Search

Introduction: Delays in discharging patients from Acute Medical Units hamper patient flows throughout the hospital. The decision to discharge a patient is mainly based on the patients' physiological condition, but may vary between physicians. An objective decision-support system based on patients' physiological data may help minimizing unnecessary delays in discharge. The aim of this proof-of-concept study is to assess the feasibility of predicting whether patients in an Acute Medical Unit are physiologically fit-for-discharge using machine learning with commonly available hospital data. Furthermore, this study investigated how long before actual time of discharge from the Acute Medical Unit we could predict discharge fitness. Also, the predictive importance of features extracted from these data was assessed., Methods: Electronic Medical Records of patients who participated in a Randomized Controlled Trial conducted in an Acute Medical Unit were used retrospectively (N = 199). Only commonly available hospital data were used. Logistic Regression and Random Forest models were applied to predict every hour whether patients were physiologically fit-for-discharge. Nested 5-fold cross-validation with 5 repeats was used to optimize the model hyperparameters and to estimate the predictive performances., Results: Physiological discharge fitness was predictable with reasonable performance for Logistic Regression (mean AUROC: 0.67) and Random Forest (mean AUROC: 0.69). For an intuitively chosen classification threshold of 0.8, mean specificity was 93.3 % and sensitivity 14.1 %. Models could predict physiological discharge fitness more than 24 h earlier than actual time of discharge for most patients who were correctly predicted to be fit-for-discharge. Patient characteristics, vital signs and laboratory results were shown to be important predictors., Conclusion: This proof-of-concept study showed that it is feasible to predict with machine learning whether patients in an Acute Medical Unit are physiologically fit-for-discharge using commonly available hospital data., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Adding continuous monitoring to usual care at an acute admission ward did not have an effect on the proportion of patients safely discharged. Implementation challenges of continuous monitoring may have contributed to the lack of effect observed.

Purpose: This study tests if the pressure variation in the HFNC-system may allow for monitoring of respiratory rate and the pressure difference during breathing may be a marker of respiratory effort., Methods: A HFNC system (Fisher & Paykel Optiflow Thrive 950) was modified by adding a GE Healthcare D-Lite spirometry sensor attached to a respiratory module and a pressure transducer. Participants were instructed to breathe regularly, quickly and slowly during 4 different conditions (HFNC flow 30 l/min and 70 l/min and with an open and closed mouth). Respiratory rate was counted based on pressure variation shown on the monitor graphs and compared with the count by observation of the participant. The pressure difference between inspiration and expiration was tested for correlation with the respiratory rate, as a surrogate marker for respiratory effort., Results: Twenty five participants were included in this study. False detection of apnea in pressure-based measurements occurred in 10% and 11% of the measurements with open mouth position at 30 l/min and 70 l/min HFNC-flow, respectively, but not with a closed mouth. The 95% Limits of Agreement were - 1.85;1.91, -13.72;9,88, -2.25;2.47, -30.32;19.93 for the conditions of 30 l/min -closed mouth, 30 l/min - open mouth, 70 l/min - closed mouth and 70 l/min - open mouth, respectively. There was a correlation between pressure difference and respiratory effort, except for the condition of 30 l/min with open mouth., Conclusions: The pressure variation in the HFNC system allows for respiratory rate and effort monitoring, but requires further development to increase precision., Trial Registration: ClinicalTrials.gov (NCT05991843)., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

In Acute Admission Wards, vital signs are commonly measured only intermittently. This may result in failure to detect early signs of patient deterioration and impede timely identification of patient stability, ultimately leading to prolonged stays and avoidable hospital admissions. Therefore, continuous vital sign monitoring may improve hospital efficacy. The objective of this randomized controlled trial was to evaluate the effect of continuous monitoring on the proportion of patients safely discharged home directly from an Acute Admission Ward. Patients were randomized to either the control group, which received usual care, or the sensor group, which additionally received continuous monitoring using a wearable sensor. The continuous measurements could be considered in discharge decision-making by physicians during the daily bedside rounds. Safe discharge was defined as no unplanned readmissions, emergency department revisits or deaths, within 30 days after discharge. Additionally, length of stay, the number of Intensive Care Unit admissions and Rapid Response Team calls were assessed. In total, 400 patients were randomized, of which 394 completed follow-up, with 196 assigned to the sensor group and 198 to the control group. The proportion of patients safely discharged home was 33.2% in the sensor group and 30.8% in the control group (p = 0.62). No significant differences were observed in secondary outcomes. The trial was terminated prematurely due to futility. In conclusion, continuous monitoring did not have an effect on the proportion of patients safely discharged from an Acute Admission Ward. Implementation challenges of continuous monitoring may have contributed to the lack of effect observed. Trial registration: https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered: January 6, 2022., (© 2024. The Author(s).)

Study Objective: Cerebrospinal fluid (CSF) drainage and lavage are reported to reduce drug exposure after inadvertant intrathecal drug administration errors. This reviews aims to provide recommendations for this salvage technique, with regard to methodology, effectiveness and adverse events., Design: Systematic review. A search in the databases of Embase, Medline, Web of Science, Cochrane Central Register of Randomized Trials and Google Scholar was performed in 2022., Study Eligibility Criteria: All reports of individual patient data with CSF drainage or lavage with a percutaneous lumbar access for an intrathecal drug error were included., Measurements: The primary outcome is the description and count of CSF drainage or lavage, such as times and volume of drainage, volume of replacement and type of replacement fluid. Secondary outcomes are the effects, adverse events and overall outcome., Main Results: 58 cases were found, of which 24 were paediatric cases. There was a large variance in methodology, with regard to volume t and type of replacement fluid. In 45% of the cases the intrathecal drug removal continued. The effects were specifically reported in 27 cases, all demonstrated drug removal based on drug concentrations in the CSF (n = 20) and clinical signs (n = 7). Adverse effects were sought for in 17 cases and found intracranial haemorrhage in 3 cases. No interventions were required for these adverse events and the only reported long-term sequelae in these three patients was short-term memory impairment up to 6 months after the event (n = 1). The overall outcome depended largely on the causative agent., Conclusions: This review shows that CSF drainage or lavage leads to intrathecal drug removal, but it is unsure if this intervention leads to improved overall patient outcome. Based on aggregated data from case reports, we provide recommendations that may guide clinicians. The risk-benefit ratio should be weighed on a case-to-case basis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

We present three patients off-label treated with intravenous (IV) esketamine for treatment-resistant depression (TRD) of whom two (patients A and B, aged 72 and 77 years, respectively) were admitted to the psychiatric unit with depressive symptoms and one outpatient (patient C, aged 66 years). After six esketamine treatments over a period of three weeks, two patients showed improvement, as measured with the Hamilton Rating Scale for Depression (HRSD): the HRSD-score of patient A decreased from 36 to 9 and of patient C from 18 to 10. Patient B had no response to esketamine but was treated successfully with electroconvulsive therapy (ECT). Despite the presence of various somatic comorbidities, esketamine treatment appeared safe and well-tolerated by the patients. After the index treatment, patients A and C received maintenance treatment with esketamine (once every 4-6 weeks). We recommend to consider off-label IV esketamine treatment in patients suffering TRD with or without suicidality.

Background: Because of high demand on hospital beds, hospitals seek to reduce patients' length of stay (LOS) while preserving the quality of care. In addition to usual intermittent vital sign monitoring, continuous monitoring might help to assess the patient's risk of deterioration, in order to improve the discharge process and reduce LOS. The primary aim of this monocenter randomized controlled trial is to assess the effect of continuous monitoring in an acute admission ward (AAW) on the percentage of patients who are discharged safely., Methods: A total of 800 patients admitted to the AAW, for whom it is equivocal whether they can be discharged directly after their AAW stay, will be randomized to either receive usual care without (control group) or with additional continuous monitoring of heart rate, respiratory rate, posture, and activity, using a wearable sensor (sensor group). Continuous monitoring data are provided to healthcare professionals and used in the discharge decision. The wearable sensor keeps collecting data for 14 days. After 14 days, all patients fill in a questionnaire to assess healthcare use after discharge and, if applicable, their experience with the wearable sensor. The primary outcome is the difference in the percentage of patients who are safely discharged home directly from the AAW between the control and sensor group. Secondary outcomes include hospital LOS, AAW LOS, intensive care unit (ICU) admissions, Rapid Response Team calls, and unplanned readmissions within 30 days. Furthermore, facilitators and barriers for implementing continuous monitoring in the AAW and at home will be investigated., Discussion: Clinical effects of continuous monitoring have already been investigated in specific patient populations for multiple purposes, e.g., in reducing the number of ICU admissions. However, to our knowledge, this is the first Randomized Controlled Trial to investigate effects of continuous monitoring in a broad patient population in the AAW., Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered on 6 January 2022. Start of recruitment: 7 December 2021., (© 2023. The Author(s).)

Background: Analgesia after robot assisted radical cystectomy aims to reduce postoperative pain and opioid consumption, while facilitating early mobilization and enteral nutrition and minimizing complications. Epidural analgesia is currently recommended for an open radical cystectomy, but it is unclear if intrathecal morphine is a suiting, less-invasive alternative for a robot-assisted radical cystectomy., Methods: The analgesic method of choice changed from epidural anesthesia to intrathecal anesthesia for patients undergoing a robot-assisted radical cystectomy. This single-center retrospective study aims to investigate if there is a difference between epidural and intrathecal analgesia in postoperative pain scores, opioid consumption, length of hospital stays and postoperative complications. An Propensity Matched Analysis was added to conventional analysis to consolidate the findings., Results: The study population consisted of 153 patients of whom 114 received an epidural catheter with bupivacaine/sufentanil and 39 received a single shot of intrathecal bupivacaine/morphine. Mean pain scores on the first two postoperative days (POD) were slightly higher in the intrathecal analgesia group (epidural versus intrathecal analgesia, NRS POD0: 0(0-2)[0-8] versus 1(0-3)[0-5], p = 0.050; POD1: 2(1-3)[0-8] versus 3(1-4)[0-7], p = 0.058; POD2: 2(0-3)[0-8] versus 3(2-4)[0-7], p = 0.010). Total postoperative morphine consumption was similar over the first seven days: 15 mg (5-35)[0-148] in the epidural group versus 11 mg (0-35)[0-148] in the intrathecal morphine group, p = 0.167. Length of hospital stay and time until fit for discharge where slightly higher in the epidural group (respectively 7 days (5-9)[4-42] versus 6 days (5-7)[4-38], p = 0.006, and 5 days (4-8)[3-30]) versus 5 days (4-6)[3-34], p = 0.018). There was no further difference in postoperative course., Conclusions: This study showed that the effects of epidural analgesia and intrathecal morphine are comparable and that intrathecal morphine may be a suiting alternative for epidural analgesia., (© 2023. The Author(s).)

Background: Presenting symptoms of COVID-19 patients are unusual compared with many other illnesses. Blood pressure, heart rate, and respiratory rate may stay within acceptable ranges as the disease progresses. Consequently, intermittent monitoring does not detect deterioration as it is happening. We investigated whether continuously monitoring heart rate and respiratory rate enables earlier detection of deterioration compared with intermittent monitoring, or introduces any risks., Methods: When available, patients admitted to a COVID-19 ward received a wireless wearable sensor which continuously measured heart rate and respiratory rate. Two intensive care unit (ICU) physicians independently assessed sensor data, indicating when an intervention might be necessary (alarms). A third ICU physician independently extracted clinical events from the electronic medical record (EMR events). The primary outcome was the number of true alarms. Secondary outcomes included the time difference between true alarms and EMR events, interrater agreement for the alarms, and severity of EMR events that were not detected., Results: In clinical practice, 48 (EMR) events occurred. None of the 4 ICU admissions were detected with the sensor. Of the 62 sensor events, 13 were true alarms (also EMR events). Of these, two were related to rapid response team calls. The true alarms were detected 39 min (SD = 113) before EMR events, on average. Interrater agreement was 10%. Severity of the 38 non-detected events was similar to the severity of 10 detected events., Conclusion: Continuously monitoring heart rate and respiratory rate does not reliably detect deterioration in COVID-19 patients when assessed by ICU physicians., (© 2023. The Author(s).)

Our aim was to determine the agreement of heart rate (HR) and respiratory rate (RR) measurements by the Philips Biosensor with a reference monitor (General Electric Carescape B650) in severely obese patients during and after bariatric surgery. Additionally, sensor reliability was assessed. Ninety-four severely obese patients were monitored with both the Biosensor and reference monitor during and after bariatric surgery. Agreement was defined as the mean absolute difference between both monitoring devices. Bland Altman plots and Clarke Error Grid analysis (CEG) were used to visualise differences. Sensor reliability was reflected by the amount, duration and causes of data loss. The mean absolute difference for HR was 1.26 beats per minute (bpm) (SD 0.84) during surgery and 1.84 bpm (SD 1.22) during recovery, and never exceeded the 8 bpm limit of agreement. The mean absolute difference for RR was 1.78 breaths per minute (brpm) (SD 1.90) during surgery and 4.24 brpm (SD 2.75) during recovery. The Biosensor's RR measurements exceeded the 2 brpm limit of agreement in 58% of the compared measurements. Averaging 15 min of measurements for both devices improved agreement. CEG showed that 99% of averaged RR measurements resulted in adequate treatment. Data loss was limited to 4.5% of the total duration of measurements for RR. No clear causes for data loss were found. The Biosensor is suitable for remote monitoring of HR, but not RR in morbidly obese patients. Future research should focus on improving RR measurements, the interpretation of continuous data, and development of smart alarm systems., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: The ratio between Pao2 and Fio2 is used as a marker for impaired oxygenation and acute respiratory distress syndrome classification. However, any discrepancy between Fio2 and o2 fraction in the alveolus affects the Pao2/Fio2 ratio. Correcting the Pao2/Fio2 ratios using the alveolar gas equation may result in an improved reflection of the pulmonary situation. This study investigates the difference between standard and corrected Pao2/Fio2 in magnitude, its correlation with the mortality of acute respiratory distress syndrome classification, and trends over time., Design: A register and a retrospective study combined with the development of a mathematical model to determine the difference between standard and corrected Pao2/Fio2 ratio for various levels of Paco2 and atmospheric pressure., Setting: ICU in a secondary hospital in The Netherlands., Patients: Patients admitted to the ICU for pneumonia or acute respiratory distress syndrome. Register cohort: January 1, 2010, till March 1, 2020 (n = 1008). Retrospective cohort: March 1, 2020, till June 1, 2020 (n = 34)., Measurements and Main Results: The register was used to determine the 7-day ICU mortality per acute respiratory distress syndrome classification based on the standard and corrected Pao2/Fio2 ratio. The retrospective dataset correlated the Paco2 with Pao2/Fio2 ratio over time in patients with assumed stable oxygenation. The model demonstrated an increased difference between the standard and corrected Pao2/Fio2 ratios by a lower Fio2 and atmospheric pressure and higher Pao2 and Paco2. Reclassification of severe acute respiratory distress syndrome resulted in an increase in mortality from 28.1% for standard Pao2/Fio2 to 30.6% for corrected Pao2/Fio2 ratios. Acute Physiology and Chronic Health Evaluation scores correlated better with 7-day ICU-mortality when corrected Pao2/Fio2 ratio was used for classification. For patients with Fio2 less than 50% (n = 55), change in Paco2 correlated with change in Pao2/Fio2 ratio (r = -0.388; p = 0.003)., Interventions: A corrected Pao2/Fio2 ratio was calculated., Conclusions: Correcting the Pao2/Fio2 ratio for the alveolar gas equation predominantly affects patients with high ratios between Pao2 and Fio2 and Paco2 and at low atmospheric pressure. Using the corrected Pao2/Fio2 ratio for acute respiratory distress syndrome classification results in improved correlation with the 7-day ICU mortality and increases generalization among acute respiratory distress syndrome studies. The authors provide a free, web-based tool., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: The dose of intrathecal morphine is important because of its narrow therapeutic range. Due to a compounding error, pharmacy-compounded, ready-to-use syringes contained 1 mg ml -1 morphine instead of the intended 50 mcg ml -1 . Six patients consequently received this twenty-fold dose. This study aims to describe the serious adverse events in these six patients and a systematic review is added to describe the characteristics of serious adverse events after intrathecal morphine., Methods: A retrospective case series described all six patients that received the erroneous morphine intrathecally for analgesia after laparoscopic segmental colonic resections. The patients' charts were reviewed for the occurrence, timing, duration and management of adverse events, the vital signs at the night after surgery, and length of hospital stay. A systematic review investigated characteristics of serious adverse events after intrathecal morphine in a perioperative setting., Results: Four patients had a serious adverse event, which was respiratory depression combined with somnolence ( n  = 3) and hypotension ( n  = 1). The review yielded 63 cases with serious adverse events, predominantly somnolence and/or respiratory depression. The onset occurred between 2 and 24 hours after injection. The severity of symptoms varied and life-threatening respiratory depression only occurred after a dose >900 mcg or when potentiating medication was used. Naloxone did not affect analgesia. No prolonged sequalae occurred., Conclusion: This study reveals that respiratory depression and somnolence are the predominant serious adverse events after intrathecal morphine in a perioperative setting and demonstrated a large variation in the presentation of symptoms., Competing Interests: The authors declare no conflicts of interest regarding the publication of this paper., (Copyright © 2022 Mark V. Koning et al.)

Accidental extubation in the prone position is a medical emergency in which quick and low resource demanding airway management is required. Regaining oxygenation is the primary goal, but sometimes intubation may be required to regain oxygenation. Blind intubation through an i-gel® (Intersurgical Ltd, Wokingham, Berkshire, UK) may be a quick and low resource demanding method. However, the success rate of the use of an i-gel as an intubation conduit in the prone position is unknown. This was a prospective study in patients scheduled for lumbar surgery. General anaesthesia was induced in the prone position and an i-gel was inserted. After successful ventilation, up to three attempts at intubation using a VivaSight-SL single-lumen tube (Ambu A/S, Ballerup, Denmark) were performed. The first attempt was blinded for the operator and the patient's head was in a neutral position. The second attempt was blinded for the operator with the patient's head rotated laterally. The third attempt was on-screen and allowed various manoeuvres to facilitate intubation. A success rate of 70% was deemed clinically acceptable. The study was terminated early after 14 subjects because the success rate of 70% was not achievable. However, ventilation using the i-gel in the prone position was successful in 13 patients (93%). Intubation was successful in only one patient at the first attempt, one patient at the second attempt and three patients at the third attempt. Overall, the success rate was 36%. Blind intubation using an i-gel as an intubation conduit in the prone position is not recommended.Netherlands Trial Register number NL6387 (NTR7659).

Background: Low concentrations of morphine are required for safe dosing for intrathecal injections. Sometimes, manual dilution of morphine is performed to achieve these low concentrations, but risks dilution errors and bacterial contamination. The primary goal was to compare the concentrations of morphine and bupivacaine between four groups of syringes. The secondary goal was to investigate the difference in contamination rate between these groups., Methods: Twenty-five experienced anesthesia providers were asked to prepare a mixture of bupivacaine 2.0 mg/ml and morphine 60 μg/ml using 3 different methods as clean and precise as possible. The fourth method used was the aspiration of ampoules prepared by the pharmacy. The concentrations of morphine and bupivacaine were measured by High-Pressure Liquid Chromatography (HPLC). The medication was cultured for bacterial contamination., Results: Group 1 (median 60 μg/ml; 95% CI: 59-110 μg/ml) yielded 3 outliers above 180 μg/ml morphine concentration. Group 2 (76 μg/ml; 95% CI: 72-80 μg/ml) and 3 (69 μg/ml; 95% CI: 66-71 μg/ml) were consistently higher than the target concentration of 60 μg. The group "pharmacy" was precise and accurate (59 μg/ml; 95% CI: 59-59 μg/ml). Group 2 and "pharmacy" had one contaminated sample with a spore-forming aerobic gram-positive rod., Conclusion: Manually diluted morphine is at risk for deviating concentrations, which could lead to increased side-effects. Medication produced by the hospital pharmacy was highly accurate. Furthermore, even when precautions are undertaken, contamination of the medication is a serious risk and appeared to be unrelated to the dilution process.

Background: Intrathecal hydrophilic opioids decrease systemic opioid consumption after abdominal surgery and potentially facilitate enhanced recovery. A meta-analysis is needed to quantify associated risks and benefits., Methods: A systematic search was performed to find RCTs investigating intrathecal hydrophilic opioids in abdominal surgery. Caesarean section and continuous regional or neuraxial techniques were excluded. Several subgroup analyses were prespecified. A conventional meta-analysis, meta-regression, trial sequential analysis, and provision of GRADE scores were planned., Results: The search yielded 40 trials consisting of 2500 patients. A difference was detected in 'i.v. morphine consumption' at Day 1 {mean difference [MD] -18.4 mg, (95% confidence interval [CI]: -22.3 to -14.4)} and Day 2 (MD -25.5 mg [95% CI: -30.2 to -20.8]), pain scores at Day 1 in rest (MD -0.9 [95% CI: -1.1 to -0.7]) and during movement (MD -1.2 [95% CI: -1.6 to -0.8]), length of stay (MD -0.2 days [95% CI: -0.4 to -0.1]) and pruritus (relative risk 4.3 [95% CI: 2.5-7.5]) but not in nausea or sedation. A difference was detected for respiratory depression (odds ratio 5.5 [95% CI: 2.1-14.2]) but not when two small outlying studies were excluded (odds ratio 1.4 [95% CI: 0.4-5.2]). The level of evidence was graded as high for morphine consumption, in part because the required information size was reached., Conclusions: This study showed important opioid-sparing effects of intrathecal hydrophilic opioids. Our data suggest a dose-dependent relationship between the risk of respiratory depression and the dose of intrathecal opioids. Excluding two high-dose studies, intrathecal opioids have a comparable incidence of respiratory depression as the control group., Clinical Trial Registration: PROSPERO-registry: CRD42018090682., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium., Objectives: This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium., Methods: A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving spinal anesthesia (SA group) were compared with patients receiving spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defined by the DSM-V classification. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed., Results: The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19.7% in the SA group versus 5.9% in the SIM group (P = 0.046). This association remained significant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1.062 - 21.006, P = 0.041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium., Conclusions: This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study., Competing Interests: Conflict of Interests: None of the authors has any conflicts of interest to declare., (Copyright © 2020, Author(s).)

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg -1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1-8 [-60% to 50%]) vs. 13% (5-24 [-6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1-7 [0-41 mg]) vs. 15 mg (12-20 [8-61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1-6 [0-9]) vs. 5 (3-7 [0-9]), p = 0.001; less bladder spasms (NRS 1 (0-2 [0-10]) vs. 2 (0-5 [0-10]), p = 0.001 and less sedation; NRS 2 (0-3 [0-10]) vs. 3 (2-6 [0-10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1-7 [0-10]) vs. 0 (0-1 [0-10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy., (© 2019 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background and Objectives: Management of postoperative pain after laparoscopic segmental colonic resections remains controversial. We compared 2 methods of analgesia within an Enhanced Recovery After Surgery (ERAS) program. The goal of the study was to investigate whether administration of intrathecal bupivacaine/morphine would lead to an enhanced recovery., Methods: A single-center, randomized, double-blind controlled trial was performed (NL43488.101.13). Patients scheduled for laparoscopic segmental intestinal resections were considered. Exclusion criteria were patients in whom contraindications to spinal anesthesia were present, conversion to open surgery, and gastric and rectal surgery. The intervention group received single-shot intrathecal bupivacaine/morphine (12.5 mg/300 μg), with an altered dose for older patients. The control group received a sham procedure and a bolus of piritramide (0.1 mg/kg). Both groups received standardized general anesthesia and a patient-controlled intravenous analgesia pump as postoperative analgesia. All patients were treated according to an ERAS protocol. A decrease in days to "fit for discharge" was the primary outcome., Results: Fifty-six patients were enrolled. Intervention group patients were fit for discharge earlier (median of 3 vs 4 days, P = 0.044). Furthermore, there was a significant decrease in opioid use and lower pain scores on the first postoperative day in the intervention group. There were no differences in adverse events (except for more pruritus), time to mobilization, fluid administration, or patient satisfaction., Conclusions: This randomized controlled trial shows that intrathecal morphine is a more effective method of postoperative analgesia in laparoscopic surgery than intravenous opioids within an ERAS program. Recovery is faster and less painful with intrathecal morphine. Other studies have confirmed these results, although data on faster recovery are new and require confirmation in future trials., Clinical Trial Registration: This study was registered at ClinicalTrials.gov, identifier NCT02284282.

Introduction: The objective of this study was to determine the long-term efficacy of percutaneous glycerol rhizolysis of the trigeminal ganglion for treating patients with trigeminal neuralgia and search for predictors associated with (long-term) benefit to improve patient selection., Methods: A retrospective study in 60 consecutive patients treated with percutaneous glycerol rhizolysis of the trigeminal ganglion for trigeminal neuralgia. Charts were reviewed in combination with follow-up by questionnaire (n = 55, 92% response)., Results: Initial pain relief was achieved in 92% of the patients. Pain-free survival was 59% of the patients at 12 months and 53% at 24 months. Most common side effects were hypesthesia (15%), dry eye (5%), and meningitis (2%). In patients without involvement of the third branch of the trigeminal nerve, the initial effect was 79%, of which 90% achieved more than 2 years pain-free survival, compared with 97% initial effect and less than 40% pain-free survival of more than 2 years when the third trigeminal branch was involved., Discussion: The present study demonstrates that involvement of the third branch is a negative predictor for long-term outcome in percutaneous glycerol rhizolysis of the trigeminal ganglion in patients with classical trigeminal neuralgia. However, in the absence of third-branch involvement, glycerol rhizolysis yields excellent long-term results when initial positive effect is obtained.

Introduction: Stiff ears appear to be a warning sign for adrenal insufficiency. This remarkable and rare sign has not been described to present in adrenal insufficiency in the setting of critical care., Case Presentation: We present the case of a 68-year-old Caucasian male who underwent a thymoma resection and suffered from preoperative weight loss and lack of strength. The perioperative phase was characterised by hypotension and sputum stasis due to muscle weakness, which caused two readmissions to the intensive care unit. His physical examination showed two fully rigid auricles. In retrospect, our patient suffered from secondary adrenal insufficiency and hypogonadism., Conclusions: The bilateral rigid auricles appeared to be a warning sign for adrenal insufficiency. This remarkable sign is easily checked, and should prompt a higher index of suspicion towards adrenal insufficiency and other hormonal deficiencies.

Introduction: The objective of this study was to determine the efficacy of percutaneous radiofrequency (RF) treatment of the trigeminal ganglion for treating patients with trigeminal neuralgia, to determine which patients have a long-term benefit, and to evaluate the effect of RF parameters., Methods: A retrospective study in 28 consecutive patients in combination with a follow-up questionnaire (n = 26, 93% response)., Results: An initial treatment effect of 89% was observed, 60% sustained at 12-month follow-up. Major side effects were hypesthesia (56%), dry eye (20%), and masseter muscle weakness (12%). A lower sensory stimulation threshold during treatment was associated with better patient satisfaction (P = 0.016), improved pain relief (P = 0.039), and trended toward more hypesthesia (P = 0.077)., Discussion: This low-volume study reported treatment effects in an older population that were similar to previous studies. Only a higher incidence of hypesthesia was detected by long-term follow-up. This study supported the high efficiency of RF treatment, but there was a high level of side effects. Most notable, low sensory stimulation was associated with increased hypesthesia, whereas higher stimulation levels yielded less effectiveness. Further investigation of an optimal sensory stimulation range for percutaneous RF treatment of the trigeminal ganglion was found to be warranted., (© 2013 World Institute of Pain.)

Purpose: In continuous venovenous hemofiltration (CVVH) issues like timing and dose remain controversial, particularly in sepsis. The objective of this study is to examine which CVVH characteristic best predicts mortality in sepsis-induced acute kidney injury (AKI)., Materials and Methods: We retrospectively studied all consecutive patients with sepsis-induced AKI requiring CVVH in a 1.5-year period. Patient, sepsis, and CVVH characteristics, including timing, dose, mode, type of substitution fluid and of anticoagulation, and azotemic control were evaluated. Primary outcome was survival at day 28 after the start of CVVH., Results: Of the 97 patients, 43 (44%) died up to day 28 after the start of CVVH. In univariate analyses, the delivered dose of CVVH was about 10% higher in survivors than nonsurvivors (median, 23 vs 20 mL kg(-1) h(-1), P = .01). In multivariate analyses, a lower delivered CVVH dose contributed to predict higher mortality, independently of disease severity, type of substitution fluid, and azotemic control. In a Kaplan-Meier curve, a delivered dose less than 19.7 mL kg(-1) h(-1) was associated with shorter survival (P = .006)., Conclusion: Our retrospective data suggest that in sepsis-induced AKI requiring CVVH, delivered dose, rather than timing, mode of administration, and azotemic control, is an independent predictor of mortality. A lower delivered dose is associated with higher mortality., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background/aims: In view of ongoing controversy, we wished to study whether patient characteristics and/or continuous venovenous hemofiltration (CVVH) characteristics contribute to the outcome of non-septic critically ill patients with acute kidney injury (AKI)., Methods: We retrospectively studied 102 consecutive patients in the intensive care unit (ICU) with non-septic AKI needing CVVH. Patient and CVVH characteristics were evaluated. Primary outcome was mortality up to day 28 after CVVH initiation., Results: Forty-four patients (43%) died during the 28-day period after the start of CVVH. In univariate analyses, non-survivors had more often a cardiovascular reason for ICU admission, greater disease acuity/severity and organ failure, lower initial creatinine levels, less use of heparin and more use of bicarbonate-based substitution fluid. The latter two can be attributed to high lactate levels and bleeding tendency in non-survivors necessitating withholding lactate-buffered fluid and heparin, respectively, according to our clinical protocol. In multivariate analyses, mortality was predicted by disease severity, use of bicarbonate-based fluids and lack of heparin, while initial creatinine and CVVH dose did not contribute., Conclusion: The outcome of non-septic AKI in need of CVVH is more likely to be determined by underlying or concurrent, acute and severe disease rather than by CVVH characteristics, including timing and dose.

Background: Haemorrhoids are a common problem in daily practice. However, symptoms may also be caused by other abnormalities in the rectum or colon. Data on the presence of these abnormalities in patients with haemorrhoids is sparse. To examine the prevalence of abnormalities of the colon or rectum in patients with and without haemorrhoids, stratified for age., Methods: In a 17-year period 1910 consecutive patients with haemorrhoids and 7936 patients without haemorrhoids were analysed retrospectively. All of these patients had an endoscopic examination for different clinical reasons. All significant endoscopic co-findings (diverticuli, polyps, cancer, angiodysplasia and varices, or colitis) were recorded., Results: The patients were divided in 2 groups. Group 1 (n = 861 (45.1%)) consisted of patients with only haemorrhoids, group 2 (n = 1049 (54.9%)) consisted of patients with haemorrhoids and another endoscopic diagnosis. Patients in group 1 were significantly younger, mean age 55.3 +/- 14.1 years versus 67.4 +/- 12.1 years (p < 0.001), and underwent significantly more often a sigmoidoscopy, 11% versus 2% (p < 0.0001). Furthermore, endoscopic co-findings were found with increasing age. The majority of diverticuli, polyps, cancer and vascular lesions were detected in the age group above 50 years, while only colitis was more often present in the younger group. There was no significant difference in gender when group 1 and 2 were compared with the reference group. Diverticuli and angiodysplasia/varices occurred significantly more often in group 2. The other significant diagnoses were diagnosed more often in the reference group., Conclusion: In patients with haemorrhoids other abnormalities can be present. Especially in older patients the clinician must be cautious to attribute complaints solely to haemorrhoids.