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Abstract Introduction The aim of this randomized controlled trial was to investigate whether volatile anesthetics used for postoperative sedation have any beneficial effects on myocardial injury in cardiac surgery patients after on-pump valve replacement. Methods Anesthesia was performed with propofol. After arrival in the intensive care unit (ICU), 117 patients were randomized to be sedated for at least 4 hours with either propofol or sevoflurane. Sevoflurane was administered by using the anesthetic-conserving device. Troponin T, creatine kinase, creatine kinase from heart muscle tissue, myoglobin, and oxygenation index were determined on arrival at the ICU, 4 hours after sedation, and in the morning of the first postoperative day (POD1). Primary end points were cardiac injury markers on POD1. As secondary end points oxygenation, postoperative pulmonary complications, and ICU and hospital stay were documented. Results Fifty-six patients were analyzed in the propofol arm, and 46 patients in the sevoflurane arm. Treatment groups were comparable with regard to patient demographics and intraoperative characteristics. Concentration of troponin T as the most sensitive marker for myocardial injury at POD1 was significantly lower in the sevoflurane group compared with the propofol group (unadjusted difference, -0.4; 95% CI, -0.7 to -0.1; P < 0.01; adjusted difference, -0.2; 95% CI, -0.4 to -0.02; P = 0.03, respectively). Conclusions The data presented in this investigation indicate that late postconditioning with the volatile anesthetic sevoflurane might mediate cardiac protection, even with a late, brief, and low-dose application. Trial registration ClinicalTrials.gov: NCT00924222.

Abstract Malignant pheochromocytoma is a neuroendocrine tumor that originates from chromaffin tissue. Although osseous metastases are common, metastatic dissemination to the spine rarely occurs. Five years after primary diagnosis of extra-adrenal, abdominal pheochromocytoma and laparoscopic extirpation, a 53-year old patient presented with recurrence of pheochromocytoma involving the spine, the pelvis, both proximal femora and the right humerus. Magnetic resonance imaging and computed tomography revealed osteolytic lesions of numerous vertebrae (T1, T5, T10, and T12). In the case of T10, total destruction of the vertebral body with involvement of the rear edge resulted in the risk of vertebral collapse and subsequent spinal stenosis. Thus, dorsal instrumentation (T8-T12) and cement augmentation of T12 was performed after perioperative alpha- and beta-adrenergic blockade with phenoxybenzamine and bisoprolol. After thorough preoperative evaluation to assess the risk for surgery and anesthesia, and appropriate perioperative management including pharmacological antihypertensive treatment, dorsal instrumentation of T8-T12 and cement augmentation of T12 prior to placing the corresponding pedicle screws did not result in hypertensive crisis or hemodynamic instability due to the release of catecholamines from metastatic lesions. To the authors' knowledge, this is the first report describing cement-augmentation in combination with dorsal instrumentation to prevent osteolytic vertebral collapse in a patient with metastatic pheochromocytoma. With appropriate preoperative measures, cement-augmented dorsal instrumentation represents a safe approach to stabilize vertebral bodies with metastatic malignant pheochromocytoma. Nevertheless, direct manipulation of metastatic lesions should be avoided as far as possible in order to minimize the risk of hemodynamic complications.

Objective: The aim of this study was to validate the revised SenTec V-Sign 2 sensor (SenTec AG, Therwil, Switzerland) for combined noninvasive continuous assessment of pulse rate, pulse oximetry (SpO2), and transcutaneous carbon dioxide tension (PtcCO2) in adults after cardiac surgery. Design: A prospective clinical study. Setting: A single-center university hospital. Participants: Twenty adult patients aged 36 to 84 years after cardiac surgery. Interventions: SpO2 and PtcCO2 values of three V-Sign 2 sensors (SenTec AG) attached at the earlobe, forehead, and cheek and SpO2 values of the Nellcor Durasensor (Model DS-100A; Nellcor Puritan Bennett Inc, Pleasanton, CA) were compared with simultaneous measurements of blood gases and end-expiratory carbon dioxide. Measurements and Main Results: Measurements were performed during periods of hyper-, normo-, and hypocapnia and then at 30-minute intervals up to 5 hours. Bland-Altman analysis and simple regression analysis were used. Results: The detection failures for PtcCO2 were 0.3% to 1.3%, for SpO2 10% to 25%, and for pulse rate 5% to 10%. The V-Sign 2 earlobe sensor provided the best results. The mean bias and limits of agreement for PtcCO2ear and PaCO2 were 1.1 and −3.4/+5.5 mmHg. The drift of PtcCO2 was negligible at all locations. The mean bias and limits of agreement of V-Sign SpO2ear and SaO2, as well as V-Sign pulse rate and the electrocardiogram, were −1.7% and −6.8/+3.9% and 1.2 beats/min and −3.3/+5.8 beats/min. End-expiratory carbon dioxide showed a weak correlation with PaCO2 (r 2 = 0.47). Conclusions: Transcutaneous capnometry using the revised V-Sign 2 sensor at the earlobe is a reliable monitoring tool during the recovery period of patients after cardiac surgery. This approach has the potential to reduce the number of arterial blood gas samples. [Copyright &y& Elsevier]

Abstract Objective  The aim of this study was to validate the V-Sign digital sensor (SenTec AG, Therweil, Switzerland) for combined noninvasive assessment of pulse oxymetric oxygen saturation (SpO2) and transcutaneous carbon dioxide tension (PtcCO2) in adults after cardiac surgery. Methods  In twenty one patients, aged 51–86 years, simultaneous measurements of blood gases with the V-Sign Sensor and with two Nellcor Durasensors (model DS-100A), one at the opposite earlobe and one with a finger clip, were compared first during hyper-, normo- and hypocapnia and at different pulse rates using a pacemaker, and then at 2-h intervals up to 8 h. Agreement was assessed by Bland-Altman analysis. Results  PtcCO2 data of three patients were excluded because of calibration failure of the device. Median (range) PtcCO2 for the remaining patients was 5.49 (3.3–7.6) kPa and arterial carbon dioxide tension (PaCO2) was 5.43 (3.61–7.41) kPa. Corresponding mean bias was +0.05 kPa and limits of agreement (LOA) were −1.2/+1.3 kPa. During normo- and hypoventilation, mean bias was good at +0.02 and +0.04 kPa respectively, but limits of agreement were poor at −0.67/+0.69 and −0.81/+0.88 kPa. In 10 patients, an initial overshoot of PtcCO2 was observed. Mean bias of SpO2 and pulse rate was close to zero (−1.5% and +0.001 bpm respectively), but limits of agreement were unacceptably high (−21.4/+18.4% and −22.3/+22.3 bpm). Conclusions  In the present state of development the SenTeC Digital monitor V-Sign device has serious limitations. Additional efforts are necessary to eliminate calibration failures and the initial overshoot of PtcCO2 as well as to improve detection of SpO2 and pulse rate. [ABSTRACT FROM AUTHOR]

Introduction: Seizures count to critical situations emergency medical systems (EMS) are confronted with.Objectives: Evaluation of a modified treatment algorithm (MTAS-EMS) using diazepam and midazolam due to a supply bottleneck of iv lorazepam in 2012.Methods: Retrospective study where data from patients treated for seizures by the EMS of the city of Zurich were analyzed. Effectiveness of the MTAS-EMS and i.v. diazepam in children and adults was compared with respect of cessation of seizure without recurrence over the period until arrival at the hospital. The chi-square and Fisher's exact test were used to compare categorical data. The Student's t-test and Mann Whitney test were used to compare numerical data. p-values < 0.05 are considered significant.Results: Of 584 documented missions, 165 treated patients (126 adults and 39 children) were included. 115 patients (80 adults and 35 children) were treated according the MTAS-EMS. Cessation of seizure was achieved in 85% of the adults and in 97% of the children, if all options of the MTAS-EMS were used. The first dose of nasal midazolam was more successful in children compared to adults (p = 0.012). In adults, the single dose of i.v. diazepam terminated the seizure in 98% (p = 0.001) compared to 57% for the single dose of iv and 64% for nasal midazolam.Conclusions: The treatment success of the MTAS-EMS is high. However, in adults the single dose of i.v. diazepam is as successful as the completely used MTAS-EMS and seems to be superior to the single dose iv and nasal midazolam. [ABSTRACT FROM AUTHOR]

Background and Objective: Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. Methods: A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. Results: 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100–4100] versus 2900 mL [1600–5900], P < 0.0001) and postoperatively (700 mL [400–1500] versus 2300 mL [1800–3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2–30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. Conclusions: Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction. [Copyright &y& Elsevier]

Background: When trauma patients arrive in the emergency department (ED), coagulopathy frequently is present. The time course, however, in which this coagulopathy develops is poorly understood. No study has fully evaluated the coagulation status, including thromboelastometry on-scene and at hospital arrival. We hypothesized that measured coagulation variables might change when measured at the scene of injury and upon arrival to the ED., Methods: We performed a prospective, single-center, observational study investigating coagulation status in 50 trauma patients on-scene and at arrival in the ED. Measurements included arterial blood gases, ROTEM®, protein S100, protein C activity, protein S, Quick value, international normalized ratio, activated partial thromboplastin time, D-dimer, coagulation factor V (FV), coagulation factor XIII (FXIII), fibrinogen, hemoglobin, hematocrit, platelets, and volume and blood products being administered during the first 24 hours., Results: Significant changes between on-scene and the ED were observed for the following values: partial venous oxygen pressure increased and sodium, glucose, and lactate decreased. For EXTEM, INTEM, and APTEM, clotting time and clot formation time increased significantly, whereas maximal clot firmness and angle α decreased significantly (all P ≤ 0.004). For FIBTEM, clotting time increased significantly and maximal clot firmness decreased significantly. In the laboratory, significant reductions in hemoglobin, hematocrit, platelets, activated partial thromboplastin time, fibrinogen, FV, FXIII, protein C activity, protein S, and protein S100 were observed (all P ≤ 0.001)., Conclusions: Although most all laboratory and rotational thromboelastometry coagulation tests worsened over time when measured on-scene and in the ED, monitoring coagulation at the scene of trauma does not provide clinically important information in a majority of trauma patients. One hour after injury, significant activation and consumption of fibrinogen, FV, FXIII, protein C activity, and protein S were observed.

Background: The aim of this study was to determine the association between standard laboratory tests, coagulation factor concentrations, and Rotation Thromboelastometry (ROTEM® delta, TEM® International GmbH, Munich, Germany) in patients undergoing major surgery with hemorrhage., Methods: In 45 patient's fibrinogen, factor VIII, factor XIII, International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), thrombin time, hemoglobin, leukocytes, and platelet count were simultaneously measured intraoperatively with ROTEM (EXTEM, INTEM, FIBTEM, APTEM) measurements. ROTEM parameters were: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle. Demographic and laboratory data were expressed as mean ± SD and median [range]; nonparametric Spearman rank correlations and multiple linear regressions were performed; P-values ≤0.003 were considered significant., Results: Significant correlations (P ≤ 0.003) were found for CFT, α-angle, and MCF, in EXTEM, INTEM, and APTEM with platelets, INR, and fibrinogen. Factor VIII (18 measurements) showed a strong correlation (r ≥ 0.7 or r ≤ -0.7; all P ≤ 0.003) with MCF, CFT, and α-angle of EXTEM, INTEM, MCF of FIBTEM excluding CT of EXTEM, INTEM, FIBTEM and strong significant correlation for α-angle of APTEM and moderate for CFT and MCF of APTEM. A significant moderate to strong correlation of factor XIII with MCF of EXTEM, INTEM, FIBTEM, and APTEM was found. Hemoglobin was moderately correlated (r = 0.3-0.7 or r = -0.3 to -0.7) with MCF in APTEM (P = 0.003). A moderate to strong correlation of the standard coagulation tests with all ROTEM parameters was found, in particular the CT. The aPTT correlated significantly moderate to strong with CT, CFT, α-angle, and MCF of INTEM. However, multiple linear regressions were not able to show an influence of INR on ROTEM parameters except for APTEM-MCF. A significant impact of the aPTT on INTEM-CT was found. EXTEM, INTEM, and APTEM are significantly influenced by fibrinogen and platelets., Conclusions: The results confirm the clinical assumption that EXTEM, INTEM, and APTEM are associated with fibrinogen and platelets levels; INTEM-CT significantly to aPTT; and FIBTEM significantly to fibrinogen. Factor VIII showed a significant correlation with all ROTEM parameters except CT of EXTEM, INTEM, FIBTEM, and CFT and MCF of APTEM.

Design: Prospective randomised controlled study., Setting: Operation unit in a tertiary academic university hospital in a central European city. Period of the study was springtime and summer 2010., Patients or Other Participants: Twenty-four anaesthesiologists with various levels of professional experience were allocated to intubate an airway manikin either with the SensaScope (group S) or with the conventional Macintosh 3 laryngoscope (group L)., Interventions: Each participant performed three consecutive intubations with normal anatomy followed by three intubations with difficult anatomy. The airway difficulty was simulated by inflation of the manikin's tongue base with 40 ml of air. The times taken to view the larynx and to insert the tracheal tube were noted. The resulting tube position and the occurrence of dental damage were recorded., Main Outcome Measures: Those planned in the protocol., Results: In normal anatomy, the laryngeal view (group L 5.9 ± 4.2 s vs. group S 9.2 ± 3.5 s) and intubation (group L 13.4 ± 7.6 s vs. group S 23.3 ± 8.6 s) was more rapidly obtained with conventional laryngoscopy (values presented as mean ± SD). In difficult anatomy, only the SensaScope permitted successful laryngeal view (group L impossible vs. group S 9.9 ± 4.8 s) and tracheal intubation (group L impossible vs. group S 23.4 ± 8.8 s). The latter always enabled correct tracheal tube position, whereas with laryngoscopy alone either oesophageal intubation or aborted attempts resulted. In the difficult airway setting, the frequency of simulated tooth damage was also significantly higher with conventional laryngoscopy (group L 26 of 36 vs. group S 6 of 36)., Conclusions: The SensaScope performed fairly well in normal intubation anatomy, although its use was more complex than with conventional laryngoscopy and it required a slightly longer time. In the difficult airway setting, the SensaScope performed as well as in normal anatomy, whereas intubation by direct laryngoscopy proved to be impossible. The SensaScope enables the user to overcome severe airway difficulties caused by large tissue masses at the level of the tongue base or mouth floor.

Introduction: We aimed at quantifying the impact of continuous wound infusion with ropivacaine 0.33% on morphine administration and subjective pain relief in patients after open abdominal aortic repair in a double-blind, placebo-controlled study., Methods: Before closing the abdominal wound, 2 multihole ON-Q® Soaker Catheters™ (I-Flow Corporation, Lake Forest, California, USA) were placed pre-peritoneally in opposite directions. Either ropivacaine 0.33% or saline 0.9% was delivered by an elastomeric pump at a rate of 2 mL/h for 72 hours in each of the catheters. Postoperative pain and morphine administration were assessed using the numerical rating scale (NRS) in 4-hour intervals. Total plasma concentrations of ropivacaine, unbound ropivacaine, and α1-acid glycoprotein (AAG) were measured daily. Mean arterial pressure, pulse rate, oxygen saturation, total amount of morphine administration, ventilation time, and length of stay in the intensive care unit (ICU) were recorded. At the end of the study period, the wound site and the condition of the catheters were assessed., Results: The study was terminated prematurely due to a malfunction of the elastomeric balloon pump resulting in toxic serum levels of total ropivacaine in 2 patients (11.4 μmol/L and 10.0 μmol/L, respectively) on the second postoperative day. Six patients had been allocated to the ropivacaine group, and 9 patients had been allocated to the control group. Demographic and surgical data were similar in both groups. During the first 3 postoperative days, no difference between the ropivacaine and the control group was found in NRS (P = .15, P = .46, and P = .88, respectively) and morphine administration (P = .48). Concentrations of unbound serum ropivacaine (0.11 ± 0.08 μmol/L) were below toxic level in all patients., Conclusion: Continuous wound infusion of ropivacaine 0.33% 2 mL/h using an elastomeric system was not reliable and did not improve postoperative pain control in patients after open abdominal aortic surgery.

Factor XIII (F XIII) is an essential parameter for final clot stability. The purpose of this study was to determine the impact of the addition of factor (F)XIII on clot stability as assessed by Rotation Thromboelastometry (ROTEM). In 90 intensive care patients ROTEM measurements were performed after in vitro addition of F XIII 0.32 IU, 0.63 IU, 1.25 IU and compared to diluent controls (DC; aqua injectabile) resulting in approximate F XIII concentrations of 150, 300 and 600%. Baseline measurements without any additions were also performed. The following ROTEM parameters were measured in FIBTEM and EXTEM tests: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), maximum lysis (ML), maximum clot elasticity (MCE) and alpha-angle (alphaA). Additionally, laboratory values for FXIII, fibrinogen (FBG), platelets and haematocrit were contemporaneously determined. In the perioperative patient population mean FBG concentration was elevated at 5.2 g/l and mean FXIII concentration was low at 62%. The addition of FXIII led to a FBG concentration-dependent increase in MCF both in FIBTEM and EXTEM. Mean increases in MCF (FXIII vs. DC) of approximately 7 mm and 6 mm were observed in FIBTEM and EXTEM, respectively. F XIII addition also led to decreased CFT, increased alphaA, and reduced ML in FIBTEM and EXTEM. In vitro supplementation of FXIII to supraphysiologic levels increases maximum clot firmness, accelerates clot formation and increases clot stability in EXTEM and FIBTEM as assayed by ROTEM in perioperative patients with high fibrinogen and low FXIII levels.

Background and Objective: The present study compares the accuracy of a new continuous venous oxygenation monitoring system (PediaSat Oximetry Catheter) with laboratory blood oximetry in paediatric surgical patients., Methods: Children and adolescents undergoing cardiac, orthopaedic or craniofacial surgery with major blood loss were included. A 4.5 Fr two-lumen or 5.5 Fr three-lumen central venous oximetry catheter (SPediaSatcvO2) was inserted preoperatively into the superior vena cava. After in-vivo calibration of the PediaSat system, repeated blood samples were obtained from the distal port of the venous catheter and oximetrically analysed for haemoglobin and central venous oxygen saturation (SCO-OXcvO2). Central venous oxygen saturation values measured by the PediaSat (SPediaSatcvO2) were compared with co-oximetry (SCO-OXcvO2) values from the simultaneously taken blood samples by Bland-Altman and simple regression analyses., Results: Overall, 142 data pairs from 27 patients, aged from 0.6 to 19.0 years (median 5.3 years) were analysed. SPediaSatcvO2 and SCO-OXcvO2 values ranged from 57 to 98% and from 57.1 to 95.8%, respectively. Correlation between SPediaSatcvO2 and SCO-OXcvO2 was poor with r equal to 0.28 (P < 0.0001). SPediaSatcvO2 overestimated SCO-OXcvO2 (mean bias +2.6%), but limits of agreement (+/-2 SD of bias) were unacceptably high (-14.4/+19.6%). Sensitivity and specificity of SPediaSatcvO2 to indicate a fall or rise of SCO-OXcvO2 between two subsequent measurements were only 0.42 and 0.24, respectively., Conclusion: In paediatric and adolescent patients undergoing major surgery, the PediaSat system did not reliably reflect SCO-OXcvO2 values and cannot replace repeated invasive ScvO2 assessments in the clinically relevant range of ScvO2.

Background and Objective: In-vitro performance of the PediaSat system for continuous monitoring of central venous oxygen saturation by spectrophotometry has been evaluated., Methods: PediaSat continuous fibre-optic oximetry catheters were inserted in a black testing chamber, connected with an extracorporeal circuit and filled with human whole blood. Oxygen inflow into the cardiopulmonary bypass system was varied, and the testing chamber was perfused with blood flow of 1000 ml min(-1). Oxygen saturation values measured by PediaSat (S PediaSat O2) were compared with cooximetry (S CO-OX O2) values from simultaneously taken blood samples by Bland-Altman and simple regression analyses., Results: Fifty data pairs were obtained. S PediaSat O2 and S CO-OX O2 values ranged between 28-98 and 24.9-99.5%, respectively. Correlation between S PediSat O2 and S CO-OX O2 was high with an r2 value equal to 0.96 (P < 0.0001). Overall, S PediaSat O2 only slightly overestimated S CO-OX O2 (mean bias +2.9%), and limits of agreement (+/-2 SD of bias) were acceptable (-6.8/+12.6%). Sensitivity and specificity of the first differences of S PediaSat O2 and S CO-OX O2 were 1.0 and 0.92, respectively. Subgroup analysis of S CO-OX O2 values below 70% resulted in an overestimation by S PediaSat O2, with a mean bias of +5.2% and limits of agreement of -4.7 and +15.1%., Conclusion: The current version of the PediaSat system does not reliably reflect S CO-OX O2 values below 70%, but it seems to be a useful tool providing an accurate trend of continuous central venous oxygen saturation.