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Spinal cord stimulation (SCS) is proven to effectively relieve chronic neuropathic pain. However, some implanted patients may face loss of efficacy (LoE) over time, and conversion to more recent devices may rescue SCS therapy. Recent SCS systems offer novel stimulation capabilities, such as temporal modulation and spatial neural targeting, and can be used to replace previous neurostimulators without changing existing leads. Our multicenter, observational, consecutive case series investigated real-world clinical outcomes in previously implanted SCS patients who were converted to a new implantable pulse generator. Data from 58 patients in seven European centers were analyzed (total follow-up 7.0 years, including 1.4 years after conversion). In the Rescue (LoE) subgroup ( n = 51), the responder rate was 58.5% at the last follow-up, and overall pain scores (numerical rating scale) had decreased from 7.3 ± 1.7 with the previous SCS system to 3.5 ± 2.5 ( p < 0.0001). Patients who converted for improved battery longevity ( n = 7) had their pain scores sustained below 3/10 with their new neurostimulator. Waveform preferences were diverse and patient dependent (34.4% standard rate; 44.8% sub-perception modalities; 20.7% combination therapy). Our results suggest that patients who experience LoE over time may benefit from upgrading to a more versatile SCS system., Competing Interests: P.R. reports a consulting agreement with Boston Scientific and grants and personal fees from Medtronic and Abbott outside the submitted work. S.R. and G.M. report consulting agreements with Boston Scientific. J.V. reports a consulting agreement with Boston Scientific, Medtronic, Abbott, and uniQure and has received grants from the German Research Council and Medtronic, outside the submitted work, and speaker honoraria from Abbott, outside the submitted work. All other authors report no conflicts.

We report two cases of anesthesia for radical retropubic prostatectomy (RRP) in obese-chronic obstructive pulmonary disease (COPD) patients using the combination of epidural anesthesia and non-invasive ventilation (NIV). This technique avoided intubation, general anesthesia and perioperative pulmonary complications., (Copyright © 2011 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.)

Introduction: A study on 149 cardiopulmonary bypass (CPB) patients was performed to elucidate possible relationships between antithrombin (AT) activity and a subject's clinical profile or surgery characteristics., Methods: An initial dose (300 IU/kg) of heparin was administered before CPB. Additional boluses (100 IU/kg) were administered if the activated clotting time (ACT)≤460 s. AT activity and hematological parameters were determined preoperatively, during and after CPB, and at 12, 24, 36, and 48 hours post-intervention., Results: 29.5% patients required an additional dose of heparin during CPB. Preoperative AT was 96.5 ± 13.9% in all but 4 patients. AT was significantly lower during CPB and upon leaving the operating room (59.7%-80.0%). A small, but significant, inverse correlation was observed between AT at the end of CPB and the patient's age, as well as between basal preoperative AT and total heparin administered., Conclusions: Patient's age could be a moderate indicator of AT activity drop and low preoperative AT activity could be a sign of reduced anticoagulant efficacy of heparin during CPB.

Objective: To evaluate transfusion requirements, morbidity and mortality when 2 antifibrinolytic agents (aprotinin and tranexamic acid) were used in patients undergoing cardiac surgery., Patients and Methods: Comparison of the effects of 2 antifibrinolytic agents in 243 patients undergoing cardiac surgery between December 2006 and June 2008. We recorded the surgical procedures used, blood product transfusions required, complications (particularly renal), mortality, and length of hospital stay., Results: The patients were distributed into 2 groups to receive tranexamic acid (n = 144) or aprotinin (n = 99). The incidence of transfusion in the tranexamic acid group (31.94%) was nonsignificantly lower than in the aprotinin group (38.38%) (PF = .31). The mean (SD) number of units of packed red blood cells transfused was 0.67 (1.18) in the tranexamic acid group and 1.01 (1.54) in the aprotinin group (P = .07). The mean preoperative hemoglobin concentration in the tranexamic acid group (11.79 [1.71] mg/dL) was significantly lower than in the aprotinin group (12.35 [1.70] mg/dL) (P < .01). Incipient postoperative renal failure tended to occur more frequently in the aprotinin group (19.6% compared to 16%; P = .47). Mortality at 1 year was 9.02% in the tranexamic acid group (compared to 14.14% in the aprotinin group; PF-.21); the trend for mortality related to postoperative renal failure was similar (7.6% in the tranexamic acid group compared to 12.4% in the aprotinin group; P = .22). No significant differences were observed in postoperative complications or length of hospital stay. However, the lack of randomization and the small sample size do not allow for definitive conclusions., Conclusions: This study, subject to the aforementioned limitations, shows that tranexamic acid is as effective as aprotinin for reducing transfusion requirements in cardiac surgery in Spain.

The case is described of a pregnant patient with Marfan's syndrome scheduled at 39 weeks' gestation for elective caesarean section carried out for the first time by total intravenous anaesthesia (TIVA) with continuous intravenous (i.v.) infusion of propofol. The diagnosis was based on a positive family history, classic phenotype, scoliosis, arachnodactyly, high narrow palate, hyperextensible joints, ectopia lentis and mitral valve prolapse, with a secondary low mitral insufficiency. Maternal and fetal surveillance did not detect complications during the course of pregnancy. Elective caesarean section was performed at 39 weeks due to high-risk pregnancy and to avoid the risk of haemodynamic alterations that take place during labour and delivery. The patient was given general anaesthesia with continuous i.v. infusion of propofol and boluses of atracurium and fentanyl after delivery. The haemodynamics and oxygen saturation remained stable during surgery. Apgar scores were 9 at 1 and 5 min. The post-delivery course was unremarkable and post partum echocardiography showed no changes from before caesarean section. The cardiovascular problems of Marfan's syndrome, the risk of haemodynamic changes associated with pregnancy and delivery, its anaesthetic implications and the possible advantages of TIVA with continuous i.v. infusion of propofol in the anaesthetic management of caesarean section in patients with this disease are discussed.

We report the use of obstetrical extradural analgesia in a primigravida with Ehlers-Danlos syndrome type III. Management focused on the possible vascular tissue involvement and the risk of bleeding during the access into the extradural space. The procedure was performed after ruling out the anomalies in the dermis and its vasculature.

We studied the acute effects of a single dose of phenytoin (250 mg/kg) on peripheral neuromuscular function. The evoked muscle action potentials of the dorsal segmental muscles in the rat tail, and the conduction velocity of the dorsal nerve trunk which innervates them, were measured before and after the intraperitoneal injection of phenytoin. The experiments were performed at different temperatures, 27 (physiological tail temperature), 36 and 37 degrees C (physiological central temperature) in different groups of animals. The amplitudes of the evoked muscle action potentials in the treated groups showed no significant modifications at 27 degrees C, at 36 degrees C a small nonsignificant decrease could be observed, and a complete block occurred at 37 degrees C. The mean blocking time was approximately one hour. No significant variations of conduction velocity were observed at 27 and 36 degrees C, whereas it decreased significantly after 30 minutes at 37 degrees C. The results presented confirm phenytoin toxicity. How far these results, especially the decrease of nerve conduction velocity observed at 37 degrees C, confirm a previous hypothesis which supported that peripheral and central nervous system are affected by phenytoin by similar mechanisms, is discussed.