (OR 0.39; 95% CI 0.16–0.93; p = 0.034), and the following values correlated with more PONV: 5% below baseline (OR 2.37; 95% CI 1.26–4.45; p = 0.007), 20% below baseline (OR 16.08; 95% CI 3.05–84.73; p = 0.001), < 70% (OR 2.86; 95% CI 1.17–6.99; p = 0.021) and < 60% (OR 6.55; 95% CI 1.11–38.53; p = 0.038). Our study suggests that a potential therapeutic goal for PONV prophylaxis may be to maintain SmtO
2
at > 70% and above baseline.
Intraoperative controlled hypotension improves surgical field visibility by reducing blood loss (efficacy) but poses potential risks linked to organ hypoperfusion (safety). The use of controlled ...hypotension persists despite increasing evidence of associations between intraoperative inadvertent hypotension and adverse outcomes. Therefore, we tested the hypothesis that the focus and results of intraoperative controlled hypertension research differ across anaesthesia and surgery investigators because of differing priorities.
We systematically reviewed randomised trials comparing controlled hypotension with usual care with trials categorised by investigators' affiliation.
We identified 48 eligible trials, of which 37 were conducted by anaesthesia investigators and 11 by surgery investigators. For the primary outcome, 54% of the anaesthesia-led trials focused on safety, whereas all (100%) surgery-led trials focused on efficacy (P=0.004). Compared with usual care, mean arterial pressure in controlled hypotension was 23% (95% confidence interval CI 17–29%) lower in anaesthesia trials and 30% (95% CI 14–37%) lower in surgery trials; estimated blood loss was 44% (95% CI 30–55%) less in anaesthesia trials and 38% (95% CI 30–49%) less in surgery trials. Overall, blood loss was reduced by 43% (95% CI 32–53%), and trial sequential analysis supported an efficacy conclusion. Mean arterial pressure and estimated blood loss reductions were associated (R2=0.41, P=0.002). All trials were underpowered for safety outcomes, and none adequately evaluated myocardial or renal injury.
Anaesthesia researchers prioritised safety outcomes, whereas surgery researchers emphasised efficacy in controlled hypotension trials. Controlled hypotension significantly reduces blood loss. In contrast, safety outcomes were poorly studied. Given increasing observational evidence linking inadvertent hypotension to myocardial and renal injury, the safety of controlled hypotension remains to be addressed.
PROSPERO (CRD42023450397).
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