Anaesthesiology Update

Hull and East Yorkshire Hospitals NHS Trust Anaesthesiology Update

September 2018

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Latest from the Cochrane Database of Systematic Reviews

Psychological interventions for needle‐related procedural pain and distress in children and adolescents Kathryn A Birnie, Melanie Noel, Christine T Chambers, Lindsay S Uman, Jennifer A Parker

Psychological therapies for the management of chronic and recurrent pain in children and adolescents Emma Fisher, Emily Law, Joanne Dudeney, Tonya M Palermo, Gavin Stewart, Christopher Eccleston

Results from Embase Contents 438 of 438 results on EMBASE - (((0304-3959 OR 0007-0912 OR 1471-6771 OR 1528-1175 OR 0003-3022 OR 1526-5900 OR 1441-2772 OR 1744-8069 OR 0049-0172 OR 1098-7339 OR 1526-7598 OR 0003-2999 OR 0885-3924 OR 0003-2409 OR 1365-2044 OR 1533-3159 OR 1090-3801 OR 0749-8047 OR 1525-1403 OR 1094-7159 OR 0001-5172 OR 1399-6576 OR 0265-0215 OR 1365-2346 OR 1155-5645 OR 1460-9592 OR 1537-1921 OR 0898-4921 OR 0832-610X OR 1496-8975 OR 1526-2375 OR 1526-4637 OR 0375-9393 OR 1178-7090 OR 1203-6765 OR 0959-289X OR 1753-3740 OR 1521-6896 OR 1473-6500 OR 0952-7907 OR 2090-1542 OR 2090-1550 OR 1387-1307 OR 1573-2614 OR 1530-7085 OR 1533-2500 OR 1471-2253 OR 1532-8422 OR 1053-0770 OR 1064-6655 OR 1534-3081 OR 1531-3433 OR 0913-8668 OR 1438-8359 OR 1687-6970 OR 1687-6962 OR 0310-057X OR 1448-0271 OR 1089-2532 OR 1754-9493 OR 0360-1293 OR 0952-8180 OR 1932-2275 OR 0970-9185 OR 0974-5181 OR 0971-9784 OR 1551-7489).is AND ((Sevoflurane AND agitation).ti,ab OR exp "RESPIRATION CONTROL"/ OR exp "AIRWAY OBSTRUCTION"/ OR exp "AIRWAY REMODELING"/ OR exp "AIRWAY RESISTANCE"/ OR exp EXTUBATION/ OR exp "DIABETES MELLITUS"/ OR exp GYNECOLOGY/ OR exp "RESPIRATORY DISTRESS SYNDROME, ADULT"/ OR exp "LARYNGEAL MASK"/ OR exp "NERVE BLOCK"/ OR exp HEART/ OR exp "VISCERAL PAIN"/ OR exp SEPSIS/ OR exp "VASCULAR SURGERY"/ OR exp "EXERCISE TEST"/ OR exp "HEART FUNCTION TEST"/ OR exp DELIRIUM/ OR exp "ANTIINFECTIVE AGENT"/ OR exp "LOW BACK PAIN"/ OR ("enhanced recovery after surgery" OR ERAS).ti,ab OR exp FIBROMYALGIA/ OR exp "QUALITY CONTROL PROCEDURES"/ OR exp "QUALITY OF LIFE"/ OR ("fluid management").ti,ab)) NOT ("Conference Proceeding" OR Editorial OR Erratum OR Letter OR Note OR "Short Survey").pt) [Since 01-sep-2018]

1. Delirium detection using relative delta power based on 1 minute single-channel EEG: a multicentre study

2. Expiratory Central Airway Collapse in Adults: Corrective Treatment (Part 2)

3. Perioperative Right Ventricular Pressure Monitoring in Cardiac Surgery

4. Preoperative Right Ventricular Dysfunction Indicates High Vasoactive Support Needed After Cardiac Surgery

5. Agitation in adults in the post-anaesthesia care unit after general anaesthesia

6. Translation and Evaluation of a Lung Cancer, Palliative Care Intervention for Community Practice

7. Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review

8. Is Intraoperative Strain Analysis for Left Ventricular Diastolic Function Practical?

9. Impact of non-invasive continuous blood pressure monitoring on maternal hypotension during cesarean delivery: a randomized-controlled study

10. Seizures After Adult Cardiac Surgery and Interventional Cardiac Procedures 11. Prescription Medication Use Among Community-Based U.S. Adults With Chronic Low Back Pain: A Cross-Sectional Population Based Study

12. Cerebral Neuromonitoring During Cardiac Surgery: A Critical Appraisal With an Emphasis on Near-Infrared Spectroscopy

13. Anesthesia for Lung Transplantation in Cystic Fibrosis: Retrospective Review from the Irish National Transplantation Centre

14. Outcomes After Transcatheter Aortic Valve Replacement: A Propensity Matched Retrospective Cohort Study

15. The Year in Vascular Anesthesia: Selected Highlights From 2017

16. Hypnosis Enhances the Effects of Pain Education in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

17. Continuous Erector Spinae Plane (ESP) Block for Postoperative Analgesia after Minimally Invasive Mitral Valve Surgery

18. Estimating minimally important differences for the PROMIS pain interference scales: Results from 3 randomized clinical trials

19. Pain as a risk factor for common mental disorders. Results from the Netherlands Mental Health Survey and Incidence Study-2: A longitudinal, population-based study

20. Disease modifying actions of interleukin-6 blockade in a rat model of bone cancer pain

21. Developing a core outcome domain set to assessing effectiveness of interdisciplinary multimodal pain therapy: The VAPAIN consensus statement on core outcome domains

22. Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: An investigation of change processes

23. Interventions for attentional disruption in pain: Cognition-general, mechanism-specific, or exercise-based?

24. Biologic Impact of Mechanical Power at High and Low Tidal Volumes in Experimental Mild Acute Respiratory Distress Syndrome

25. In Vitro Negative Inotropic Effect of Low Concentrations of Bupivacaine Relates to Diminished Ca²⁺ Sensitivity but Not to Ca²⁺ Handling or beta-Adrenoceptor Signaling

26. Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial

27. Energetics and the Root Mechanical Cause for Ventilator-induced Lung Injury

28. Pharmacodynamics and pharmacokinetics of lidocaine in a rodent model of diabetic neuropathy 29. Astrocytic N-Myc downstream-regulated gene-2 is involved in nuclear transcription factor kappab-mediated inflammation induced by global cerebral ischemia

30. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation

31. Four types of pulse oximeters accurately detect hypoxia during low perfusion and motion

32. Prediction of bispectral index during target-controlled infusion of propofol and remifentanil

33. Practice guidelines for moderate procedural sedation and analgesia 2018

34. Advancing patient safety in airway management

35. Comparison of analgesic effect of oxycodone and morphine on patients with moderate and advanced cancer pain: A meta-analysis

36. Dopamine D2-receptor Antagonist Droperidol Deepens Sevoflurane Anesthesia

37. Cyclosporine before Coronary Artery Bypass Grafting Does Not Prevent Postoperative Decreases in Renal Function: A Randomized Clinical Trial

38. Suppressed descending pain modulatory and enhanced sensorimotor networks in patients with chronic low back pain

39. Half a century of anesthesia for children: An interview with Dr. Nishan G. 'Nick' Goudsouzian

40. Early US Experience With Stimulation of the Dorsal Root Ganglia for the Treatment of Peripheral Neuropathy in the Lower Extremities: A Multicenter Retrospective Case Series

41. Comparison of preoperative assessment of patient's metabolic equivalents (METs) estimated from history versus measured by exercise cardiac stress testing

42. Pilot Trial of the Reboot Online Program: An Internet-Delivered, Multidisciplinary Pain Management Program for Chronic Pain

43. Is HIV painful? An epidemiologic study of the prevalence and risk factors for pain in HIV-infected patients

44. Leading a horse to water facilitating registration and use of a prescription drug monitoring program

45. Mast cell stabilizer (ketotifen) in fibromyalgia phase 1 randomized controlled clinical trial

46. Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practices across VA health care systems

47. Contemporary pain management in elderly patients after hip fracture surgery: Cross-sectional analyses at baseline of a randomized controlled trial

48. Do patients with thalassemia minor or trait benefit from blood conservation methods preoperatively before undergoing high blood loss surgery? 49. High autologous wastage rate identifies opportunities for improving patient blood management

50. Standardization reliable recognition and treatment of pre-operative anemia using anemia reflex testing and pharmacy driven workflows

51. Bloodless revascularization: The protected PCI approach at Englewood Hospital

52. Variation on transfusion practice in first elective coronary artery bypass graft (CABG) surgery demonstrated by a statewide quality initiative

53. Can thromboelastography really assess coagulation in anemic patients?

54. Anemia clinic treatment and pre-operative management of cardiovascular surgery patients

55. Risk reduction versus blood conservation in the in the neonatal ICU

56. Utilizing change management to reduce transfusions in isolated coronary artery bypass grafting: Leveraging business models for clinical improvement

57. Prevalence of folate deficiency among preoperative anemia clinic patients: Retrospective research and quality improvement study

58. The safety of restrictive allogeneic blood transfusions strategy in patients with extremity sarcoma

59. Iron deficiency in pregnancy: A commonly unrecognized problem

60. Discharge hemoglobin <8 g/dL is associated with increased 30-day readmission rates after CABG

61. SABM 2018 Abstracts

62. Extended reliability and clinical utility of a validated intraoperative bleeding scale (VIBe SCALE)

63. Salvage of life-threatening acute blood loss anemia in the traumatic and post-operative setting: A case series of clinical experiences with hemopure (HBOC-201) blood substitute

64. Case series: The use of dexmedetomidine for sedation in patients undergoing carotid stent placement

65. Anesthesiologists' perspectives on total intravenous anesthesia

66. Acetaminophen does not reduce postoperative opiate consumption in patients undergoing craniotomy for cerebral revascularization

67. Anesthetic experience and management of awake craniotomy in a single academic center

68. Pilot retrospective study investigating ETCO₂ in stroke patients for emergency thrombectomy using JED (jaw elevation device)

69. Critical, subfatal venous air embolism during ventriculoperitoneal shunt placement 70. Institutional analysis of best practice related to usage of ASA monitors and hemodynamic changes with prone to supine emergence transition in neuroanesthesia practice: A retrospective analysis

71. Suspected propofol infusion syndrome during intraoperative total intravenous anesthesia for anterior and posterior cervical discectomy and fusion

72. Spinal cord ischemia and infarct presenting as cauda equina syndrome from disk herniation

73. The unarousable patient with nonconvulsive status epilepticus

74. This tube shall pass: Airway management in the setting of undiagnosed tracheal stenosis

75. Effect of the sitting versus the supine position on microbubble clearance times from the right atrium, right ventricle, and pulmonary artery

76. Effect of goal-directed intraoperative fluid therapy on hospital stay in patients undergoing excision of supratentorial tumors

77. The impact of anesthesia and perioperative factors on postcraniotomy infection in supratentorial high-grade gliomas patients: A retrospective analysis

78. Intravenous versus inhalational anaesthesia ( IVIA) trial for outcome following intracranial aneurysm surgery

79. Cardiovascular autonomic dysfunction in multiple sclerosis contributing to severe intraoperative hypotension

80. Intracranial aneurysms in patients under 18 years of age: Critical care experience of a tertiary care institute

81. Bioactivity of s-nitrosothiols as a novel indicator of hypoxia in brain-dead organ donors

82. A retrospective study comparing discrepancy between estimated and calculated blood loss and infectious complications in multilevel spinal fusion surgery

83. Early cardiovascular and cerebral hemodynamics response and cardiac dysfunction following moderate-severe traumatic brain injury

84. Predictive factors for hypotension after the supineto-prone positional change in patients undergoing spine surgery

85. Extubation criteria after posterior high cervical and occipital fusion: A single-center retrospective analysis

86. Diabetes mellitus and the risk of vasospasm after aneurysmal subarachnoid hemorrhage

87. Impact of concussion on postoperative complications: A retrospective matched cohort study

88. Effects of serum sodium level on postoperative outcome in patients after neurosurgical procedures 89. Perioperative use of IV milrinone for cerebral hypoperfusion in extracranial to intracranial bypass surgery: A case series

90. Conscious sedation versus general anesthesia during mechanical thrombectomy: A retrospective study (our institutional experience)

91. Exercise mediates anesthetic recovery in diabetic and control rats

92. Noninvasive intraoperative cerebral autoregulation: Monitoring and retrospective calculation of optimal arterial blood pressure in elective neurosurgical patients

93. Multimodal intraoperative management for severe carotid occlusion during spine surgery: A case report

95. Inadvertent burst suppression in a case series of 130 spine patients under total intravenous anesthesia

96. The risk factor of postoperative transient neurological events in pediatric patients of moyamoya disease: A retrospective study

97. A rare and unexpected cause of acute unilateral loss of transcranial motor evoked potential signal during posterior thoracic spine surgery

98. Incidence of post-operative visual dysfunction after robot-assisted laparoscopic radical prostatectomy

99. Effect of fosaprepitant on EEG, SSEP, and tcmep neuromonitoring under general anesthesia

100. Predictive factors of unpredicted movement in motor evoked postential during intraoperative neurophysiologic monitoring in adult patients undergoiing brain surgery

101. Shaking spell during a repeat epidural blood patch: Convulsive syncope, epileptic seizure, or local anesthetic toxicity? A diagnostic dilemma

102. Dermatomal somatosensory evoked potential (SSEP) monitoring using a novel automated SSEP deivce: A feasibility study

103. Phenylephrine modulates CSF IL-6 concentration in a sex dependent manner to protect cerebral autoregulation and reduce hippocampal necrosis after traumatic brain injury in newborn pigs

104. Cardiomyopathy in limb-girdle muscular dystrophy: A case presentation and perioperative implications

105. Clinical utility of intraoperative cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic and thoracoabdominal aneurysm repair: An audit of the Japanese association of spinal cord protection in aortic surgery database 106. Ultra-low tidal volume ventilation (ULTVV) reduces neuroinflammation after experimental cardiopulmonary resuscitation

107. Trans-odontoid screw migration and airway management in the neurosurgical patient

108. Delayed onset macroglossia after posterior fossa surgery requiring enteral feeding tube

109. Effect of anesthetic choice on hemodynamics and vasopressor use after mechanical thrombectomy for acute ischemic stroke

110. Variability in cerebral oxygen extraction fraction during anesthesia: Luxury and misery perfusion patterns

111. Case series: A novel approach to maintaining normothermia in major spinal deformity surgery

112. Delivering anesthesia for emergent neurosurgery in the parturient

113. Spontaneous oscillation in brain electroencephalography, hemodynamics and metabolism: An opportunity to evaluate neurovascular coupling?

114. Loss of motor evoked potentials before posterior cervical fusion and return with subtle head manipulation

115. Anesthetic management of awake craniotomy under intraoperative MRI versus traditional operating room setup

116. Descriptive analysis of quality improvement reporting patterns in neuroanesthesia

117. Unilateral, lower extremity loss of somatosensory evoked potential in a patient undergoing general anesthesia for spine surgery

118. Attainment of neuromonitoring signals using long subdermal needle electrodes in a morbidly obese patient

119. Intraoperative pulmonary embolism during craniotomy: A case report

120. Protocolized perioperative care for complex spine surgeries and the resulting reduction in ICU/hospital length of stay

121. Bias in before?after studies: Narrative overview for anesthesiologists

122. American college of surgeons children's surgery verification quality improvement program: What anesthesiologists need to know now

123. Occupational and ergonomic factors associated with low back pain among car-patrol police officers

124. Association between the 2011 Fibromyalgia Survey Criteria and Multisite Pain Sensitivity in Knee Osteoarthritis

125. Back to living: Long-term functional status of pediatric patients who completed intensive interdisciplinary pain treatment 126. Effect of stellate ganglion block on the regional hemodynamics of the upper extremity: A randomized controlled trial

127. Peripheral nerve blocks for hip fractures: A cochrane review

128. Teaching medical students clinical anesthesia

129. Delineating the trajectory of cognitive recovery from general anesthesia in older adults: Design and rationale of the TORIE (Trajectory of recovery in the elderly) project

130. Reduction in operating room plasma waste after evidence-based quality improvement initiative

131. Validation of a new method to automatically select cases with intraoperative red blood cell transfusion for audit

132. Physiology and role of intraocular pressure in contemporary anesthesia

133. Preventing adverse events in cataract surgery: Recommendations from a Massachusetts expert panel

134. The technology of video laryngoscopy

135. Usefulness of basophil activation tests for diagnosis of sugammadex-induced anaphylaxis

136. Section editor: Tong j. Gan intensive care unit enhanced recovery pathway for patients undergoing orthotopic liver transplants recipients: A prospective, observational study

138. The American college of surgeons children?s surgery verification and quality improvement program: Be careful what you wish for!

139. Pain reconceptualisation after pain neurophysiology education in adults with chronic low back pain: A qualitative study

140. The MitraClip Procedure-A Comprehensive Review for the Cardiac Anesthesiologist

142. Validation of a Limitations in Daily Activities Scale for Chronic Pain

143. Quality improvement studies - pitfalls of the before and after study design

144. Machine learning based framework to predict cardiac arrests in a paediatric intensive care unit: Prediction of cardiac arrests

145. Assessment of central hemodynamic effects of phenylephrine: an animal experiment 146. Identify and monitor clinical variation using machine intelligence: a pilot in colorectal surgery

147. Evaluation of the Neuropathic Component of Chronic Low Back Pain

150. Intraoperative Transesophageal Echocardiography and Right Ventricular Failure After Left Ventricular Assist Device Implantation

151. Successful Rescue Utilization of Intraoperative Tissue Plasminogen Activator in the Setting of Massive Thrombosis of Avalon Catheter and Patient in Extremis with Refractory Hypoxemia

152. Acute Kidney Injury After Total Arch Replacement Combined With Frozen Elephant Trunk Implantation: Incidence, Risk Factors, and Outcome

153. Cardiopulmonary Bypass and Malaria Relapse

154. Cardiovascular Collapse During Liver Transplantation-Echocardiographic-Guided Hemodynamic Rescue and Perioperative Management

155. Preoperative Intra-Aortic Counterpulsation in Cardiac Surgery: Insights From a Retrospective Series of 588 Consecutive High-Risk Patients

156. Heart Failure With Preserved Ejection Fraction-A Systematic Review and Analysis of Perioperative Outcomes

157. Comparison of Levosimendan and Milrinone for ECLS Weaning in Patients After Cardiac Surgery-A Retrospective Before-and-After Study

158. A Diastolic Murmur and the Mitral Valve

159. Chronic Lung Disease and Mortality after Cardiac Surgery: A Prospective Cohort Study

160. Serratus Anterior Plane Block for Apical TAVR in an Awake Patient

161. Alkaptonuric Ochronosis and the Failure of Regional Cerebral Tissue Oxygen Saturation Monitoring by Two Different Near-infrared Spectroscopy Devices

162. Unexpected Findings in a Man with a Repaired Type A Aortic Dissection and a New Stroke

163. Six-Month Outcomes After High-Risk Coronary Artery Bypass Graft Surgery and Preoperative Intra-aortic Balloon Counterpulsation Use: An Inception Cohort Study

164. Association of Oral Intake and Transient Mixed Venous Oxygen Desaturation in Patients Undergoing Fast-Track Postoperative Care After Open-Heart Surgery

165. A Peculiar Radial Artery Pressure Waveform After Aortic Valve Replacement 166. Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project

167. The effect of the volume of supra-inguinal injected solution on the spread of the injectate under the fascia iliaca: a preliminary study

168. Establishment of Predictive Models for Nonocclusive Mesenteric Ischemia Comparing 8,296 Control with 452 Study Patients

169. Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles

170. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: renal endpoints

171. Pulmonary-Systemic Pressure Ratio Correlates with Morbidity in Cardiac Valve Surgery

172. Minute ventilation assessment in the PACU is useful to predict postoperative respiratory depression following discharge to the floor: A prospective cohort study

173. Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update

174. Comparison between neurally-assisted, controlled, and physiologically variable ventilation in healthy rabbits

175. Factor IX from prothrombin complex concentrate augments low dose tissue factor-triggered thrombin generation in vitro

176. Blood flow index as an indicator of successful sciatic nerve block: a prospective observational study using laser speckle contrast imaging

177. Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model

178. Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation

179. Femoral nerve catheter vs local infiltration for analgesia in fast track total knee arthroplasty: short-term and long-term outcomes

180. Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome

181. European Pain Federation (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management

182. Fascial layers influence the spread of injectate during ultrasound-guided infraclavicular brachial plexus block: a cadaver study

183. Controversies in office-based anesthesia: Obstructive sleep apnea considerations 184. Non-ventilatory therapies for acute respiratory distress syndrome

185. Chronic non-cancer pain in children: We have a problem, but also solutions

186. Monitoring the Oxygen Reserve Index can contribute to the early detection of deterioration in blood oxygenation during one-lung ventilation

187. Mortality and long-term quality of life after percutaneous tracheotomy in Intensive Care Unit: A prospective observational study

189. Comorbid fibromyalgia: A qualitative review of prevalence and importance

190. Quality of life after spinal cord injury: The impact of pain

191. Ultrasound-guided adductor canal block: a cadaver study investigating the effect of a thigh tourniquet

192. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications

193. Renal Angina Is a Sensitive, but Nonspecific Identifier of Postcardiac Surgery Acute Kidney Injury

194. Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study

195. Predicting pain recovery in patients with acute low back pain: Updating and validation of a clinical prediction model

196. Misaligned feeding may aggravate pain by disruption of sleep-awake rhythm

197. Proximal versus distal continuous adductor canal blocks: Does varying perineural catheter location influence analgesia? A randomized, subject-masked, controlled clinical trial

198. Benefit and harm of adding epinephrine to a local anesthetic for neuraxial and locoregional anesthesia: A meta-analysis of randomized controlled trials with trial sequential analyses

199. Newborn resuscitation skills in health care providers at a zambian tertiary center, and comparison to world health organization standards

200. Rates of perioperative respiratory adverse events among caucasian and African American children undergoing general anesthesia

201. Clonidine effect on pain after cesarean delivery: A randomized controlled trial of different routes of administration

202. Safety and effectiveness of a novel facemask for positive pressure ventilation

203. Perioperative peripheral nerve injury after general anesthesia: A qualitative systematic review 204. Consensus statement on perioperative use of neuromuscular monitoring

205. Complications associated with mortality in the national surgical quality improvement program database

206. Anesthesia for percutaneous pulmonary valve implantation: A case series

207. Anesthesiology and palliative care: Past, present, and future

208. Safety and efficacy of addition of hyaluronidase to a mixture of lidocaine and bupivacaine in scalp nerves block in elective craniotomy operations; Comparative study

210. Epidemiology of acute kidney injury and the role of urinary [TIMP-2].[IGFBP7]: a prospective cohort study in critically ill obstetric patients

211. Multimodal general anesthesia approach for Ex Utero Intrapartum Therapy (EXIT) procedures: two case reports

212. Familial factors predicting recovery and maintenance of physical activity in people with low back pain: Insights from a population-based twin study

213. Current Aura Without Headache

215. The effects of general anaesthesia on oxygen consumption: A meta-analysis guiding future studies on perioperative oxygen transport

216. Beyond Hypnograms: Assessing Sleep Stability Using Acoustic and Electrical Stimulation

217. Required cefazolin concentration to maximize diagnostic accuracy of the basophil activation test for cefazolin-induced anaphylaxis

221. Diagnostic point-of-care ultrasound: applications in obstetric anaesthetic management

222. The impact of preinduction fentanyl dosing strategy on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

223. Meta-analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy

224. A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery

226. Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005- 2015: a national observational study

227. Factors influencing consent to organ donation after brain death certification: A survey of 29 Intensive Care Units

228. Analysis of inpatient falls after total knee arthroplasty in patients with continuous femoral nerve block

229. A survey of current anesthesia trends for electrophysiology procedures

230. The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

231. Effect of remifentanil on postoperative nausea and vomiting: a randomized pilot study

232. The Adjective Rating Scale for Withdrawal: Validation of its ability to assess severity of prescription opioid misuse

233. Effect of a lateral infraclavicular brachial plexus block on the axillary and suprascapular nerves as determined by electromyography - a cohort study

234. Left Ventricular Decompression Using a Percutaneous Transvalvular Microaxial Ventricular Assist Device in Patients Receiving VA ECMO

235. To OTE or Not to OTE: That Is the Question-Current International Trends of on the Table Extubation After Pediatric Cardiac Surgery

236. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care

237. Extended-Release Morphine for Chronic Breathlessness in Pulmonary Arterial Hypertension-A Randomized, Double-Blind, Placebo-Controlled, Crossover Study

238. Ultrasound-guided phrenic nerve block for intraoperative persistent hiccups: A case report 239. Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

240. Sacral neuromodulation for fecal incontinence (FI)

241. Use of vancomycin impregnated beads to salvage intrathecal pump pocket dehiscence

242. A systematic review of parasthesia-free spinal cord stimulation modes for complex regional pain syndrome

243. Posterior lumbar/sacral nerve root stimulation for treatment of chronic foot and/or Ankle pain

244. Correlation of patient-reported and objectively monitored activity and sleep in patients undergoing neuromodulation trials for neuropathic pain syndromes

245. Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: 12-month results of an international multicenter randomized trial (PROMISE Study)

246. In reply: Encouraging a bare minimum while striving for the gold standard: a response to the updated WHO-WFSA guidelines

247. Encouraging a bare minimum while striving for the gold standard: a response to the updated WHO-WFSA guidelines

248. Factors Associated with Sport-Related Post-concussion Headache and Opportunities for Treatment

249. A Concurrent Cognitive Task Does Not Perturb Quiet Standing in Fibromyalgia and Chronic Fatigue Syndrome

250. Procalcitonin kinetics after burn injury and burn surgery in septic and non-septic patients - a retrospective observational study

251. Expanding Goals of Care Conversations Across a Health System: The Mapping the Future Program

252. Quality of Life Trends in People With and Without Cancer Referred to Volunteer-Provided Palliative Care Services (ELSA): A Longitudinal Study

253. Treat to target strategy in early rheumatoid arthritis versus routine care - A comparative clinical practice study

254. Exploring the patient experience of digital ulcers in systemic sclerosis

255. Diagnostic accuracy of a calibrated abdominal compression to predict fluid responsiveness in children

256. Airway management in microgravity: A systematic review

257. Haemodynamic stability after paracervical block: A randomized, controlled, double-blind study comparing bupivacaine-adrenaline with bupivacaine 258. Bias and sample size in intensive care unit trials: Protocol for a meta-epidemiological study

259. Intraoperative anesthetic management of an infant with a bridging bronchus: A case report

260. Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass

261. Assessment of skin temperature during regional anaesthesia-What the anaesthesiologist should know

262. Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography-A randomised trial

263. Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis

264. Renal effects of norepinephrine-induced variations in mean arterial pressure after liver transplantation: A randomized cross-over trial

265. Artificial ventilation during transport: A randomized crossover study of manual resuscitators with comparison to mechanical ventilators in a simulation model

266. Continuous vital sign monitoring after major abdominal surgery-Quantification of micro events

267. Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit

268. Pre-operative haemodynamic monitoring and resuscitation in hip fracture patients: Protocol for a prospective observational study

269. Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial

270. Characteristics of jugular bulb oxygen saturation in patients after cardiac arrest: A prospective study

271. The association between pre-operative sepsis and 30-day mortality in hip fracture patients-A cohort study

272. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests

273. Validation of the pictorial Baxter Retching Faces scale for the measurement of the severity of postoperative nausea in Spanish-speaking children

274. Sevoflurane based anaesthesia does not affect already impaired cerebral autoregulation in patients with type 2 diabetes mellitus

275. Volume of ropivacaine 0.2% and common peroneal nerve block duration: a randomised, double-blind cohort trial in healthy volunteers 276. Characteristics of children aged 2-17 years undergoing anaesthesia in Danish hospitals 2005- 2015: a national observational study

277. Predicting Procedure-Specific Morphine Consumption of Intravenous Patient-Controlled Analgesia with Random Effects Model Approach

278. Effect of Intravenous Oxycodone in Combination with Different Doses of Dexmedetomdine on Sleep Quality and Visceral Pain in Patients after Abdominal Surgery: A Randomized Study

279. Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI >= 40): A retrospective observational study from the National Trauma Data Bank

280. Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?

281. Transfusion practices in traumatic brain injury

282. Cardiac dysfunction in critical illness

283. Minocycline Before Aortic Occlusion Reduces Hindlimb Motor Impairment, Attenuates Spinal Cord Damage and Spinal Astrocytosis, and Preserve Neuronal Cytoarchitecture in the Rat

284. Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study

285. Permissive Hypercapnia, Alveolar Recruitment and Low Airway Pressure (PHARLAP): a protocol for a phase 2 trial in patients with acute respiratory distress syndrome

286. The comparative effects of 3% saline and 0.5M sodium lactate on cardiac function:a randomised, crossover study in volunteers

287. Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug- resistant organism acquisition

288. Ventilation management in Victorian intensive care unit patients without acute respiratory distress syndrome

289. Hypercapnia and hypercapnic acidosis in sepsis: harmful, beneficial or unclear?

290. The search for biomarkers in the critically ill: a cautionary tale

291. A Rare Case of Recurrent Coronary Cameral Fistula: A Unique Surgical Challenge

292. The Relationship of Endocannabinoidome Lipid Mediators With Pain and Psychological Stress in Women With Fibromyalgia: A Case-Control Study

293. Ward monitoring 3.0

294. Development of a practical prediction score for chronic kidney disease after cardiac surgery

295. Lung Isolation Techniques in Patients With Early-Stage or Long-Term Tracheostomy: A Case Series Report of 70 Cases and Recommendations 296. Assessing Symptoms, Concerns, and Quality of Life in Noncancer Patients at End of Life: How Concordant Are Patients and Family Proxy Members?

297. Bleeding, Thrombosis, and Transfusion With Two Heparin Anticoagulation Protocols in Venoarterial ECMO Patients

298. The Adolescent Minor and Urgent Aortic Surgery: Challenges and Solutions With Capacity and Competence in Informed Consent

299. Perioperative Management of Mild Hemophilia B During and After Coronary Artery Bypass Grafting: Challenges and Solutions

300. Adjunct medications for peripheral and neuraxial anesthesia

301. A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation

302. A case report of sustained resolution of cancer pain by continuous perineural infusion of local anaesthetic

303. Elevated serum S-100beta in patients with septic shock is associated with delirium

304. Echocardiographic determination of resting haemodynamics and optimal positioning in term pregnant women

305. Long-Term Outcome Following Implanted Pulse Generator Change in Patients Treated With Sacral Nerve Modulation for Fecal Incontinence

306. Effect of a single pre-operative 125 mg dose of methylprednisolone on postoperative delirium in hip fracture patients; a randomised, double-blind, placebo-controlled trial

307. Performance of cardiac output monitoring in the peri-operative setting

309. The Safety and Efficacy of Using the O-Arm Intraoperative Imaging System for Deep Brain Stimulation Lead Implantation

310. Subthalamic Stimulation Improves Quality of Life of Patients Aged 61 Years or Older With Short Duration of Parkinson's Disease

311. Post-Operative Localization of Deep Brain Stimulation Electrodes in the Subthalamus Using Transcranial Sonography

312. Massive venous air embolism

313. Optimised dosing of vancomycin in critically ill Indigenous Australian patients with severe sepsis

314. A clinical audit of an office-based anaesthesia service for dental procedures in Victoria 315. Audit of ten years of donation after circulatory death experience in Queensland: observations of agonal physiology following withdrawal of cardiorespiratory support

316. Remifentanil suppresses increase in interleukin-6 mRNA in the brain by inhibiting cyclic AMP synthesis

317. Randomized comparative study between two different techniques of intercostobrachial nerve block together with brachial plexus block during superficialization of arteriovenous fistula

318. A pilot study to record visual evoked potentials during prone spine surgery using the SightSaverTM photic visual stimulator

319. Corticosteroid and Cortisol Serum Levels Following Intra-articular Triamcinolone Acetonide Lumbar Facet Joint Injections

320. Prevention and Treatment of Postoperative Pain after Lumbar Spine Procedures: A Systematic Review

321. Temporal and Spatial Quantification of Pain- Related Small Fiber Functionality Assessed Using Laser Speckle Contrast Analysis

324. Can thyromental distance be measured accurately?

325. Ultrasound-Guided Intercostal Nerve Block Following Esophagectomy for Acute Postoperative Pain Relief in the Postanesthesia Care Unit

326. Clinical and echocardiographic risk factors for extubation failure in infants with congenital diaphragmatic hernia

327. Off-hour admission and impact on neurological outcome in endovascular treatment for acute ischemic stroke

328. Pneumococcal sepsis requiring mechanical ventilation: Cohort study in 38 patients with rapid progression to septic shock

329. The effect of haemodynamic and peripheral vascular variability on cardiac output monitoring: thermodilution and non-invasive pulse contour cardiac output during cardiothoracic surgery

330. Environmental safety: Air pollution while using MIRUSTM for short-term sedation in the ICU

331. Evaluating Dorsal Root Ganglion Stimulation in a Prospective Dutch Cohort 332. Modeling the pharmacokinetics and pharmacodynamics of sevoflurane using compartment models in children and adults

333. Prescription opioid analgesic use in France: Trends and impact on morbidity-mortality

334. Comparison of blood pressure monitoring by applanation tonometry and invasively assessed blood pressure in cardiological patients

335. Evaluation of the use of the fourth version FloTrac system in cardiac output measurement before and after cardiopulmonary bypass

336. Assessment of liver perfusion and function by indocyanine green in the perioperative setting and in critically ill patients

337. Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures

338. Randomized Controlled Trial of Nurse-Delivered Cognitive-Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain

339. Video-based heart rate monitoring across a range of skin pigmentations during an acute hypoxic challenge

340. Catastrophizing, Solicitous Responses From Significant Others, and Function in Individuals With Neuropathic Pain, Osteoarthritis, or Spinal Pain in the General Population

341. Evaluation of a wireless, portable, wearable multi-parameter vital signs monitor in hospitalized neurological and neurosurgical patients

342. A Controlled Pilot Trial of PainTracker Self-Manager, a Web-Based Platform Combined With Patient Coaching, to Support Patients' Self-Management of Chronic Pain

343. A Comparison of the Assay Sensitivity of Average and Worst Pain Intensity in Pharmacologic Trials: An ACTTION Systematic Review and Meta-Analysis

344. Pilot Randomized Trial of Integrated Cognitive-Behavioral Therapy and Neuromuscular Training for Juvenile Fibromyalgia: The FIT Teens Program

345. Effects of ultrasound-guided stellate-ganglion block on sleep and regional cerebral oxygen saturation in patients undergoing breast cancer surgery: a randomized, controlled, double-blinded trial

346. Pupillary reflex dilation in response to incremental nociceptive stimuli in patients receiving intravenous ketamine

348. Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia 349. Incidence of peripheral nerve injury during shoulder arthroplasty when motor evoked potentials are monitored

350. Comparison of the accuracy of noninvasive hemoglobin monitoring for preoperative evaluation between adult and pediatric patients: a retrospective study

351. Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy

352. "I Was a Little Surprised": Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain

353. Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery

354. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey

355. Fiberoptic intubation of severely obese patients through supraglottic airway: A prospective, randomized trial of the Ambu AuraGainTM laryngeal mask vs the i-gelTM airway

356. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study

357. Infraorbital foramen location in the pediatric population: A guide for infraorbital nerve block

358. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia

359. Spinal Cord Stimulation Infection Rate and Risk Factors: Results from a United States Payer Database

360. Ultrasound-Guided Neurolysis of Six Genicular Nerves for Intractable Pain from Knee Osteoarthritis: A Case Series

361. Cutaneous anaesthesia of hip surgery incisions with iliohypogastric and subcostal nerve blockade: A randomised trial

362. Efficacy, acceptability and safety of Internet-delivered psychological therapies for fibromyalgia syndrome: A systematic review and meta-analysis of randomized controlled trials

363. Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury

364. Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition

365. Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study 366. Changes in tissue oxygen tension, venous saturation, and Fick-based assessments of cardiac output during hyperoxia

367. Selective Decrease in Allodynia With High-Frequency Neuromodulation via High-Electrode- Count Intrafascicular Peripheral Nerve Interface After Brachial Plexus Injury

368. Endotracheal tube cuff pressure changes during manual cuff pressure control manoeuvres: An in-vitro assessment

369. The effect of rate of injection on injection pressure profiles measured using in-line and needle- tip sensors: an in-vitro study

Full strategy

Results 369 of 369 results on EMBASE - (((0304-3959 OR 0007-0912 OR 1471-6771 OR 1528-1175 OR 0003-3022 OR 1526-5900 OR 1441- 2772 OR 1744-8069 OR 0049-0172 OR 1098-7339 OR 1526-7598 OR 0003-2999 OR 0885-3924 OR 0003-2409 OR 1365-2044 OR 1533-3159 OR 1090-3801 OR 0749-8047 OR 1525-1403 OR 1094-7159 OR 0001- 5172 OR 1399-6576 OR 0265-0215 OR 1365-2346 OR 1155-5645 OR 1460-9592 OR 1537-1921 OR 0898-4921 OR 0832-610X OR 1496- 8975 OR 1526-2375 OR 1526-4637 OR 0375-9393 OR 1178-7090 OR 1203-6765 OR 0959-289X OR 1753-3740 OR 1521-6896 OR 1473- 6500 OR 0952-7907 OR 2090-1542 OR 2090-1550 OR 1387-1307 OR 1573-2614 OR 1530-7085 OR 1533-2500 OR 1471-2253 OR 1532-8422 OR 1053-0770 OR 1064-6655 OR 1534-3081 OR 1531-3433 OR 0913- 8668 OR 1438-8359 OR 1687-6970 OR 1687-6962 OR 0310-057X OR 1448-0271 OR 1089-2532 OR 1754-9493 OR 0360-1293 OR 0952-8180 OR 1932-2275 OR 0970-9185 OR 0974-5181 OR 0971-9784 OR 1551- 7489).is AND ((Sevoflurane AND agitation).ti,ab OR exp "RESPIRATION CONTROL"/ OR exp "AIRWAY OBSTRUCTION"/ OR exp "AIRWAY REMODELING"/ OR exp "AIRWAY RESISTANCE"/ OR exp EXTUBATION/ OR exp "DIABETES MELLITUS"/ OR exp GYNECOLOGY/ OR exp "RESPIRATORY DISTRESS SYNDROME, ADULT"/ OR exp "LARYNGEAL MASK"/ OR exp "NERVE BLOCK"/ OR exp HEART/ OR exp "VISCERAL PAIN"/ OR exp SEPSIS/ OR exp "VASCULAR SURGERY"/ OR exp "EXERCISE TEST"/ OR exp "HEART FUNCTION TEST"/ OR exp DELIRIUM/ OR exp "ANTIINFECTIVE AGENT"/ OR exp "LOW BACK PAIN"/ OR ("enhanced recovery after surgery" OR ERAS).ti,ab OR exp FIBROMYALGIA/ OR exp "QUALITY CONTROL PROCEDURES"/ OR exp "QUALITY OF LIFE"/ OR ("fluid management").ti,ab)) NOT ("Conference Proceeding" OR Editorial OR Erratum OR Letter OR Note OR "Short Survey").pt) [Since 01-Sep-2018] 1. Delirium detection using relative delta power based on 1 minute single-channel EEG: a multicentre study Author(s): Numan T.; Peelen L.M.; Slooter A.J.C.; van den Boogaard M.; Rood P.J.T.; Kamper A.M.; van der Zwaag S.; Abawi M.; Rood P.J.; Wassenaar A.; Claassen J.A.; Schoon Y.; Coesmans M.; Osse R.J.; Rius Ottenheim N.; Dautzenberg P.; van Marum R.J.; Dhondt T.A.; de Man T.; Diraoui S.B.; de Jonghe A.-M.; Eikelenboom P.; Emmelot-Vonk M.H.; Koek H.L.; Lefeber G.J.; Vondeling A.M.; Faaij R.A.; van Gool W.A.; Witlox J.; Groot E.R.; Hagestein-de Bruijn C.; van der Mast R.C.; Roder C.H.; van der Vlugt J.B.; Hovens J.G.; van der Jagt M.; van der Kooi A.W.; Slooter A.J.; Zeman P.M.; Kromkamp M.; Lagro J.; Leentjens A.F.; Leue C.; Leijten F.S.; van Munster B.C.; Barbara Portier C.; Tromp A.; Weinstein H.; van Zanten J.S. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Delirium is frequently unrecognised. EEG shows slower frequencies (i.e. below 4 Hz) during delirium, which might be useful in improving delirium recognition. We studied the discriminative performance of a brief single-channel EEG recording for delirium detection in an independent cohort of patients. Methods: In this prospective, multicentre study, postoperative patients aged >=60 yr were included (n=159). Before operation and during the first 3 postoperative days, patients underwent a 5-min EEG recording, followed by a video-recorded standardised cognitive assessment. Two or, in case of disagreement, three delirium experts classified each postoperative day based on the video and chart review. Relative delta power (1-4 Hz) was based on 1-min artifact-free EEG. The diagnostic value of the relative delta power was evaluated by the area under the receiver operating characteristic curve (AUROC), using the expert classification as the gold standard. Results: Experts classified 84 (23.3%) postoperative days as either delirium or possible delirium, and 276 (76.7%) non-delirium days. The AUROC of the relative EEG delta power was 0.75 [95% confidence interval (CI) 0.69-0.82]. Exploratory analysis showed that relative power from 1 to 6 Hz had significantly higher AUROC (0.78, 95% CI 0.72-0.84, P=0.014). Conclusions: Delirium/possible delirium can be detected in older postoperative patients based on a single-channel EEG recording that can be automatically analysed. This objective detection method with a continuous scale instead of a dichotomised outcome is a promising approach for routine detection of delirium. Clinical trial registration: NCT02404181.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

2. Expiratory Central Airway Collapse in Adults: Corrective Treatment (Part 2) Author(s): Diaz Milian R.; Foley E.; Bauer M.; Martinez-Velez A.; Castresana M.R. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Corrective treatment of expiratory central airway collapse (ECAC) consists of placement of airway stents or tracheobronchoplasty (TBP). The indication for corrective treatment is severe central airway collapse (>90 %), and severe symptoms that cause decline in quality of life. Patients are selected to undergo a trial of tracheal "Y" stent placement. If symptoms improve (positive trial) they undergo a TBP, provided they are good surgical candidates. Patients who are considered poor surgical candidates because of the severity of comorbidities can be offered permanent stenting to palliate symptoms. The anesthetic management of airway stent placement and TBP is complex. This article reviews the medical management and corrective treatment of ECAC, anesthetic management of airway stent placement, and considerations during TBP.Copyright © 2018 Elsevier Inc. Database: EMBASE

3. Perioperative Right Ventricular Pressure Monitoring in Cardiac Surgery Author(s): Raymond M.; Desjardins G.; Cogan J.; Couture P.; Deschamps A.; Chamberland M.-E.; Ayoub C.; Lebon J.-S.; Julien M.; Taillefer J.; Rochon A.; Gronlykke L.; Ravn H.B.; Couture E.J.; Cloutier J.; Lamarche Y.; L'Allier P.L.; Denault A.Y. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Right ventricular (RV) dysfunction is a cause of increased morbidity and mortality in both cardiac surgery and noncardiac surgery and in the intensive care unit. Early diagnosis of this condition still poses a challenge. The diagnosis of RV dysfunction traditionally is based on a combination of echocardiography, hemodynamic measurements, and clinical symptoms. This review describes the method of using RV pressure waveform analysis to diagnose and grade the severity of RV dysfunction. The authors describe the technique, optimal use, and pitfalls of this method, which has been used at the Montreal Heart Institute since 2002, and review the current literature on this method. The RV pressure waveform is obtained using a pulmonary artery catheter with the capability of measuring RV pressure by connecting a pressure transducer to the pacemaker port. The authors describe how RV pressure waveform analysis can facilitate the diagnosis of systolic and diastolic RV dysfunction, the evaluation of RV-arterial coupling, and help diagnose RV outflow tract obstruction. RV pressure waveform analysis also can be used to guide pharmacologic treatment and fluid resuscitation strategies for RV dysfunction.Copyright © 2018 Elsevier Inc. Database: EMBASE

4. Preoperative Right Ventricular Dysfunction Indicates High Vasoactive Support Needed After Cardiac Surgery Author(s): Ting P.-C.; Liao C.-C.; Chou A.-H.; Chen C.-Y.; Wu V.C.-C.; Tsai F.-C.; Lin P.-J.; Chen S.-W. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: The aim of this study was to explore the relationship between preoperative right ventricular (RV) function and high vasoactive-inotropic score (VIS) after cardiac surgery. Design: Prospective observational study. Setting: A single medical center setting. Participants: One hundred three patients undergoing elective cardiac surgery. Interventions: None. Measurements and Main Results: Consecutive patients referred for cardiac surgery were enrolled prospectively. Comprehensive transesophageal echocardiography was performed before sternal incision. Specific RV indices, encompassing RV fractional area change, tricuspid annular plane systolic excursion, and RV global longitudinal strain (RVGLS), were measured offline. High VIS was defined as a maximum VIS of >=20 in 24 hours postoperatively. Postoperative adverse events were recorded. One hundred three patients (mean age 61.2 +/- 11.0, 72 men) were included in this study, where 17 patients (16.5%) achieved high VIS with a mean maximum VIS of 39 in 24 hours postoperatively. Patients with high VIS encountered increased occurrence of extracorporeal membrane oxygenation placement, acute kidney injury, and mortality. Risk factors for high VIS included operation type, cardiopulmonary bypass duration, left atrium size, and pre-incisional RV indices. After adjustment for age, left ventricular ejection fraction, and the covariates, only RVGLS (odds ratio 1.19, p = 0.011) showed an independent association with high VIS. The optimal cutoff of RVGLS was -16.7% (sensitivity of 88.2%, specificity of 75.6%). Conclusion: Preoperative RV dysfunction is an independent risk factor for postoperative high VIS. Pre-incisional RVGLS is a reliable tool to predict high VIS after cardiac surgery. Patients with high VIS had increased adverse events postoperatively.Copyright © 2018 Elsevier Inc. Database: EMBASE

5. Agitation in adults in the post-anaesthesia care unit after general anaesthesia Author(s): Fields A.; Huang J.; Sprung J.; Weingarten T.; Schroeder D. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Agitation after general anaesthesia can lead to self-harm, violence against staff, and increased resource utilisation. We aimed to assess patient and procedural characteristics associated with this complication in adults. Methods: We identified cases of agitation (Richmond Agitation-Sedation Scale score +3 or +4, or administration of haloperidol) in patients after general anaesthesia in the PACU from July 1, 2010 to September 30, 2016. The cases were matched 1:1 with control patients without agitation by age, sex, and procedure. Potential clinical associations were assessed with a multivariable analysis. Results: We identified agitation in 510 patients [incidence: 2.5 cases/1000 patients; 95% confidence interval (CI): 2.3-2.7]. Variables associated with agitation were substance misuse [odds ratio (OR): 6.77; 95% CI: 1.23-37.2; P=0.03], cognitive impairment (OR: 4.66; 95% CI: 1.79-12.1; P=0.002), obesity (OR: 2.49; 95% CI: 1.66-3.73; P<0.001), psychiatric problems (OR: 2.05; 95% CI: 1.32-3.19; P=0.002), fall risk (OR: 1.66; 95% CI: 1.02-2.70; P=0.04), postoperative presence of a tracheal tube (OR: 16.6; 95% CI: 7.25-38.2; P<0.001), urine catheter (OR: 7.25; 95% CI: 4.31-12.2; P<0.001), nasogastric tube (OR: 4.06; 95% CI: 1.51-10.9; P=0.006), or chest tube (OR: 3.46; 95% CI: 1.07-11.2; P=0.006). Compared with control patients, more agitated patients had postoperative delirium (16.1% vs 6.3%; P<0.001) and pulmonary complications (9.8% vs 4.7%; P=0.002). Conclusions: Agitation after general anaesthesia was associated with postoperative indwelling catheters, tracheal intubation and patient features suggestive of pre-existing mental health problems. Anticipation of high-risk patients could allow allocation of staffing resources to provide a safe environment for anaesthetic recovery.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

6. Translation and Evaluation of a Lung Cancer, Palliative Care Intervention for Community Practice Author(s): Nguyen H.Q.; Macias M.; Ruel N.; Borneman T.; Alian M.; Becher M.; Lee K.; Ferrell B. Source: Journal of Pain and Symptom Management; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Context: A notable gap in the evidence base for palliative care (PC) for cancer is that most trials were conducted in specialized centers with limited translation and further evaluation in "real- world" settings. Health systems are desperate for guidance on effective, scalable models. Objectives: The objective of this study was to determine the effects of a nurse-led PC intervention for patients with non-small-cell lung cancer and their family caregivers (FCGs) in a community-based setting. Methods: Two-group, sequential, quasi-experimental design with Phase 1 (usual care [UC]) followed by Phase 2 (intervention) was conducted at three Kaiser Permanente Southern California sites. Participants included patients with Stage 2-4 non-small-cell lung cancer and their FCG. Standard measures of quality of life (QOL) included Functional Assessment of Cancer Therapy-Lung, Functional Assessment of Chronic Illness Therapy-Spirituality Subscale, City of Hope Family QOL; other outcomes were distress, health care utilization, caregiver preparedness, and burden. Results: Patients in the intervention cohort had significant improvements in three (physical, emotional, and functional well-being) of the five QOL domains at one month that were sustained through three month compared to UC (P < 0.01). Caregivers in the intervention cohort had improvements in physical (P = 0.04) and spiritual well-being (P = 0.03) and preparedness (P = 0.04) compared to UC. There were no differences in distress or health care utilization between cohorts. Conclusion: Our findings suggest that a research-based PC intervention can be successfully adapted to community settings to achieve similar, if not better, QOL outcomes for patients and FCGs compared to UC. Nonetheless, additional modifications to ensure consistent referrals to PC and streamlining routine assessments and patient/FCG education are needed to sustain and disseminate the PC intervention.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

7. Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review Author(s): Zeng Y.S.; Wang C.; Ward K.E.; Hume A.L. Source: Journal of Pain and Symptom Management; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Context: The aim of palliative care is to improve quality of life for patients with serious illnesses by treating their symptoms and adverse effects. Hospice care also aims for this for patients with a life expectancy of six months or less. When conventional therapies do not provide adequate symptom management or produce their own adverse effects, patients, families, and caregivers may prefer complementary or alternative approaches in their care. Objectives: The objectives of this study were to evaluate the available evidence on the use of complementary or alternative medicine (CAM) in hospice and palliative care and to summarize their potential benefits. Methods: A defined search strategy was used in reviewing literature from major databases. Searches were conducted using base terms and the symptom in question. Symptoms included anxiety, pain, dyspnea, cough, fatigue, insomnia, nausea, and vomiting. Studies were selected for further evaluation based on relevancy and study type. References of systematic reviews were also assessed. After evaluation using quality assessment tools, findings were summarized and the review was structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Out of 4682 studies, 17 were identified for further evaluation. Therapies included acupressure, acupuncture, aromatherapy massage, breathing, hypnotherapy, massage, meditation, music therapy, reflexology, and reiki. Many studies demonstrated a short-term benefit in symptom improvement from baseline with CAM, although a significant benefit was not found between groups. Conclusion: CAM may provide a limited short-term benefit in patients with symptom burden. Additional studies are needed to clarify the potential value of CAM in the hospice or palliative setting.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

8. Is Intraoperative Strain Analysis for Left Ventricular Diastolic Function Practical? Author(s): Sheu R.; Ferreira R. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

9. Impact of non-invasive continuous blood pressure monitoring on maternal hypotension during cesarean delivery: a randomized-controlled study Author(s): Juri T.; Suehiro K.; Kimura A.; Mukai A.; Tanaka K.; Yamada T.; Mori T.; Nishikawa K. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: This study aimed to investigate the efficacy of the ClearSightTM system (Edwards Lifesciences, Irvine, CA) for reducing the incidence of hypotension compared with the traditional oscillometric blood pressure monitoring in cesarean delivery under spinal anesthesia. Methods: Forty patients undergoing cesarean delivery under spinal anesthesia were enrolled. The patients were randomly divided into two groups (Control and ClearSight groups). All patients received spinal anesthesia using 0.5% hyperbaric bupivacaine (11.5 mg) and fentanyl (10 micro g). Blood pressure was managed with the same protocol using the ClearSightTM system (ClearSight group) and oscillometric blood pressure monitoring (Control group). Furthermore, we compared the accuracy of the ClearSightTM system with the traditional oscillometric monitoring for blood pressure measurement using Bland-Altman, four-quadrant plot, and polar plot analyses. Results: The incidence of hypotension was significantly lower in the ClearSight group from induction to delivery (45% vs. 0%, p < 0.001) and to the end of surgery (50% vs. 20%, p = 0.049). Intraoperative nausea occurred more frequently in the Control group (45% vs. 10%, p = 0.012). The ClearSightTM system demonstrated acceptable accuracy with a bias of - 4.3 +/- 11.7 mmHg throughout the procedure. Four-quadrant analysis revealed an excellent trending ability of the ClearSightTM system with a concordance rate of approximately 95%. In the polar plot analysis, the angular bias and concordance rate were - 13.5degree +/- 19.0degree and 76.9%, respectively. Conclusions: The accuracy and trending ability of the ClearSightTM system for blood pressure measurement was clinically acceptable in cesarean delivery under spinal anesthesia, leading to reductions in maternal hypotension and nausea.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

10. Seizures After Adult Cardiac Surgery and Interventional Cardiac Procedures Author(s): Pataraia E.; Jung R.; Aull-Watschinger S.; Skhirtladze-Dworschak K.; Dworschak M. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2323-2329 Publication Date: Oct 2018 Publication Type(s): Review Abstract:The aim of this narrative review is to evaluate the incidence of seizures after adult cardiac surgery or cardiac interventions, to describe risk factors, and to provide suggestions regarding diagnostic measures and proper management. Based on published peer-reviewed articles, the authors demonstrate specific procedure-related risks for seizures. Early diagnosis, the identification of underlying causes, and avoidance of amenable risk factors are crucial to reduce associated long- term morbidity and mortality. Methods of early recognition of seizures, particularly focusing on the initiation of appropriate diagnostic measures, their management, and their timely treatment, are presented in the article.Copyright © 2018 Elsevier Inc. Database: EMBASE

11. Prescription Medication Use Among Community-Based U.S. Adults With Chronic Low Back Pain: A Cross-Sectional Population Based Study Author(s): Shmagel A.; Ngo L.; Ensrud K.; Foley R. Source: Journal of Pain; Oct 2018; vol. 19 (no. 10); p. 1104-1112 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Many classes of medications have been evaluated in chronic low back pain (cLBP), however their utilization in the community remains unclear. We examined patterns of prescription medication use among Americans with cLBP in a nationally representative, community-based sample. The Back Pain Survey was administered to a representative sample of U.S. adults aged 20 to 69 years (N = 5,103) during the 2009 to 2010 cycle of the National Health and Nutrition Examination Survey. cLBP was defined as self-reported pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold on most days for at least 3 months (N = 700). Home-based interviews with pill bottle verification were used to capture commonly prescribed medications for chronic pain. Among the sample of U.S. adults with cLBP aged 20 to 69 years, 36.9% took at least 1 prescription pain medication in the past 30 days; of them, 18.8% used opioids, 9.7% nonsteroidal anti-inflammatory drugs, 8.5% muscle relaxants, and 6.9% gabapentin or pregabalin. Nonpain antidepressants and hypnotics were used by 17.8% and 4.7%, respectively. Opioids were used long- term in 76.9% of cases (median = 2 years) and were frequently coadministered with antidepressants, benzodiazepines, or hypnotics. Ninety-four percent of prescription opioids in the cLBP population were used by individuals with less than a college education. Opioids were the most widely used prescription analgesic class in community-based U.S. adults with cLBP and were often coadministered with other central nervous system-active medications. Opioid use was highly prevalent among less educated Americans with cLBP. Perspective: Because prescription opioid use is an issue of national concern, we examined pain-related prescription medication use in community- dwelling U.S. adults with cLBP. Opioids were the most common prescription pain medication, typically used long-term, in combination with other central nervous system-active agents, and disproportionately among individuals with less than a college education.Copyright © 2018 The American Pain Society Database: EMBASE

12. Cerebral Neuromonitoring During Cardiac Surgery: A Critical Appraisal With an Emphasis on Near-Infrared Spectroscopy Author(s): Lewis C.; Parulkar S.D.; Bebawy J.; Sherwani S.; Hogue C.W. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2313-2322 Publication Date: Oct 2018 Publication Type(s): Review Abstract:Neurological complications of cardiac surgery have a large effect on patient outcomes. In this review, the value of several modes of central nervous system monitoring for improving perioperative care is critiqued. The electroencephalogram (EEG) has been used as a means for detecting brain ischemia. Even though EEG changes are specific for ischemia, the reliability is tempered by many confounding factors. The effectiveness of the processed EEG for ensuring amnesia during surgery is controversial, but it may have value for optimizing anesthetic dose and thus reducing the risk for delirium. Transcranial Doppler may be beneficial in confirming flow to both cerebral hemispheres during antegrade cerebral perfusion such as during aortic arch surgery and in detecting cerebral emboli. Transcranial Doppler can be used for monitoring cerebral autoregulation, allowing for individualization of blood pressure targets during surgery. Measures of adequacy of cerebral oxygen balance include jugular bulb venous oxygen saturation and near-infrared spectroscopy monitoring. Both monitors have limitations that reduce the sensitivity for detecting brain ischemia. Because near-infrared spectroscopy-measured regional cerebral oxygen saturation does not distinguish arterial from venous blood, these measurements reflect the adequacy of oxygen delivery versus demand. Over short periods, filtered regional cerebral oxygen saturation data may provide a clinically feasible method of monitoring cerebral autoregulation that overcomes many limitations of transcranial Doppler. Ongoing studies have demonstrated that the latter methodology for determining perioperative blood pressure targets has large potential for reducing organ injury from cardiac surgery.Copyright © 2018 Elsevier Inc. Database: EMBASE

13. Anesthesia for Lung Transplantation in Cystic Fibrosis: Retrospective Review from the Irish National Transplantation Centre Author(s): Lenihan M.; Mullane D.; Buggy D.; Flood G.; Griffin M. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2372-2380 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Cystic fibrosis (CF) is an autosomal recessive disorder affecting approximately 1 in 2,500 live births worldwide, with double this estimated frequency in Ireland. CF is characterized by a genetic defect of the CF transmembrane regulator protein, causing impairment of chloride ion transportation. This has multisystem consequences, particularly in the lungs, where it results in intensely mucoid secretions, which increases susceptibility to infection. Lung transplantation is indicated in CF when there is progressive decline in a patient's functional reserve. In this report, the authors present a 6-year case review of allograft lung transplantations in 41 CF patients from the Irish National Centre for Lung Transplantation from 2010 through 2015. Preoperative risk factors for morbidity and major mortality are discussed. The authors' experience with intraoperative anesthetic challenges and management options are outlined, and postoperative complications are discussed.Copyright © 2017 Elsevier Inc. Database: EMBASE

14. Outcomes After Transcatheter Aortic Valve Replacement: A Propensity Matched Retrospective Cohort Study Author(s): Brovman E.Y.; Kuo C.; Lekowski R.W.; Urman R.D. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2169-2175 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: To examine patient acuity and perioperative outcomes in a contemporary cohort of patients undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Design: A retrospective propensity-matched cohort study with univariable logistic regression to assess postoperative outcomes. Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Participants: The study comprised 2,043 patients who underwent either TAVR or SAVR that was reported in the American College of Surgeons-National Surgical Quality Improvement Program. Interventions: None. Measurement and Main Results: Age greater than 65 years, patients with dyspnea with moderate exertion or dependence in activities of daily living, high American Society of Anesthesiologists physical status classification, and history of chronic obstructive pulmonary disease were associated with TAVR, whereas body mass index greater than 25 was associated with SAVR. After propensity matching, no differences in 30-day mortality, length of stay, or most postoperative outcomes were observed between the 2 cohorts. Patients undergoing TAVR were less likely to require a perioperative blood transfusion and on an individual patient basis had a lower number of complications than patients in the SAVR group. Conclusions: Patients undergoing TAVR have similar mortality, length of stay, and risk for postoperative complications as do patients undergoing SAVR, but patients undergoing TAVR are less likely to have blood transfused.Copyright © 2018 Elsevier Inc. Database: EMBASE

15. The Year in Vascular Anesthesia: Selected Highlights From 2017 Author(s): Valentine E.A.; Zhou E.Y.; Gordon E.K.; Ochroch E.A. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2043-2053 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

16. Hypnosis Enhances the Effects of Pain Education in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial Author(s): Rizzo R.R.N.; Medeiros F.C.; Pires L.G.; Pimenta R.M.; Costa L.O.P.; McAuley J.H.; Jensen M.P. Source: Journal of Pain; Oct 2018; vol. 19 (no. 10); p. 1103 Publication Date: Oct 2018 Publication Type(s): Article Abstract:The potential benefits of combining pain education (PE) with clinical hypnosis (CH) has not yet been investigated in individuals with chronic pain. A total of 100 patients with chronic nonspecific low back pain were randomized to receive either: 1) PE alone, or 2) PE with CH. Outcomes were collected by a blinded assessor at 2 weeks and 3 months after randomization. The primary outcomes were average pain intensity, worst pain intensity (both assessed with 11-point numeric rating scales), and disability (24-item Roland Morris Disability Questionnaire) at 2 weeks. At 2 weeks, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.35 points, 95% confidence interval [CI] =.32-2.37) and disability (mean difference = 2.34 points, 95% CI =.06-4.61), but not average pain intensity (mean difference =.67 point, 95% CI = -.27 to 1.62), relative to participants who received PE alone. PE with CH participants also reported more global perceived benefits at 2 weeks (mean difference = -1.98 points, 95% CI = -3.21 to -.75). At 3 months, participants who received PE with CH reported lower worst pain intensity (mean difference = 1.32 points, 95% CI =.29-2.34) and catastrophizing (mean difference = 5.30 points, 95% CI = 1.20-9.41). No adverse effects in either treatment condition were reported. To our knowledge, this is the first trial showing that additional use of hypnosis with PE results in improved outcomes over PE alone in patients with chronic nonspecific low back pain. Perspective: This study provides evidence supporting the efficacy of another treatment option for teaching patients to self-manage chronic low back pain that has a relatively low cost and that can be offered in groups.Copyright © 2018 The American Pain Society Database: EMBASE

17. Continuous Erector Spinae Plane (ESP) Block for Postoperative Analgesia after Minimally Invasive Mitral Valve Surgery Author(s): Leyva F.M.; Mendiola W.E.; Bonilla A.J.; Cubillos J.; Moreno D.A.; Chin K.J. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2271-2274 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

18. Estimating minimally important differences for the PROMIS pain interference scales: Results from 3 randomized clinical trials Author(s): Chen C.X.; Carpenter J.S.; Kroenke K.; Bair M.J.; Damush T.M.; Stump T.E.; Monahan P.O.; Kean J.; Krebs E.E. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 775-782 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Minimally important difference (MID) refers to the smallest meaningful difference that carries implications for patient care. Minimally important differences are necessary to help interpret patient-reported pain outcomes in research and clinical practice. The PROMIS pain interference scales were validated across diverse samples; however, more information about their MIDs could improve their interpretability. The purpose of this study was to estimate MIDs for 4 fixed-length PROMIS pain interference scales, including the 6-item Pain Short Form and the 4-, 6-, and 8-item pain interference scales used in the PROMIS profile instruments. Data were analyzed from 3 randomized controlled trials (N = 759). The 3 samples, respectively, consisted of patients with chronic low back pain (n = 261), chronic back pain or hip/knee osteoarthritis pain (n = 240), and a history of stroke (n = 258). For each sample, anchor- and distribution-based approaches were used to estimate MIDs. Standard error of measurement and effect sizes were used as distribution-based MID estimates. Anchor-based MID estimates were established by mapping PROMIS pain interference scores onto established anchor measures, including the Brief Pain Inventory, and retrospective and prospective global ratings of change. The distribution- and anchor-based MID estimates showed convergence. For the pain samples, MID estimates ranged from 2 to 3 T-score points. For the nonpain sample, MID estimates ranged from 3.5 to 4.5 T-score points. The MID estimates were comparable across the 4 fixed-length scales. These MIDs can be used to evaluate treatment effects in research and clinical care and to calculate estimates for powering clinical trials.Copyright © 2017 International Association for the Study of Pain. Database: EMBASE

19. Pain as a risk factor for common mental disorders. Results from the Netherlands Mental Health Survey and Incidence Study-2: A longitudinal, population-based study Author(s): De Heer E.W.; Van Der Feltz-Cornelis C.M.; Ten Have M.; De Graaf R.; Van Marwijk H.W.J.; Dekker J.; Beekman A.T.F. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 712-718 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Pain might be an important risk factor for common mental disorders. Insight into the longitudinal association between pain and common mental disorders in the general adult population could help improve prevention and treatment strategies. Data were used from the first 2 waves of the Netherlands Mental Health Survey and Incidence Study-2, a psychiatric epidemiological cohort study among the Dutch general population aged 18 to 64 years at baseline (N = 5303). Persons without a mental disorder 12 months before baseline were selected as the at-risk group (n = 4974 for any mood disorder; n = 4979 for any anxiety disorder; and n = 5073 for any substance use disorder). Pain severity and interference due to pain in the past month were measured at baseline using the Short Form Health Survey. DSM-IV mental disorders were assessed at both waves using the Composite International Diagnostic Interview version 3.0. Moderate to very severe pain was associated with a higher risk of mood (odds ratio [OR] = 2.10, 95% confidence interval [CI] = 1.33- 3.29) or anxiety disorders (OR = 2.12, 95% CI = 1.27-3.55). Moderate to very severe interference due to pain was also associated with a higher risk of mood (OR = 2.14, 95% CI = 1.30-3.54) or anxiety disorders (OR = 1.92, 95% CI = 1.05-3.52). Pain was not significantly associated with substance use disorders. No interaction effects were found between pain severity or interference due to pain and a previous history of mental disorders. Moderate to severe pain and interference due to pain are strong risk factors for first-incident or recurrent mood and anxiety disorders, independent of other mental disorders. Pain management programs could therefore possibly also serve as a preventative program for mental disorders.Copyright © 2017 International Association for the Study of Pain. Database: EMBASE

20. Disease modifying actions of interleukin-6 blockade in a rat model of bone cancer pain Author(s): Remeniuk B.; Sukhtankar D.; Porreca F.; King T.; Nippert A.; Li N.; Li F.; Cheng K.; Rice K.C. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 684-698 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Metastasis of cancer to the skeleton represents a debilitating turning point in the lives of patients. Skeletal metastasis leads to moderate to severe ongoing pain along with bone remodeling that can result in fracture, events that dramatically diminish quality of life. Interleukin-6 (IL-6) levels are elevated in patients with metastatic breast cancer and are associated with a lower survival rate. We therefore determined the consequences of inhibition of IL-6 signaling using a novel small molecule antagonist, TB-2-081, on bone integrity, tumor progression, and pain in a rodent model of breast cancer. Rat MAT B III mammary adenocarcinoma cells were injected and sealed within the tibia of female Fischer rats. Growth of these cells within the rat tibia elicited increased IL-6 levels both within the bone exudate and in the plasma, produced ongoing pain and evoked hypersensitivity, and bone fracture that was observed by approximately day 12. Systemic TB-2-081 delivered by subcutaneous osmotic minipumps starting at tumor implantation prevented tumor- induced ongoing bone pain and evoked hypersensitivity without altering tumor growth. Remarkably, TB-2-081 infusion significantly reduced osteolytic and osteoblastic bone remodeling and time to fracture likely by decreasing osteoclastogenesis and associated increase in bone resorption. These findings indicate that blockade of IL-6 signaling may represent a viable, disease-modifying strategy to prevent tumor-induced bone remodeling allowing for stabilization of bone and decreased fractures as well as diminished ongoing pain that may improve quality of life of patients with skeletal metastases. Notably, anti-IL-6 antibodies are clinically available allowing for rapid testing of these possibilities in humans.Copyright © 2017 International Association for the Study of Pain. Database: EMBASE

21. Developing a core outcome domain set to assessing effectiveness of interdisciplinary multimodal pain therapy: The VAPAIN consensus statement on core outcome domains Author(s): Kaiser U.; Neustadt K.; Gossrau G.; Sabatowski R.; Kopkow C.; Deckert S.; Jacobi L.; Schmitt J.; Cameron P.; De Angelis V.; Apfelbacher C.; Arnold B.; Birch J.; Bjarnegard A.; Christiansen S.; C De C Williams A.; Heinks A.; Huppe M.; Kiers H.; Kleinert U.; Martelletti P.; McCracken L.; De Meij N.; Nagel B.; Nijs J.; Norda H.; Singh J.A.; Spengler E.; Terwee C.B.; Tugwell P.; Vlaeyen J.W.S.; Wandrey H.; Neugebauer E. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 673-683 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Interdisciplinary multimodal pain therapy (IMPT) is a biopsychosocial treatment approach for patients with chronic pain that comprises at least psychological and physiotherapeutic interventions. Core outcome sets (COSs) are currently developed in different medical fields to standardize and improve the selection of outcome domains, and measurement instruments in clinical trials, to make trial results meaningful, to pool trial results, and to allow indirect comparison between interventions. The objective of this study was to develop a COS of patient-relevant outcome domains for chronic pain in IMPT clinical trials. An international, multiprofessional panel (patient representatives [n = 5], physicians specialized in pain medicine [n = 5], physiotherapists [n = 5], clinical psychologists [n = 5], and methodological researchers [n = 5]) was recruited for a 3-stage consensus study, which consisted of a mixed-method approach comprising an exploratory systematic review, a preparing online survey to identify important outcome domains, a face-to-face consensus meeting to agree on COS domains, and a second online survey (Delphi) establishing agreement on definitions for the domains included. The panel agreed on the following 8 domains to be included into the COS for IMPT: pain intensity, pain frequency, physical activity, emotional wellbeing, satisfaction with social roles and activities, productivity (paid and unpaid, at home and at work, inclusive presentism and absenteeism), health-related quality of life, and patient's perception of treatment goal achievement. The complexity of chronic pain in a biopsychosocial context is reflected in the current recommendation and includes physical, mental, and social outcomes. In a subsequent step, measurement instruments will be identified via systematic reviews.Copyright © 2017 International Association for the Study of Pain. Database: EMBASE

22. Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: An investigation of change processes Author(s): Lin J.; McCracken L.M.; Klatt L.-I.; Baumeister H. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 663-672 Publication Date: Apr 2018 Publication Type(s): Article Available at PAIN - from Unpaywall Abstract:One way to improve treatment effects of chronic pain is to identify and improve control over mechanisms of therapeutic change. One treatment approach that includes a specific proposed mechanism is acceptance and commitment therapy (ACT) with its focus on increasing psychological flexibility (PF). The aim of the present study was to examine the role of PF as a mechanism of change in ACT. This is based on mediation analyses of data from a previously reported randomized controlled trial, evaluating the effectiveness of an ACT-based online intervention for chronic pain (ACTonPain). We performed secondary analyses on pretreatment, posttreatment, and follow-up data from 302 adults, receiving a guided (n = 100) or unguided (n = 101) version of ACTonPain, or allocated to the waitlist control group (n = 101). Structural equation modelling and a bias-corrected bootstrap approach were applied to examine the indirect effects of the treatment through pretreatment and posttreatment changes in the latent construct reflecting PF. The latent construct consisted of data from the Chronic Pain Acceptance Questionnaire and the Acceptance and Action Questionnaire. The outcomes were pretreatment to follow-up changes in pain interference, anxiety, depression, pain, and mental and physical health. Structural equation modelling analyses revealed that changes in PF significantly mediated pretreatment to follow-up changes in all outcomes in the intervention groups compared with waitlist (standardized estimates ranged from I0.16I to I0.69I). Global model fit yielded modest but acceptable results. Findings are consistent with the theoretical framework behind ACT and contribute to growing evidence, supporting a focus on PF to optimize treatment effects.Copyright © 2017 International Association for the Study of Pain. Database: EMBASE

23. Interventions for attentional disruption in pain: Cognition-general, mechanism-specific, or exercise-based? Author(s): Attridge N.; Niederstrasser N.G. Source: Pain; Apr 2018; vol. 159 (no. 4); p. 621-622 Publication Date: Apr 2018 Publication Type(s): Review Database: EMBASE

24. Biologic Impact of Mechanical Power at High and Low Tidal Volumes in Experimental Mild Acute Respiratory Distress Syndrome Author(s): Santos R.S.; Maia L.D.A.; Oliveira M.V.; Santos C.L.; Moraes L.; Pinto E.F.; Samary C.D.S.; MacHado J.A.; Carvalho A.C.; Fernandes M.V.D.S.; Martins V.; Silva P.L.; Rocco P.R.M.; Capelozzi V.L.; Morales M.M.; Koch T.; De Abreu M.G.; Pelosi P. Source: Anesthesiology; Jun 2018; vol. 128 (no. 6); p. 1193-1206 Publication Date: Jun 2018 Publication Type(s): Article Abstract:Background: The authors hypothesized that low tidal volume (VT) would minimize ventilator-induced lung injury regardless of the degree of mechanical power. The authors investigated the impact of power, obtained by different combinations of VT and respiratory rate (RR), on ventilator-induced lung injury in experimental mild acute respiratory distress syndrome (ARDS). Methods: Forty Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 h, 32 rats were randomly assigned to be mechanically ventilated (2 h) with a combination of different VT (6 ml/kg and 11 ml/kg) and RR that resulted in low and high power. Power was calculated as energy (DELTAP,L2/E,L) x RR (DELTAP,L = transpulmonary driving pressure; E,L = lung elastance), and was threefold higher in high than in low power groups. Eight rats were not mechanically ventilated and used for molecular biology analysis. Results: Diffuse alveolar damage score, which represents the severity of edema, atelectasis, and overdistension, was increased in high VT compared to low VT, in both low (low VT: 11 [9 to 14], high VT: 18 [15 to 20]) and high (low VT: 19 [16 to 25], high VT: 29 [27 to 30]) power groups. At high VT, interleukin-6 and amphiregulin expressions were higher in high-power than in low-power groups. At high power, amphiregulin and club cell protein 16 expressions were higher in high VT than in low VT. Mechanical energy and power correlated well with diffuse alveolar damage score and interleukin-6, amphiregulin, and club cell protein 16 expression. Conclusions: In experimental mild ARDS, even at low VT, high mechanical power promoted ventilator-induced lung injury. To minimize ventilator-induced lung injury, low VT should be combined with low power.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

25. In Vitro Negative Inotropic Effect of Low Concentrations of Bupivacaine Relates to Diminished Ca²⁺ Sensitivity but Not to Ca²⁺ Handling or beta-Adrenoceptor Signaling Author(s): Flenner F.; Nasib M.; Friedrich F.; Christ T.; Schobesberger S.; Nikolaev V.; Arlt N.; Ravens U.; Koch T.; Stehr S.N. Source: Anesthesiology; Jun 2018; vol. 128 (no. 6); p. 1175-1186 Publication Date: Jun 2018 Publication Type(s): Article Abstract:Background: Systemic toxicity of local anesthetics is predominantly complicated by their myocardial toxicity. Especially long-acting local anesthetics exert a negative inotropic effect that has been described at lower concentrations than defined for blockade of myocardial ion channels. We evaluated the negative inotropic effect of bupivacaine at a concentration described for clinical toxicity testing the hypothesis that negative inotropy is a result of reduced Ca2+ sensitivity rather than blockade of ion channels. Methods: We simultaneously measured force development and action potentials in Guinea pig right papillary muscles (n = 5 to 7). L-type Ca2+ currents (n = 8 to 16) and Ca2+ transients (n = 10 to 11) were measured in isolated cardiomyocytes. Sensitivity of myofilaments to Ca2+ was assessed in skinned fibers (n = 10). Potential effects of bupivacaine on 3',5'-cyclic adenosine monophosphate concentrations were measured using Forster Resonance Energy Transfer (n = 12 to 14) microscopy. Results: Bupivacaine reduced force in a concentration- dependent manner from 173 +/- 119 muN at baseline to 28 +/- 13 muN at 300 muM (mean +/- SD). At concentrations giving half-maximum negative inotropic effects (5 muM), the maximum upstroke velocity of action potentials, as a surrogate of sodium channel activity, was unaffected. Maximum positive inotropic effects of isoprenaline were also reduced to 50%. Neither basal nor isoprenaline- induced 3',5'-cyclic adenosine monophosphate accumulation, L-type Ca2+ currents, or Ca2+ transients were affected by 5 muM bupivacaine, but this concentration significantly decreased Ca2+ sensitivity of myofilaments, changing the negative logarithm of the half-maximum effective Ca2+ concentrations from 5.66 to 5.56-log[M]. Conclusions: We provide evidence that the negative inotropic effect of bupivacaine may be caused mainly by a reduction in myofilament sensitivity to Ca2+.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

26. Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial Author(s): Ramgolam A.; Hegarty M.; Von Ungern-Sternberg B.S.; Hall G.L.; Zhang G. Source: Anesthesiology; Jun 2018; vol. 128 (no. 6); p. 1065-1074 Publication Date: Jun 2018 Publication Type(s): Article Abstract:Background: Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events. Methods: Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia. Results: Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5.2, P < 0.001). Conclusions: Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

27. Energetics and the Root Mechanical Cause for Ventilator-induced Lung Injury Author(s): Marini J.J.; Gattinoni L. Source: Anesthesiology; Jun 2018; vol. 128 (no. 6); p. 1062-1064 Publication Date: Jun 2018 Publication Type(s): Article Database: EMBASE

28. Pharmacodynamics and pharmacokinetics of lidocaine in a rodent model of diabetic neuropathy Author(s): Ten Hoope W.; Hollmann M.W.; Horn J.; Picardi S.; Lirk P.; De Bruin K.; Verberne H.J.; Verkerk A.O.; Tan H.L.; Verhamme C.; Rigaud M. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 609-619 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: Clinical and experimental data show that peripheral nerve blocks last longer in the presence of diabetic neuropathy. This may occur because diabetic nerve fibers are more sensitive to local anesthetics or because the local anesthetic concentration decreases more slowly in the diabetic nerve. The aim of this study was to investigate both hypotheses in a rodent model of neuropathy secondary to type 2 diabetes. Methods: We performed a series of sciatic nerve block experiments in 25 Zucker Diabetic Fatty rats aged 20 weeks with a neuropathy component confirmed by neurophysiology and control rats. We determined in vivo the minimum local anesthetic dose of lidocaine for sciatic nerve block. To investigate the pharmacokinetic hypothesis, we determined concentrations of radiolabeled (14 C) lidocaine up to 90 min after administration. Last, dorsal root ganglia were excised for patch clamp measurements of sodium channel activity. Results: First, in vivo minimum local anesthetic dose of lidocaine for sciatic nerve motor block was significantly lower in diabetic (0.9%) as compared to control rats (1.4%). Second, at 60 min after nerve block, intraneural lidocaine was higher in the diabetic animals. Third, single cell measurements showed a lower inhibitory concentration of lidocaine for blocking sodium currents in neuropathic as compared to control neurons. Conclusions: We demonstrate increased sensitivity of the diabetic neuropathic nerve toward local anesthetics, and prolonged residence time of local anesthetics in the diabetic neuropathic nerve. In this rodent model of neuropathy, both pharmacodynamic and pharmacokinetic mechanisms contribute to prolonged nerve block duration.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

29. Astrocytic N-Myc downstream-regulated gene-2 is involved in nuclear transcription factor kappab-mediated inflammation induced by global cerebral ischemia Author(s): Deng Y.-L.; Ma Y.-L.; Qin P.; Hou Y.-S.; Gao Z.-J.; Hou W.-G.; Zhang Z.-L.; Zhang L.-X.; Guo H. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 574-586 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: Inflammation is a key element in the pathophysiology of cerebral ischemia. This study investigated the role of N-Myc downstream-regulated gene-2 in nuclear transcription factor kappaB-mediated inflammation in ischemia models. Methods: Mice (n = 6 to 12) with or without nuclear transcription factor kappaB inhibitor pyrrolidinedithiocarbamate pretreatment were subjected to global cerebral ischemia for 20 min. Pure astrocyte cultures or astrocyte-neuron cocultures (n = 6) with or without pyrrolidinedithiocarbamate pretreatment were exposed to oxygen-glucose deprivation for 4 h or 2 h. Astrocytic nuclear transcription factor kappaB and N-Myc downstream-regulated gene-2 expression, proinflammatory cytokine secretion, neuronal apoptosis and survival, and memory function were analyzed at different time points after reperfusion or reoxygenation. Proinflammatory cytokine secretion was also studied in lentivirus-transfected astrocyte lines after reoxygenation. Results: Astrocytic nuclear transcription factor kappaB and N- Myc downstream-regulated gene-2 expression and proinflammatory cytokine secretion increased after reperfusion or reoxygenation. Pyrrolidinedithiocarbamate pretreatment significantly reduced N-Myc downstream-regulated gene-2 expression and proinflammatory cytokine secretion in vivo and in vitro, reduced neuronal apoptosis induced by global cerebral ischemia/reperfusion (from 65 +/- 4% to 47 +/- 4%, P = 0.0375) and oxygen-glucose deprivation/reoxygenation (from 45.6 +/- 0.2% to 22.0 +/- 4.0%, P < 0.001), and improved memory function in comparison to vehicle-treated control animals subjected to global cerebral ischemia/reperfusion. N-Myc downstream-regulated gene-2 lentiviral knockdown reduced the oxygen-glucose deprivation-induced secretion of proinflammatory cytokines. Conclusions: Astrocytic N-Myc downstream-regulated gene-2 is up- regulated after cerebral ischemia and is involved in nuclear transcription factor kappaB-mediated inflammation. Pyrrolidinedithiocarbamate alleviates ischemia-induced neuronal injury and hippocampal-dependent cognitive impairment by inhibiting increases in N-Myc downstream- regulated gene-2 expression and N-Myc downstream-regulated gene-2 - mediated inflammation.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

30. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation Author(s): Spadaro S.; Fogagnolo A.; Bollini G.; Ragazzi R.; Verri M.; Cavallesco N.G.; Volta C.A.; Grasso S.; Karbing D.S.; Rees S.E.; Contoli M.; Cinnella G. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 531-538 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: Arterial oxygenation is often impaired during one-lung ventilation, due to both pulmonary shunt and atelectasis. The use of low tidal volume (VT) (5 ml/kg predicted body weight) in the context of a lung-protective approach exacerbates atelectasis. This study sought to determine the combined physiologic effects of positive end-expiratory pressure and low VT during one-lung ventilation. Methods: Data from 41 patients studied during general anesthesia for thoracic surgery were collected and analyzed. Shunt fraction, high V/Q and respiratory mechanics were measured at positive end-expiratory pressure 0 cm H2O during bilateral lung ventilation and one-lung ventilation and, subsequently, during one-lung ventilation at 5 or 10 cm H2O of positive end-expiratory pressure. Shunt fraction and high V/Q were measured using variation of inspired oxygen fraction and measurement of respiratory gas concentration and arterial blood gas. The level of positive end- expiratory pressure was applied in random order and maintained for 15 min before measurements. Results: During one-lung ventilation, increasing positive end-expiratory pressure from 0 cm H2O to 5 cm H2O and 10 cm H2O resulted in a shunt fraction decrease of 5% (0 to 11) and 11% (5 to 16), respectively (P < 0.001). The Pao2/Fio2 ratio increased significantly only at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). Driving pressure decreased from 16 +/- 3 cm H2O at a positive end-expiratory pressure of 0 cm H2O to 12 +/- 3 cm H2O at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). The high V/Q ratio did not change. Conclusions: During low VT one-lung ventilation, high positive end-expiratory pressure levels improve pulmonary function without increasing high V/Q and reduce driving pressure.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

31. Four types of pulse oximeters accurately detect hypoxia during low perfusion and motion Author(s): Louie A.; Feiner J.R.; Bickler P.E.; Rhodes L.; Lucero J.; Bernstein M. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 520-530 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: Pulse oximeter performance is degraded by motion artifacts and low perfusion. Manufacturers developed algorithms to improve instrument performance during these challenges. There have been no independent comparisons of these devices. Methods: We evaluated the performance of four pulse oximeters (Masimo Radical-7, USA; Nihon Kohden OxyPal Neo, Japan; Nellcor N-600, USA; and Philips Intellivue MP5, USA) in 10 healthy adult volunteers. Three motions were evaluated: tapping, pseudorandom, and volunteer-generated rubbing, adjusted to produce photoplethsmogram disturbance similar to arterial pulsation amplitude. During motion, inspired gases were adjusted to achieve stable target plateaus of arterial oxygen saturation (SaO 2) at 75%, 88%, and 100%. Pulse oximeter readings were compared with simultaneous arterial blood samples to calculate bias (oxygen saturation measured by pulse oximetry [SpO 2 ] - SaO 2), mean, SD, 95% limits of agreement, and root mean square error. Receiver operating characteristic curves were determined to detect mild (SaO 2 < 90%) and severe (SaO 2 < 80%) hypoxemia. Results: Pulse oximeter readings corresponding to 190 blood samples were analyzed. All oximeters detected hypoxia but motion and low perfusion degraded performance. Three of four oximeters (Masimo, Nellcor, and Philips) had root mean square error greater than 3% for SaO 2 70 to 100% during any motion, compared to a root mean square error of 1.8% for the stationary control. A low perfusion index increased error. Conclusions: All oximeters detected hypoxemia during motion and low- perfusion conditions, but motion impaired performance at all ranges, with less accuracy at lower SaO 2. Lower perfusion degraded performance in all but the Nihon Kohden instrument. We conclude that different types of pulse oximeters can be similarly effective in preserving sensitivity to clinically relevant hypoxia.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

32. Prediction of bispectral index during target-controlled infusion of propofol and remifentanil Author(s): Lee H.-C.; Ryu H.-G.; Chung E.-J.; Jung C.-W. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 492-501 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: The discrepancy between predicted effect-site concentration and measured bispectral index is problematic during intravenous anesthesia with target-controlled infusion of propofol and remifentanil. We hypothesized that bispectral index during total intravenous anesthesia would be more accurately predicted by a deep learning approach. Methods: Long short- term memory and the feed-forward neural network were sequenced to simulate the pharmacokinetic and pharmacodynamic parts of an empirical model, respectively, to predict intraoperative bispectral index during combined use of propofol and remifentanil. Inputs of long short-term memory were infusion histories of propofol and remifentanil, which were retrieved from target-controlled infusion pumps for 1,800 s at 10-s intervals. Inputs of the feed-forward network were the outputs of long short-term memory and demographic data such as age, sex, weight, and height. The final output of the feed-forward network was the bispectral index. The performance of bispectral index prediction was compared between the deep learning model and previously reported response surface model. Results: The model hyperparameters comprised 8 memory cells in the long short-term memory layer and 16 nodes in the hidden layer of the feed-forward network. The model training and testing were performed with separate data sets of 131 and 100 cases. The concordance correlation coefficient (95% CI) were 0.561 (0.560 to 0.562) in the deep learning model, which was significantly larger than that in the response surface model (0.265 [0.263 to 0.266], P < 0.001). Conclusions: The deep learning model-predicted bispectral index during target-controlled infusion of propofol and remifentanil more accurately compared to the traditional model. The deep learning approach in anesthetic pharmacology seems promising because of its excellent performance and extensibility.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

33. Practice guidelines for moderate procedural sedation and analgesia 2018 Author(s): Apfelbaum J.L.; Gross J.B.; Connis R.T.; Agarkar M.; Arnold D.E.; Cote C.J.; Madias C.; Tung A.; Dutton R.; Nickinovich D.G.; Schwartz P.J.; Tom J.W.; Towbin R. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 437-479 Publication Date: Mar 2018 Publication Type(s): Review Database: EMBASE

34. Advancing patient safety in airway management Author(s): Aziz M.F. Source: Anesthesiology; Mar 2018; vol. 128 (no. 3); p. 434-436 Publication Date: Mar 2018 Publication Type(s): Article Database: EMBASE

35. Comparison of analgesic effect of oxycodone and morphine on patients with moderate and advanced cancer pain: A meta-analysis Author(s): Guo K.-K.; Lu G.-J.; Zhao G.-L.; Deng C.-Q. Source: BMC Anesthesiology; Sep 2018; vol. 18 (no. 1) Publication Date: Sep 2018 Publication Type(s): Article Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Available at BMC anesthesiology - from PubMed Central Abstract:Background: Morphine and oxycodone are considered as wide-spreadly used opioids for moderate/severe cancer pain. However, debate exists about the evidence regarding their relative tolerability and underlying results. Methods: A systematic search of online electronic databases, including PubMed, Embase, Cochrane library updated on October 2017 were conducted. The meta- analysis was performed including the studies that were designed as randomized controlled trials. Results: In total, seven randomized clinical trials met our inclusion criteria. No statistical differences in analgesic effect between oxycodone and morphine were observed. Both the pooled analysis of API (MD =0.01, 95% CI -0.22 - 0.23; p = 0.96) and WPI (MD = - 0.05, 95% CI -0.21 - 0.30; p = 0.72) demonstrated clinical non-inferiority of the efficacy of morphine compared with oxycodone, respectively. Additionally, no significant difference in PRR response was observed in either oxycodone or morphine that were used in patients (MD =0.99, 95% CI -0.88 - 1.11; p = 0.87). With the pooled result of AEs indicating the comparable safety profiles between the 2 treatment groups, the meta-analysis on the nausea (OR = 1.20, 95% CI 0.90-1.59; p = 0.22), vomiting (OR = 1.33, 95% CI 0.75-2.38; p = 0.33), somnolence (OR = 1.35, 95% CI 0.95-1.93; p = 0.10), diarrhea (OR = 1.01, 95% CI 0.60-1,67; p = 0.98), and constipation (OR = 1.04, 95% CI 0.77-1.41; p = 0.79) was conducted, respectively. Conclusions: In the current study, no remarkable difference was identified either in analgesic efficacy or in tolerability of oxycodone and morphine as the first-line therapy for patients with moderate to severe cancer pain. Thus, no sufficient clinical evidence on the superior effects of oxycodone to morphine was provided in this experimental hypothesis.Copyright © 2018 The Author(s). Database: EMBASE

36. Dopamine D2-receptor Antagonist Droperidol Deepens Sevoflurane Anesthesia Author(s): Araki R.; Hayashi K.; Sawa T. Source: Anesthesiology; Apr 2018; vol. 128 (no. 4); p. 754-763 Publication Date: Apr 2018 Publication Type(s): Conference Paper Abstract:Background: Although midbrain dopaminergic pathways are known to contribute to arousal and emergence from anesthesia, few reports exist regarding the anesthetic effects of dopamine D2 receptor antagonism in humans. This study examined the effect of the D2 receptor antagonist droperidol on sevoflurane anesthesia by examining alpha and slow wave electroencephalogram oscillations. Methods: Forty-five patients, age 20 to 60 yr, were enrolled. Frontal electroencephalograms were continuously collected for offline analysis via Bispectral Index monitoring. After induction of anesthesia, end-tidal sevoflurane concentration was deliberately maintained at 1%, and intravenous droperidol (0.05 mg/kg bolus) was administered. Electroencephalogram changes were examined in power spectrum and bicoherence, before and 10 min after droperidol injection, then compared using the Wilcoxon signed-ranks test and/or paired t test. Results: Droperidol significantly augmented the alpha-bicoherence peak induced by sevoflurane from 30.3% (24.2%, 42.4%) to 50.8% (41.7%, 55.2%) (median [25th, 75th percentiles]; P < 0.0001), Hodges-Lehman median difference, 15.8% (11.3 to 21.4%) (95% CI). The frequency of the alpha- bicoherence peak was simultaneously shifted to the lower frequency; from 11.5 (11.0, 13.0) to 10.5 (10.0, 11.0) Hz (median [25th, 75th percentiles], P < 0.0001). Averaged bicoherence in the delta- theta area increased conspicuously from 17.2% (15.6 to 18.7%) to 25.1% (23.0 to 27.3%) (mean [95% CI]; P < 0.0001), difference, 8.0% (6.0 to 9.9%). Conclusions: Droperidol augments both alpha and delta-theta bicoherences while shifting the alpha-bicoherence peaks to lower frequencies, and enhances the effect of sevoflurane anesthesia on the electroencephalogram via gamma- aminobutyric acid-mediated oscillatory network regulation.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

37. Cyclosporine before Coronary Artery Bypass Grafting Does Not Prevent Postoperative Decreases in Renal Function: A Randomized Clinical Trial Author(s): Ederoth P.; Dardashti A.; Grins E.; Bronden B.; Metzsch C.; Erdling A.; Algotsson L.; Nozohoor S.; Mokhtari A.; Bjursten H.; Hansson M.J.; Elmer E.; Jovinge S. Source: Anesthesiology; Apr 2018; vol. 128 (no. 4); p. 710-717 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Background: Acute kidney injury is a common complication after cardiac surgery, leading to increased morbidity and mortality. One suggested cause for acute kidney injury is extracorporeal circulation-induced ischemia-reperfusion injury. In animal studies, cyclosporine has been shown to reduce ischemia-reperfusion injury in the kidneys. We hypothesized that administering cyclosporine before extracorporeal circulation could protect the kidneys in patients undergoing cardiac surgery. Methods: The Cyclosporine to Protect Renal Function in Cardiac Surgery (CiPRICS) study was an investigator-initiated, double-blind, randomized, placebo-controlled, single-center study. The primary objective was to assess if cyclosporine could reduce acute kidney injury in patients undergoing coronary artery bypass grafting surgery with extracorporeal circulation. In the study, 154 patients with an estimated glomerular filtration rate of 15 to 90 ml . min-1 . 1.73 m-2 were enrolled. Study patients were randomized to receive 2.5 mg/kg cyclosporine or placebo intravenously before surgery. The primary endpoint was relative plasma cystatin C changes from the preoperative day to postoperative day 3. Secondary endpoints included biomarkers of kidney, heart, and brain injury. Results: All enrolled patients were analyzed. The cyclosporine group (136.4 +/- 35.6%) showed a more pronounced increase from baseline plasma cystatin C to day 3 compared to placebo (115.9 +/- 30.8%), difference, 20.6% (95% CI, 10.2 to 31.2%, P < 0.001). The same pattern was observed for the other renal markers. The cyclosporine group had more patients in Risk Injury Failure Loss End-stage (RIFLE) groups R (risk), I (injury), or F (failure; 31% vs. 8%, P < 0.001). There were no differences in safety parameter distribution between groups. Conclusions: Administration of cyclosporine did not protect coronary artery bypass grafting patients from acute kidney injury. Instead, cyclosporine caused a decrease in renal function compared to placebo that resolved after 1 month.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

38. Suppressed descending pain modulatory and enhanced sensorimotor networks in patients with chronic low back pain Author(s): Li T.; Zhang S.; Kurata J. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: Although cerebral structural and functional changes were uncovered by neuroimaging in patients with chronic low back pain (CLBP), their associations remain to be clarified. We co-analyzed anatomical and functional magnetic resonance imaging data in those patients and tested whether cortical gray matter volume changes are associated with altered pain modulatory networks underlying chronification of pain. Methods: In 16 patients with CLBP and 16 heathy controls, we performed functional magnetic resonance imaging during mechanical pain stimulation on the lower back followed by anatomical imaging. We performed voxel-based morphometry and functional connectivity analysis from the seeds with altered gray matter volume, and examined correlations between imaging and psychophysical parameters. Results: Patients showed decreases in gray matter volume at the right dorsolateral prefrontal cortex, middle occipital gyrus, and cerebellum, and showed increases at the bilateral primary sensorimotor cortices, left fusiform gyrus, and right cerebellum compared with controls (P < 0.001). Dorsolateral prefrontal and fusiform volumes showed negative associations with affective comorbidity, whereas motor cortex volume with impaired daily activity (P < 0.05). Connectivity was decreased between the cerebellar and limbic, and increased between the bilateral sensorimotor regions (PFDR< 0.05). Higher pain intensity and unpleasantness correlated with enhanced bilateral sensorimotor and dorsolateral-medial prefrontal networks, respectively (P < 0.05). Conclusion: Patients showed a decreased volume of cortical center for descending pain modulation and an increased volume of sensorimotor network, in association with suppressed descending pain modulatory and cerebellum-limbic networks and enhanced sensorimotor network during pain. Such structural and functional alterations might be part of cerebral pathophysiology of CLBP.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

39. Half a century of anesthesia for children: An interview with Dr. Nishan G. 'Nick' Goudsouzian Author(s): King M.R.; Mai C.L.; Firth P.G. Source: Paediatric Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pediatric Anesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:The career of Dr Nishan Goudsouzian spanned half a century of pediatric anesthesia. His 50 years saw seminal contributions to the use of neuromuscular blocking agents in children, the development of proton beam therapy and magnetic resonance imaging for pediatric cancer, the introduction of the laryngeal mask airway, an explosion in the volume and depth of knowledge about pediatric anesthesia, the expansion of formal training in pediatric anesthesia, and the widening of academic efforts to improve anesthetic care for children worldwide. Based on interviews with Dr Goudsouzian, this article reviews the contributions of this Robert M. Smith Award winner to the development of pediatric anesthesia.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

40. Early US Experience With Stimulation of the Dorsal Root Ganglia for the Treatment of Peripheral Neuropathy in the Lower Extremities: A Multicenter Retrospective Case Series Author(s): Falowski S.; Pope J.E.; Raza A. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Peripheral neuropathy is a chronic pain disorder involving physical, chemical, or metabolic damage to peripheral nerves. Its pain can be intense and disabling. Dorsal root ganglion (DRG) stimulation is an effective treatment for neuropathic pain, including cases with the limited regional distributions that often characterize peripheral neuropathy. Methods: A retrospective analysis was completed. Patients were included on the basis of having chronic intractable peripheral neuropathy of the legs and/or feet and responding successfully to a trial of DRG stimulation with leads at L4-S1. Visual analog scale pain scores and pain medication usage were collected at the baseline visit and after six weeks of treatment. Eight consecutive patients across two study centers were included (7 male, 1 female; mean age: 64.8 +/- 10.2 years). Six cases of neuropathy were bilateral and two were unilateral. One patient presented with chronic radiculopathy, two patients had neuropathy associated with diabetes, and five patients had neuropathy not associated with a diabetes history. Results: The pain was rated 7.38 +/- 0.74 at baseline and decreased to 1.50 +/- 1.31 at the 6-week follow-up, a reduction of 79.5 +/- 18.8%. For individual patients, pain relief ranged from 42.86% to 100.00%; two patients experienced complete elimination of pain while seven of the eight patients experienced greater than 50% pain relief. In addition, three patients significantly decreased their pain medication use and four were able to discontinue their medications entirely. Conclusion: This small multicenter retrospective case series provides preliminary evidence that the painful symptoms of general peripheral neuropathy in the lower extremities, as well as associated pain medication usage, can be effectively managed by DRG stimulation at the L4-S1 spinal level. Importantly, this treatment appears efficacious for peripheral neuropathy. Conflict of Interest: Steven Falowski is a consultant for Abbott, Medtronic and Nevro. He performs research with Abbott and Medtronic. Jason Pope is a consultant for Abbott, Saluda, VertiFlex, Flowonix, and Jazz Pharmaceuticals. He performs research with Abbott, Flowonix, Jazz Pharmaceuticals. Adil Raza is an employee of Abbott Laboratories.Copyright © 2018 International Neuromodulation Society Database: EMBASE

41. Comparison of preoperative assessment of patient's metabolic equivalents (METs) estimated from history versus measured by exercise cardiac stress testing Author(s): Weinstein A.S.; Bader A.M.; Sigurdsson M.I. Source: Anesthesiology Research and Practice; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Anesthesiology research and practice - from Europe PubMed Central - Open Access Available at Anesthesiology research and practice - from Hindawi Open Access Journals Available at Anesthesiology research and practice - from Pubmed Central - Open Access Available at Anesthesiology research and practice - from Publishers' website (via doi.org) Abstract:Background. Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient's functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient's physical activity, with the goal of providing an estimate of the metabolic equivalents (METs) that the patient can perform without signs of myocardial ischemia or cardiac failure. We sought to compare estimates of patients' METs between preoperative assessment by medical history with quantified assessment of METs via the exercise cardiac stress test. Methods. A single-center retrospective chart review from 12/1/2005 to 5/31/2015 was performed on 492 patients who had preoperative evaluations with a cardiac stress test ordered by a perioperative anesthesiologist. Of those, a total of 170 charts were identified as having a preoperative evaluation note and an exercise cardiac stress test. The METs of the patient estimated by history and the METs quantified by the exercise cardiac stress test were compared using a Bland-Altman plot and Cohen's kappa. Results. Exercise cardiac stress test quantified METs were on average 3.3 METS higher than the METs estimated by the preoperative evaluation history. Only 9% of patients had lower METs quantified by the cardiac stress test than by history. Conclusions. The METs of a patient estimated by preoperative history often underestimates the METs measured by exercise stress testing. This demonstrates that the preoperative assessments of patients' METs are often conservative which errs on the side of patient safety as it lowers the threshold for deciding to order further cardiac stress testing for screening for ischemia or cardiac failure.Copyright © 2018 Adam S. Weinstein et al. Database: EMBASE

42. Pilot Trial of the Reboot Online Program: An Internet-Delivered, Multidisciplinary Pain Management Program for Chronic Pain Author(s): Schultz R.; Gardner T.; Shiner C.T.; Faux S.G.; Smith J.; Newby J.M.; Andrews G. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Available at Pain research & management - from Publishers' website (via doi.org) Abstract:Objectives. Chronic pain causes significant disability and psychological distress, but barriers often prevent people with pain from engaging in traditional face-To-face pain management programs. Accessible, feasible, and effective alternative treatment options are needed. Methods. A prospective, feasibility pilot study was conducted to trial a novel, multidisciplinary online pain management program: The "Reboot Online" program. Twenty participants experiencing pain of at least three months duration were recruited. All participants were enrolled in the "Reboot Online" program, consisting of eight online lessons completed over 16 weeks. Lessons incorporated multidisciplinary input from medical pain specialists, physiotherapists, and psychologists. Participants were assessed at pretreatment, posttreatment, and follow-up using a suite of outcome measures examining pain, disability, catastrophising, self-efficacy, mood, and psychological distress. Results. 13 participants completed the program (65% adherence). Following treatment, the participants had significantly improved scores on measures of pain-related disability, self-efficacy, catastrophising thoughts, acceptance of pain, symptoms of depression, and general psychological distress. These findings were retained at three months posttreatment. Participants also reported high levels of acceptability and satisfaction with the program. Discussion. This study provides pilot evidence for the feasibility, acceptability, and effectiveness of an online, multidisciplinary pain program: "Reboot Online." Future investigations will focus on conducting a randomised controlled trial of this innovative and promising treatment for chronic pain. This trial is registered with ACTRN12615000660583.Copyright © 2018 Regina Schultz et al. Database: EMBASE

43. Is HIV painful? An epidemiologic study of the prevalence and risk factors for pain in HIV- infected patients Author(s): Lawson E.; Sabin C.; Perry N.; Richardson D.; Gilleece Y.; Churchill D.; Dean G.; Williams D.; Fisher M.; Walker-Bone K. Source: Clinical Journal of Pain; Sep 2015; vol. 31 (no. 9); p. 813-819 Publication Date: Sep 2015 Publication Type(s): Article Abstract:Objectives: To evaluate the prevalence, impact, and risk factors for pain among a cohort of human immunodeficiency virus (HIV)infected adults treated with combination antiretroviral therapy if indicated according to current guidelines. Methods: This was a cross-sectional epidemiological observational study. All patients attending 1 HIV-outpatient center in the United Kingdom in a 10- month period were eligible. Patients completed a validated questionnaire enquiring about demographics, HIV factors, and symptoms of pain. Results: Of 1050 eligible participants, 859 (82%) completed a questionnaire. The 1-month period prevalence of pain lasting >1 day was 62.8% among whom 63% reported current pain. The prevalence of pain at most anatomic sites was broadly similar to that observed in population studies using the same questionnaires except that we found considerably higher rates of foot/ankle pain. The median duration of pain was 3 years (range, 0 to 51 y) and the median pain score was 5.0 on an 11-point visual analogue score. Over 40% of people in pain had consulted their primary care physician and >20% were taking analgesics daily. Independent risk factors for current pain were older age (P = 0.001), time since diagnosis of HIV infection (P = 0.001), and receipt of a protease inhibitor-based regimen (P = 0.04). Discussion: Pain, and notably foot/ankle pain, is common among adults living with prevalent HIV and is associated with substantial morbidity and health care utilization.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

44. Leading a horse to water facilitating registration and use of a prescription drug monitoring program Author(s): Deyo R.A.; Marino M.; Irvine J.M.; Hallvik S.E.; Hildebran C.; Beran T.; Millet L.M. Source: Clinical Journal of Pain; Sep 2015; vol. 31 (no. 9); p. 782-787 Publication Date: Sep 2015 Publication Type(s): Article Abstract:Objectives: Prescription Drug Monitoring Programs (PDMPs) can help inform patient management, coordinate care, and identify drug safety risks, abuse, or diversion. However, many clinicians are not registered to use these systems, and use may be suboptimal. We sought to describe outreach efforts in 1 state (Oregon); quantify uptake of system use; identify barriers; and identify potential system improvements. Methods: Program reports of outreach efforts and operational metrics provided rates of registration and use. A statewide survey identified perceived barriers and potential improvements from users and nonusers of the system. Results: Even with extensive registration efforts, <25% of clinicians and pharmacists acquired PDMP accounts over 2 years of operation. Rapid increases in registration and use in 2013 corresponded to new requirements among large pharmacy chains that pharmacists register for and use the PDMP. Among surveyed PDMP nonusers, nearly half were unaware that they could register. Among users and nonusers, over two thirds indicated that time constraints were a major barrier and over half thought that inability to delegate access was a major barrier. Desired improvements included linking state systems, faster entry of pharmacy data, and use of unique patient identifiers. Users also wanted better insurance coverage for mental health and addiction referrals. Discussion: Increasing registration and use of PDMPs remains important. Clinician feedback indicates that program enhancements and health care system changes would facilitate using and responding to PDMP information. It appears premature to judge the efficacy of PDMPs until best practices for their use are identified and impacts are assessed.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

45. Mast cell stabilizer (ketotifen) in fibromyalgia phase 1 randomized controlled clinical trial Author(s): Ang D.C.; Hilligoss J.; Stump T. Source: Clinical Journal of Pain; Sep 2015; vol. 31 (no. 9); p. 836-842 Publication Date: Sep 2015 Publication Type(s): Article Abstract:Objectives: Compared with pain-free controls, patients with fibromyalgia (FM) have more mast cells in the skin. Whether mast cells are involved in the pathogenesis of FM is unclear. We sought to determine the effects of a mast cell stabilizer (ketotifen) on FM symptoms. Materials and Methods: Fifty-one FM patients were randomized to daily oral ketotifen 2 mg bid (n = 24) for 8 weeks or placebo (N = 27). Mean age of patients was 51.2 years (SD = 8.4); 88% were female and 88% were white; 22% were taking concomitant opiates; and mean pressure pain sensitivity (range, 0 to 20) was 10.0 (0.4). At study entry, the weekly average pain intensity was 6.4 (1.1) and the mean score on the Revised Fibromyalgia Impact Questionnaire-Revised was 66.8 (14.0). Results: We found no statistically significant treatment group differences from baseline in either group for the 2 primary measures: weekly average pain intensity (ketotifen 1.3 [1.9] vs. placebo 1.5 [1.9], P = 0.7); and Fibromyalgia Impact Questionnaire-Revised score ( 12.1 [19.5] vs. 12.2 [18.1], P = 0.9). No secondary outcome measures (Brief Pain Inventory pain intensity and pressure pain sensitivity) reached statistical significance; results did not differ in the intent-to-treat and completer analyses. Other than transient sedation (6 [28.6%] vs. 1 [4.0%]), ketotifen was well tolerated. Discussion: The study results question whether skin mast cells play a major role in the pathogenesis of FM. However, given the role of mast cells in peripheral and central nociception, and the minimal side effects of ketotifen, a randomized clinical trial using increasing doses of ketotifen may be warranted.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

46. Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practices across VA health care systems Author(s): Buscaglia A.C.; Paik M.C.; Lewis E.; Trafton J.A. Source: Clinical Journal of Pain; Sep 2015; vol. 31 (no. 9); p. 803-812 Publication Date: Sep 2015 Publication Type(s): Article Abstract:Objectives: The purpose of this study was to determine baseline adherence to key recommendations from the 2010 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain at Veterans Health Administration (VA) facilities. We hoped to understand practice patterns at the time of guideline release to guide quality improvement and implementation efforts. Methods: Overall practice patterns were examined at each of the 140 VA Health Care Systems based on quality metrics developed to assess adherence to the VA/DOD Clinical Practice Guideline. Results: Clinical practice varied widely across facilities on measures of use of urine drug screens, substance use disorder treatment for diagnosed substance use disorder patients, and use of rehabilitative treatments. Less variation was observed in measures of sedative coprescription and use of adjunctive pharmacotherapy. Use of guideline recommended practices was generally more frequent for patients prescribed long-acting opioid formulations and those with chronic use. Relative facility- level implementation was correlated across most measures. Overall implementation of guideline recommended practices was lower at less complex facilities and facilities in the Western United States. Discussion: In 2010, guideline-recommended practices for opioid prescribing were variably used across VA health care systems. Efforts to disseminate practices used at high-performing sites, and increase consistency of use of recommended practices across patients and facilities should be considered to improve pain management and reduce adverse events.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

47. Contemporary pain management in elderly patients after hip fracture surgery: Cross-sectional analyses at baseline of a randomized controlled trial Author(s): Mak J.C.S.; Cameron I.D.; Klein L.; Mason R.S. Source: Clinical Journal of Pain; Sep 2015; vol. 31 (no. 9); p. 788-793 Publication Date: Sep 2015 Publication Type(s): Article Abstract:Background: Adequate pain management following hip fracture surgery reduces length of stay, reduces incidence of delirium, promotes recovery, and improves mobility. Previous research suggests that hip fracture pain is undertreated in some patient subgroups, and that hypovitaminosis D can further aggravate pain which could hinder active rehabilitation. We provide a cross-sectional analysis of the baseline characteristics of participants in the REVITAHIP study with the aim of documenting pain intensity and its associations after hip fracture and to explore the characteristics of people who report higher levels of pain. Method: We analyzed the baseline characteristics with a focus on pain scores in patients admitted with a hip fracture (undergoing surgery) to 3 teaching hospitals over New South Wales, Australia, between January 2011 and April 2013. Patients were evaluated using the Verbal Rating Scale (VRS). Secondary measures including 25-hydroxyvitamin D levels at baseline, hip fracture subtype, type of surgical intervention, quality of life score, and cognitive and mobility status were correlated with the VRS using the Pearson correlation, ANOVA, and regression analysis. Results: The 218 participants had a mean age of 83.9 +/- 7.2 years and 77.1% were women of whom 16.0% had a Mini Mental State Examination score of r23 of 30. The mean and SD VRS pain score was 3.5 +/- 2.3. More than half (61.9%, n = 113) had VRS Z 3 and 18.1% (n = 52) had VRS Z 5. Using the EuroQOL pain subscore, 78.1% had moderate pain or discomfort and 7.9% had extreme pain or discomfort. Using a multivariate regression model, postoperative VRS was significantly higher in persons with a higher comorbidity count, those previously living independently alone, and surgical fixative modality with hemiarthroplasty. Conclusions: Overall, the levels of pain reported by this cohort are acceptable although approximately 10% to 15% had higher than reasonable levels of pain. This study provides an insight into pain assessment and management by identifying certain patient subtypes who are vulnerable to undertreatment of pain.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

48. Do patients with thalassemia minor or trait benefit from blood conservation methods preoperatively before undergoing high blood loss surgery? Author(s): Jadunandan S.; Iacovelli M.; Lin Y. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 63 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Thalassemias are inherited blood disorders in which the body makes an abnormal form of hemoglobin. This disorder can be challenging in preoperative patient blood management when patients present with chronic anemia. Anemic patients are known to be at increased risk of transfusion with increased perioperative morbidity, mortality and hospital length of stay. The purpose of this analysis was to analyze the effectiveness of preoperative erythropoietin in this patient population. Methods: A single institution retrospective analysis of patients referred to the Blood Conservation Clinic from January 2009 to March 2018. Inclusion criteria included: preoperative assessment for an elective procedure recent CBC showing anemia evidence of thalassemia minor or trait (by hemoglobin electrophoresis, Hb H inclusion bodies, or a documented medical history of thalassemia minor or trait) treatment with subcutaneous erythropoietin and a posttreatment CBC. Erythropoietin was either given alone or in conjunction with intravenous iron (iron sucrose) if iron deficiency was present. In most cases, erythropoietin was administered at a dose of 40,000 units weekly targeting a hemoglobin of 12-13 g/dL preoperatively. Results: 45 patients met the inclusion criteria: 37 women and 8 men with a median age of 66 years (IQR 61-76). The majority (68.9%) were preoperative for orthopedic surgery followed by cardiac (17.8%) and other surgeries (13.3%) including gynecology and general surgery. The median pre-treatment hemoglobin was 10.6 g/dL (IQR 97-112). Patients received an average of 2.6 doses each with a mean hemoglobin increase of 0.98 g/dL. Treatment was commenced a median of 18 days (IQR 14-22) prior to the post-treatment measurement and improved hemoglobin by at least 10 g/L in 22 patients (48.9%). Seven patients (15.6%) had no change or a decrease following treatment. The median increase in hemoglobin with 1, 2, 3 and 4 doses was 0.6 g/dL (IQR 0.4-0.9), 0.55 g/dL (0.18-1.13), 1.0 g/dL (0.4-1.65) and 2.25 g/dL (1.63-2.58) respectively. Limitations: Beta and alpha thalassemia trait were not differentiated for those who had a documented evidence of thalassemia therefore the effects of treatment on each type of thalassemia could not be measured. Discussion: With close to half of patients experiencing at least a 1.0 g/dL hemoglobin increase, there can be benefit to treating thalassemia minor or trait patients with erythropoietin preoperatively. Multiple doses may be required to achieve this effect therefore treatment should start early in the preoperative phase. This analysis is preliminary and warrants further study to determine the effectiveness of erythropoietin with these patients. Database: EMBASE

49. High autologous wastage rate identifies opportunities for improving patient blood management Author(s): Bakhtary S.; Nedelcu E.; Perez A.R.; Manuel S.P. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 53 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Despite the very few indications and declining use of preoperative autologous blood donation (PABD), a subset of patients scheduled for elective surgery continue to choose this option. Our study aimed to better understand this practice at our institution by classifying the patient subset who participated in PABD. Methods: A retrospective review was conducted at a multicenter academic institution on the PABD program. Autologous units received in the transfusion service over a two-year period (1/1/2016 to 12/31/2017) were reviewed and the following data were collected from the patient medical records: demographics, surgical service and surgery type, estimated blood loss (EBL), hemoglobin values, and transfusion of any blood products. Statistical analyses were performed using STATA 15.1 (StataCorp LP Texas, USA). Results: 118 patients underwent PABD and donated 141 autologous red blood cell (RBC) units. 83% donated one unit, and the rest donated 2-5 units. Surgery was canceled or postponed for 9%. A total of 95 units were wasted (67%) and 46 (33%) were transfused. The four most common clinical services using a PABD program were liver transplant (45%), gynecology (13%), orthopedic surgery (10%), and urology (9%). The wastage rates for each of the above services were 59%, 89%, 86%, and 100%, respectively. Of the 141 units, 90 (64%) were collected for surgeries performed by four surgeons. The most common surgeries performed were hepatic lobectomy for live donor liver transplant (47%), abdominal or laparoscopic myomectomy or laparoscopic hysterectomy for fibroids (8%), total hip/knee replacement/revision (8%), and partial nephrectomy or radical prostatectomy (8%). For all surgeries, autologous transfusion was predicted by low pre-donation (p=0.004) and pre-surgery (p=0.011) hemoglobin values. Patients who received autologous transfusion had mean hemoglobin of 13.3 g/dL (+/- 1.4) prior to autologous donation and 12.1 g/dL (+/- 1.2) presurgery, whereas patients who were not transfused had mean hemoglobin 14.4 g/dL (+/- 1.5) prior to donation and 12.9 g/dL (+/- 1.5) pre-surgery. Only 29% patients who were transfused had an EBL of 500 mL or greater (range 500-1800). Conclusion: PABD is still utilized for elective surgeries by clinical services and is associated with high wastage rates without justification for the increased cost. Patients with lower baseline and pre-surgery hemoglobin values were more likely to receive autologous transfusion, but 71% of transfused patients had EBL of less than 500 mL. Education of patients and clinical services may decrease blood wastage and assist with formulation of guidelines for cost-effective blood management. Database: EMBASE

50. Standardization reliable recognition and treatment of pre-operative anemia using anemia reflex testing and pharmacy driven workflows Author(s): O'Connell J.; O'Brien M.A.; Hohmuth B.; Haynes A. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 50 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: Geisinger's patient blood management (PBM) department sees all anemic patients who are anticipating major joint arthroplasty to facilitate both diagnosis and treatment of anemia prior to surgery. \Our original workflow relied upon our PBM nurses making recommendations for further diagnostic testing for those patients who were found to be anemic on pre-operative screening. For the subset of these patients found to be iron deficient our PBM nurses made further recommendations regarding appropriate treatment. This workflow relied upon surgical teams to enter the recommended orders which compromised reliability of the process. In addition, bringing back those patients found to be anemic back for an additional diagnostic phlebotomy was inconvenient for patients and decreased the time to treat prior to surgery. Methods: We developed an anemia reflex test to facilitate anemia diagnosis as well as a pharmacy driven protocol to facilitate treatment of iron deficiency. The anemia reflex draws an additional tube of blood with the preoperative screening CBC. If the patient is not anemic the tube is discarded. If the patient is anemic, the MCV determines which additional studies will be performed from the additional tube. The pharmacy protocol enables a standardized action to be carried out without relying on the surgical service. Our pharmacists enter orders directly as dictated by our anemia management algorithms as well as follow up hemoglobin testing to assess response to treatment. We piloted this approach at two of our largest campuses for hip and knee arthroplasty. Results: We have successfully implemented our anemia reflex testing and have treated a total of 54 patients using pharmacy driven protocols for iron deficiency. Conclusion: Anemia reflex testing and pharmacy driven workflow are a viable option for identifying and treating preoperative anemia. We have hired a full-time pharmacist to focus on expanding this protocol to other preoperative patient populations and are investigating a similar approach for our ambulatory systolic heart failure patients. Database: EMBASE

51. Bloodless revascularization: The protected PCI approach at Englewood Hospital Author(s): Serhan M.; Al Shamy T.; Hakeem H.; Schwarcz A. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 46 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: Certain patients do not accept blood products in their medical care. We sought to describe the use of Impella heart pump (ABIOMED, Danvers) as a prophylactic support in non-emergent procedure in these patients. Methods: We reviewed the charts of all bloodless medicine patients who underwent prophylactic support with Impella for a non-emergent procedure and all non-shock patients who underwent a Protected PCI with Impella at our institution between Jun 2012 and Dec 2016. We compared baseline characteristics and in-hospital outcomes including in-hospital mortality, vascular complications, Impella access site bleeding, requiring surgery or transfusion, and need for transfusion in general. Results: A total of 34 patients were included in this analysis 72.8+/-13.1 years old and 70.6% were male. At baseline 45.5% had diabetes, 24.1% peripheral vascular disease, 21% chronic kidney disease, 75.8% coronary artery disease and 73.5% congestive heart failure. Prior to Impella initiation the average left ventricular ejection fraction was 30.6%+/-13.5%, serum creatinine was 1.5+/-1.5mg/dL and the hemoglobin was 12.4+/-2.1 g/dL. Of the 34 patients, 8 bloodless medicine patients underwent prophylactic Impella for a non-emergent procedure (7 Protected PCI, 1 electrophysiology procedure for ventricular tachycardia ablation) and 26 underwent prophylactic Impella for a Protected PCI. The two groups were well matched in terms of baseline and procedural characteristics. There were no significant differences between the bloodless medicine group and the rest of the patients with regard to in-hospital mortality (0.0% vs. 3.9%, p=1.00), need for transfusion (0.0% vs. 7.7%%, p=1.00) Impella access site bleeding (0.0% vs. 3.9%, p=1.00), or days of hospital stay (7.3+/-5.6 vs. 8.7+/-7.9, p=0.60). No patient had vascular complication requiring surgery or transfusion. Conclusions: Our results suggest that in patients requesting bloodless medicine, prophylactic Impella support in this patient population in whom avoiding emergent need for surgery and repeat revascularization outweighs the potential related hazard of vascular complications and bleeding is feasible, especially when meticulous attention to access and closure is used. Database: EMBASE

52. Variation on transfusion practice in first elective coronary artery bypass graft (CABG) surgery demonstrated by a statewide quality initiative Author(s): Wu Y.; Collins-Brandon J.; Hira R.S.; Glover T.; Gallagher T. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 45 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background/Case Studies: Many factors can result in variation in transfusion practice. As part of a quality program, we evaluated the degree of transfusion practice variation for adult first elective coronary artery bypass graft (CABG) surgery in Washington State. Methods: All hospitals in Washington State that provide adult cardiac surgery are invited to participate in this quality initiative. In order to evaluate variation in blood use we identified a cohort of patients undergoing their first elective CABG surgery. This cohort of patients has been validated in other data sets to evaluate variation in transfusion patterns as they can be optimized prior to surgery and are at lower risk for bleeding compared to other cardiac surgical procedures. Data from cases reported in 2017 was used for this analysis. The data are abstracted from the medical record at each participating hospital following adult cardiac surgery. We used de-identified data for analysis. Results/Finding: We have observed significant unadjusted practice variation both at the hospital and at the provider level. Conclusion: There is wide variation in transfusion practice for patients undergoing first elective CABG in Washington State. Database: EMBASE

53. Can thromboelastography really assess coagulation in anemic patients? Author(s): Kuperman A.A.; Braester A.; Shaoul E.; Polack R. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 43-44 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: Thromboelastography (TEG) is a method performed on whole blood, examining the physical properties of blood clots (figure 1). Two published studies [1,2] investigating the effect of ex-vivo hemodilution on TEG parameters, revealed conflicting results. Another study [3] examining the effect of high Hct (hematocrit) in cyanotic congenital heart disease revealed a lower ROTEM MCF, indicating "hypocoagulability". TEG is often performed in bleeding patients so it is essentially important to examine its significance when hematocrit (Hct) decreases. Aim: Assessing the effect of ex-vivo Hct reduction (by erythrocyte removal) on TEG parameters in healthy volunteers. Methods: Fifty one healthy volunteers aged 18-50 years, were studied. Blood drawn into EDTA tube served as a baseline measure. Four citrate tubes were used for measuring TEG, PT, PTT and derived fibrinogen. Two of the citrate tubes retained Hct of 35-55%, and served as reference. The other tubes were used to produce a variable Hct around 20-25% by removal of red blood cells pellet. Two methods of TEG were used: citrate kaolin TEG on all 51 blood samples, and FFR (functional fibrinogen reagent) TEG (figure 2) used to determine the functional fibrinogen contribution on the TEG MA (maximal amplitude) of 38 blood samples. Results: Using the citrate kaolin TEG, there was a significant elevation of MA correlated with Hct reduction (Pearson correlation, R =-0.551, p< 0.001, n=51), which may imply a pattern of hypercoagulation. Using the FFR TEG there was a statistically significant correlation between Hct reduction and elevation of functional fibrinogen levels (Spearman correlation, R =-0.390, p=0.016, n=38), indicating its contribution to the MA changes. Fibrinogen levels measured in all tubes were not significantly changed by Hct reduction. The changes in platelet numbers were in all cases in normal range, and no statistical correlation was found between platelets number changes and the Hct changes (Spearman correlation, R = 0.027, p=0.850, n=51). Discussion: Rheological studies imply that low Hct contributes to bleeding tendency, wheres low Hct will result in more bleeding. The current study is first to explore why TEG MA unexpectedly implies hypercoagulation. We chose to perform ex-vivo erythrocyte reduction since it reflects the pathophysiology of blood loss better then hemodilution with normal saline. We were able to demonstrate, via the TEG FFR test, that the high MA is caused by elevation of functional fibrinogen. The explanation we suggest is that since TEG is performed on whole blood, in "anemic blood" which contains higher proportion of plasma (and thus functional fibrinogen); clot strength may falsely increase ex-vivo. Conclusions: 1. Ex-vivo reduction of Hct is strongly associated with MA elevation. 2. The high MA is explained by elevation of functional fibrinogen levels. 3. It is not clear whether these findings reflect physiology or an artifact of the method and further in-vivo studies are needed. Database: EMBASE

54. Anemia clinic treatment and pre-operative management of cardiovascular surgery patients Author(s): Barlow C.M.; Upchurch C.A.; Kober E.; Mitchell M.D.; Ford P.A.; Furukawa S. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 31-32 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: The efficacy of an Anemia Clinic in medically optimizing cardiovascular surgery (CVS) patients preoperatively has not yet been examined. A retrospective chart review was performed to explore whether such an intervention might minimize resource utilization, improve outcomes and decrease health system cost. Methods: Twenty-five patients with a history of anemia (defined as hemoglobin <= 13.5 in men and 12.0 in women) undergoing cardiac surgeries-inclusive of Coronary Artery Bypass Graft (CABG), valvular (mitral or aortic) surgery, or a combination of the two- were referred to the Department of Hematology's Anemia Clinic at Pennsylvania Hospital by cardiovascular surgeons throughout the University of Pennsylvania Health System between January 01, 2016 and June 01, 2017. Three patients had comorbidities that precluded surgery and one with normal hemoglobin was referred for further optimization. Twenty-one anemic CVS patients met criteria for evaluation and nineteen were treated in the preoperative setting, receiving erythropoietic-stimulating agents (ESA) and/or IV iron. Eleven of nineteen received both ESA and IV iron, while eight received only the latter. Three of the patients in the treatment cohort preemptively refused blood products at time of presentation on account of religious convictions. Results: Special attention was paid to patients' hemoglobin at initial encounter, final hemoglobin prior to surgery, post-operative hemoglobin, doses of ESA and/or IV iron, number of subsequent transfusions, and 30-day hospital readmissions with comparison to the standard of care. Four of the sixteen patients (25%) managed pre-operatively with ESA and/or IV iron who were willing to accept blood products following CVS ultimately required transfusion, as compared to transfusion rates that typically near 50% for patients undergoing cardiac surgery (Mehta et al., 2009 Murphy et al., 2015). Two of these four had received both ESA and parenteral iron, while two had received iron alone. Zero of the nineteen patients treated pre-operatively in the Anemia Clinic were readmitted within 30 days of their discharge from the hospital, as compared to a state-specific 30-day readmission rate of 11.7% for patients undergoing CVS between 01/2014 and 03/2016 (Martin, 2017). Conclusion: The medical optimization of cardiovascular surgery patients pre-operatively via an Anemic Clinic platform decreases post-operative transfusions and may play a prominent role in preventing 30-day hospital readmissions. A potential improvement in patient outcomes at decreased cost to the health system advocates strongly for further cost-benefit analysis as well as examination of this model's validity in larger data sets and across other healthcare specialties. Database: EMBASE

55. Risk reduction versus blood conservation in the in the neonatal ICU Author(s): Squires J.E.; Toeppner H.D. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 30 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: For a variety of clinical indications, patients in neonatal intensive care units (NICU) often require multiple, small volume transfusions during their hospital stay. To accommodate the transfusion needs of these patients, many hospitals dedicate single or partial red blood cell units to individual neonates. Multiple transfusions from single donor units can then be given during the neonate's hospitalization thereby reducing donor exposure for the patient. A collateral benefit is that each RBC unit can be more completely used reducing wastage. We report the results of a quality improvement audit to assess our neonatal transfusion program. Methods: Our neonatal transfusion protocol is designed to reduce multiple donor exposures for each neonate. Inpatient transfusions were reviewed for all RBC units assigned for the NICU. The following information was collected: the number of transfusion events and the total volume transfused for each neonate the volume of each unit discarded and the number of separate units to which each patient was exposed. Results: In this four month review of NICU blood usage, 31 separate patients were transfused with RBCs involving 116 separate transfusion events. Twenty-three of these patients (72%) were exposed to only one unit of RBCs, but 15 received only 1 transfusion. The remaining 8 patients received multiple transfusions from the single unit assigned (range 2-6 transfusions). Nine patients received RBC transfusions from 2-5 separate units, largely due to patient length of stay in the NICU or special therapies. In reviewing the aggregate amount of blood transfused from the 66 RBC units used, it was found that 47% of the blood in these units were discarded, usually due to outdating. Conclusions: It is widely accepted that the use of single RBC units to support the multiple small-volume transfusion needs of NICU patients reduces donor exposure and potentially results in the overall use of fewer RBC units. Our data supports this observation in that 116 separate transfusions were completed using only 66 RBC units. An important additional observation was that 47% of the blood volume assigned for use in the NICU was discarded. We believe that one of the reasons for this is the difficulty in prospectively determining the transfusion needs of each patient. For example, nearly half of total patients transfused received only one small-volume transfusion in the NICU suggesting that additional patients could have been assigned to that unit further reducing the overall need for RBC units. Database: EMBASE

56. Utilizing change management to reduce transfusions in isolated coronary artery bypass grafting: Leveraging business models for clinical improvement Author(s): TenClay S.; Watson N.C.; Kramer Z.; Sang S.L.W.; Michaud C.J. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 24-25 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Perioperative packed red blood cell (PRBC) transfusion is associated with increased morbidity and mortality after isolated coronary artery bypass grafting (iCABG). In 2016 our institution performed 598 iCABGs, with 40% of patients receiving one or more PRBC units. The national average was 36.1%. We sought to reduce utilization to 35.5%. To achieve this target, we adopted principles from the discipline of change management. Change management borrows from fields such as social psychology, behavioral science, and information technology. It is most commonly used to structure organizational change in the business world and carries theoretical benefits for quality improvement processes in medicine. Methods: We created a customized change management strategy for blood conservation in iCABGs by employing elements from various change management models. Our focus was on the process of change rather than an event that forced change upon health care workers. We aligned key stakeholders by identifying the shared need to improve transfusion practice and solicited ideas for excellence. We then enlisted a core Change Team comprised of multidisciplinary champions for change. Ideas for excellence, data from a deep dive into our current practices, and multiple societal guidelines were blended to inform the development of our plan. We concentrated on making change easy by aligning the people, equipment, and information technology involved in bedside care. Next, a transitional state established the following: standardized and algorithmic perioperative workflow, routine meetings of stakeholders, seeking and processing feedback, expert consultation, changes to equipment, and changes to the order entry system. Emotional engagement of individual stakeholders was maintained by sharing patient stories and by public reporting of individual provider performance. Finally, in the consolidation phase we asked which interventions were working well and which were not. Answers to this question and the subsequent interventions are an ongoing process in our change management. Results: In the 14-month period following initiation of our change management strategy, PRBC use in iCABG dropped from 40% to 31.2%. Following the 6-month transitional state of our change management, the PRBC use in iCABG was 29.5% for the next 8 months. Discussion: We integrated elements of change management with common quality improvement strategies to design a successful approach to blood conservation in iCABGs. Future work should focus on: (1) refining clinical change management strategies by identifying the factors with the highest impact and the lowest cost and (2) spreading clinical change management into other areas of medicine. Database: EMBASE

57. Prevalence of folate deficiency among preoperative anemia clinic patients: Retrospective research and quality improvement study Author(s): Pasula S.; Tran P.; Gandhi N.; Steinbrunner J.; Coyle T. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 22 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Anemia is common in patients undergoing elective surgery and is associated with increased perioperative morbidity and mortality, increased length of hospital stay and an increased rate of blood transfusions. Correction of anemia by preoperative anemia clinics is a standard procedure to decrease transfusion rates and improve outcomes. Nutritional deficiency accounts for approximately one-third of preoperative anemia. Folate deficiency is the least common of the nutritional deficiency anemias, due to fortification of foods with folate since 1998. To assess the effectiveness of routine screening for folic acid deficiency in preoperative anemia clinic patients, this study aimed to assess the prevalence of folic acid deficiency in this population. Methods: 930 anemic patients scheduled to undergo elective surgery were referred to the TriHealth anemia clinic between July 2013 and November 2016. Men with hemoglobin less than 13 g/dl, women less than 12 g/dl who were scheduled for surgery were included in the study. The majority were scheduled for joint replacement surgery. A CBC, serum iron, TIBC, ferritin, vitamin B12 and Folic acid levels were obtained automatically on each patient prior to their being seen at the anemia clinic. Patients who were referred but not seen at the clinic, non-preoperative, pregnant patients, and patients with incomplete data were excluded. A total of 512 patients were included in the study. Per TriHealth laboratory values, 90% reference range of folate level is 5.9 to >24.8 ng/ml. Folate deficiency was defined as a level less than 4 ng/ml consistent with the WHO definition. Descriptive analysis was conducted using SPSS software. Results: 3(0.58%) patients were found to be folate deficient out of 512 patients. In the folate deficient population, 33% were male, 67% were female, and all were under the age of 65. The MCV in these three patients ranged between 78-95 fL. and there were no other signs of megaloblastosis. No patient was treated with folate supplementation. Conclusion: Folate deficiency is rare in outpatients referred to a preoperative anemia clinic. Our results suggest that routine serum folate testing may be omitted in this setting unless there are clinical risk factors for folic acid deficiency or signs of megaloblastosis. Database: EMBASE

58. The safety of restrictive allogeneic blood transfusions strategy in patients with extremity sarcoma Author(s): Jang W.Y.; Hong S.H.; Park J.H. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 16-17 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Allogeneic blood transfusions (ABT) are common in patient with cancer. The aim was to investigate the safety of restrictive ABT strategy in patients with extremity sarcoma. Method: We retrospectively reviewed patients who underwent operation for extremity bone or soft tissue sarcoma between May 2008 and November 2017. To investigate surgical outcome of restrictive ABT strategy, clinical outcome based on variation in hemoglobin (Hb) concentration, postoperative surgical site infection, and hospital stay days were compared between 20 patients who underwent liberal ABT as control (group 1) and 19 patients who underwent restrictive ABT strategy (group 2). Rate of distant metastasis and death after operation were also compared between the groups. Result: There was no significant difference in sex, age, tumor grade and tumor size between the groups (p=0.89, p=0.57, p=0.39, p=0.46 respectively). The mean of ABT was 3.6 +/- 3.8 unit in group 1 and 0.23+/- 0.66 unit in group 2. Only 2 of 17 patients received transfusions and 2 packs were administered. The Hb had a tendency to fall during the three first days after surgery and seemed to be stabilized on day 5 in both group. Postoperative surgical site infection only occurred in 4 patients who underwent ABT. Length of stay was longer in group 1 (40.7 +/- 20.9 days) than group 2 (30.9 +/- 19.8 days), but there was no significant difference (p= 0.16). The rate of distant metastasis and death were higher in group 1 than group 2 (18.2 % vs. 6.7%, 9.1% vs. 0 % respectively), but no significant difference (p=0.60, 0.64 respectively). Conclusion: This study demonstrated that restrictive ABT strategy can be safely performed for wide excision or limb salvage operation in patients with extremity sarcoma. Database: EMBASE

59. Iron deficiency in pregnancy: A commonly unrecognized problem Author(s): Ziola K.; Karreman E.; Lett C. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 14 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Objectives: For a community general obstetrics population, the objectives are: 1) To determine the incidence of iron deficiency and anemia during pregnancy and postpartum 2) To determine the impact of iron supplementation on pre-delivery and postpartum anemia in iron deficient patients. Study methods: A retrospective review of 280 patients between November 2016 and November 2017 was performed using an office electronic medical record database. Complete blood count (CBC) and iron studies (iron, %saturation, and ferritin) were performed with second trimester diabetes screening. Anemia was defined as hemoglobin <110g/L and iron deficiency was defined as ferritin < 30 ng/mL and/or %saturation < 15%. Iron deficiency was treated with antepartum oral iron supplementation at the discretion of the care provider. Hemoglobin values pre- delivery and postpartum were recorded. Results: Between the 24th and 28th week of pregnancy, 87% of our sample was iron deficient. During this time, only 8% was anemic, while this number climbed to 44% postpartum (p < .001). A total of 74% (135/182) of iron deficient patients received antepartum oral iron supplementation. Oral iron supplementation increased pre-delivery hemoglobin by 6.76g/L. The mean pre-delivery hemoglobin levels increased by 2.66 g/L more in iron deficient patients who were supplemented compared to those who did not receive a supplement (p = .054). Antepartum oral iron supplementation did not impact the incidence of postpartum anemia. Conclusions: Iron deficiency in pregnancy was very common in our cohort and would not have been recognized by hemoglobin level measurements only. While anemia is not prevalent during pregnancy, postpartum anemia is common. Finally, oral iron supplementation of iron deficient women increased hemoglobin levels prior to delivery but could not prevent a substantial rise of postpartum anemia in our cohort. Database: EMBASE

60. Discharge hemoglobin <8 g/dL is associated with increased 30-day readmission rates after CABG Author(s): Visagie M.; DeMario V.M.; Cho B.C.; Grant M.C.; Hensley N.B.; Brown C.H.; Hebbar S.; Frank S.M.; Mandal K.; Whitman G.J. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 11 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels upon discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). Methods: We retrospectively evaluated 1,552 patients undergoing isolated CABG at our institution from Jan 2013 to May 2016. We evaluated two Hb cohorts: "High" (above) and "Low" (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (< 8 g/dL) discharge Hb levels on 30-day readmission rates. Risk adjustment accounted for age, gender, Charlson comorbidity index, preoperative comorbidities, and patient blood management program implementation. Results: Figure 1A is a LOWESS curve showing an increase in 30-day readmission rates when discharge Hb levels are < 8 g/dL, and a plateau in the 30-day readmission rate between 8 g/dL and 12.5 g/dL. Figure 1B shows an increase in readmissions with discharge Hb < 8 g/dL. On multivariable analysis, the risk-adjusted odds of readmission in the "Low" Hb cohort (OR 1.16 95% CI 0.84 to 1.61) (P = 0.36) was not significant compared to the "High" Hb cohort. However, a Hb < 8 g/dL upon discharge was predictive of increased 30-day readmissions (OR 1.77 95% CI 1.05-2.88) (P = 0.036). Conclusions: A discharge Hb < 8 g/dL after CABG surgery may increase the risk for 30-day readmission. Although several trials support a restrictive transfusion strategy in cardiac surgery, further studies are needed to determine the lower limit for a safe discharge Hb. Database: EMBASE

61. SABM 2018 Abstracts Author(s): anonymous Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3) Publication Date: Sep 2018 Publication Type(s): Conference Review Abstract:The proceedings contain 55 papers. The topics discussed include: laparoscopic D1+ lymph node dissection for gastric cancer in Jehovah's witness patients: a 1:3 matched case control study; a multimodal approach reduced allogeneic blood transfusions by over 50% in pediatric posterior spinal fusion (PSF) surgeries; automated quantification of blood loss versus visual estimation: a prospective study of 274 vaginal deliveries; sickle red blood cells are more susceptible to in vitro hemolysis when exposed to normal saline versus plasma-lyte a; blood utilization, mortality, and costs for transfused victims of gun violence; program to reduce redundant laboratory sampling in an intensive care unit leads to non-inferior patient care and outcomes; impact of perioperative allogeneic blood transfusion on prognosis in high-grade extremity sarcoma: a meta-analysis; prevalence of folate deficiency among preoperative anemia clinic patients: retrospective research and quality improvement study; utilizing change management to reduce transfusions in isolated coronary artery bypass grafting: leveraging business models for clinical improvement; assessment of hyperfibrinolysis and coagulopathy in gastrointestinal hemorrhage using rotational thromboelastometry; utilizing data combined with specialty champions as drivers for accelerating and maximizing patient blood management initiatives; standardization reliable recognition and treatment of pre-operative anemia using anemia reflex testing and pharmacy driven workflows; and high autologous wastage rate identifies opportunities for improving patient blood management. Database: EMBASE

62. Extended reliability and clinical utility of a validated intraoperative bleeding scale (VIBe SCALE) Author(s): Jones D.S.; Li Q.; Lewis K.M.; Cheatem D.; Shander A. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 78-79 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Background: Patient blood management recommendations identify periodic, intraoperative communication between surgeons and anesthesiologists as an effective measure to proactively manage and effectively treat blood loss. To date such assessments are subjective estimates. A Validated Intraoperative Bleeding Scale (VIBe SCALE) has been developed for use in clinical studies to objectively assess bleeding severity (Table 1). Understanding how the VIBe SCALE is designed and applied, it may have broader applicability in surgical practice. We describe new data and analyses of this scale and explore the clinical utility of the scale for the anesthesia and operating room teams. Methods: The validation of the scale was conducted by having 102 surgeons across 11 specialties use the scale to grade bleeding in 15 videos via an online tool. Construct validation was evaluated according to United States Food and Drug Administration (FDA) criteria: ability to detect change, response range, clarity, relevance, usability, and reliability (repeatability and reproducibility). In addition, reliability over an extended test-retest period was conducted by having 30 surgeons across 5 surgical specialties use the scale to grade bleeding in 10 videos via the same online tool. Results: Participants could detect change in bleeding severity and gave appropriate responses across the full response range. Clarity, relevance and usability were confirmed, with >=80% of participants agreeing, the scale used objective and non-overlapping terms all participants confirmed the scale was very or mostly self-explanatory and 99% of participants considered the scale clinically relevant for evaluating hemostasis. Repeatability and reproducibility of all participants were excellent with Kendall's W values of 0.977 and 0.906, respectively. Over an average extended test-retest period of 370 days repeatability was excellent, with a Kendall's W value of 0.934. Reproducibility was appreciable at both the test and retest, with Kendall's W values of 0.884 and 0.876, respectively. Conclusion: The VIBe SCALE fulfills the FDA criteria for development of a clinician-reported scale and has demonstrated reliability over an extended test-retest period, indicating high clinical utility for the patient care team. The scale allows the surgeon to identify bleeding requiring treatment and clearly communicate the level of blood loss to the anesthesia team consistent with recommendations for patient blood management. The anesthesia team can then proactively take appropriate measures to prevent the foreseeable consequences of blood loss. Database: EMBASE

63. Salvage of life-threatening acute blood loss anemia in the traumatic and post-operative setting: A case series of clinical experiences with hemopure (HBOC-201) blood substitute Author(s): Soe-Lin H.; Lynn M. Source: Anesthesia and Analgesia; Sep 2018; vol. 127 (no. 3); p. 75 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Hemoglobin based oxygen carriers (HBOC) have been broadly studied as alternative oxygen carrying blood substitutes for the past three decades. More recently third generation HBOCs such as Hemopure (HBOC-201) have been used in Phase III clinical trials in elective orthopedic, noncardiac elective, post cardiopulmonary bypass, and aortic aneurysm reconstruction surgery. The following case series reports our single institutional experience with 7 critically ill patients enrolled in HBOC- 201 therapy. All patients were Jehovah's Witnesses who had symptomatic anemia with evidence of end organ ischemia and/or a cutoff Hgb of less than 5. Patients received full protocolized hematopoietic support including high dose iron and Procrit therapy. HBOC-201 transfusion was used as a bridge for maintaining oxygen carrying capacity until surgical hemostasis was obtained and the patient's intrinsic hematopoiesis replenished their native red blood cell volume. Patients received between 3 and 7 total units of HBOC-201. Our seven patients had a median age of 73 and a variety of complex surgical problems including cardiac tamponade with arrest following a coronary artery dissection during a percutaneous catheter revascularization with coronary artery stent placement, decompensated cirrhosis following a laparoscopic cholecystectomy with hematogeneous ascites, oropharyngeal bleeding in the setting of a prior maxillofacial squamous cell carcinoma resection with sinus involvement, a bleeding root-of-mesentery spindle cell tumor in the setting of Acute Lymphocytic Leukemia, post-operative massive hematuria following a prostatic enucleation, and 2 patients with traumatic falls with complex long-bone femur fractures requiring urgent operative fixation. Of the seven patients enrolled with life threatening anemia, four survived to discharge. Complications included hypertension, methemoglobinemia, troponemia, and one stroke with improving residual deficit. No fatal cardiac events were reported. One patient died of decompensated cirrhosis while two died from multisystem organ failure as a sequelae of their original hemorrhagic shock. No patients died as a direct result of complications of HBOC administration. Enthusiasm for broader use in the critically ill trauma and emergency general surgery population have been tempered by early concerns of increased morbidity and mortality. The following data using a third generation HBOC provides evidence that HBOC-201 can be used in the acute traumatic and emergency surgery setting as a salvage strategy for tissue oxygenation in the face of life threatening acute blood loss anemia in those patients for whom allogeneic blood transfusion is not an option. Database: EMBASE

64. Case series: The use of dexmedetomidine for sedation in patients undergoing carotid stent placement Author(s): Faulkner A.; Green A.; Dority J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 459 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:For symptomatic carotid stenosis, carotid artery stenting is a minimally invasive procedure performed under monitored anesthesia care with sedation. The aim of the sedation is to both facilitate a rapid neurological examinations as well as promote patient cooperation while on the operating table; the patient must remain very still for imaging, balloon angioplasty, and stenting. In what literature that exists and at our institution, standard sedation is usually achieved with a combination of midazolam and fentanyl, which may or may not be supplemented by propofol boluses. However, little literature exists on sedation regimens for patients with absolute or relative contraindications to these medications. Dexmedetomidine is a selective alpha-2 agonist that has found favor as an anxiolytic, analgesic, and anesthetic. Its rapid onset and rapid metabolism would seem to make it an ideal alternative for carotid artery stenting, but side effects including titration- dependent bradycardia and hypotension are known. Further, during balloon angioplasty and stenting of the carotid artery, bradycardia and hypotension can occur as a result of direct stimulation of the carotid sinus. We present a case series of at least 4 patients in which dexmedetomidine was utilized as an infusion to provide sedation under monitored anesthesia care for carotid artery stenting. Further, we demonstrate its safety for use as an alternative sedation regimen with minimal impact on hemodynamics throughout the procedure. Database: EMBASE

65. Anesthesiologists' perspectives on total intravenous anesthesia Author(s): Fiorda-Diaz J.; Stoicea N.; Moran K.; Zuleta Alarcon A.; Echeverria-Villalobos M.; Bergese S.; Lim A.; Riedel B. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 427 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Several studies suggest that total intravenous anesthesia with propofol (TIVA) may associate with improved long-term survival in patients undergoing cancer surgery.1 Furthermore, in the neurosurgical setting TIVA is associated with lower interference with evoked potentials and lower PONV in elective craniotomies.2,3 In spite of these findings, inhaled anesthesia (IA) continues to be the most commonly used anesthesia technique.4 Objective: We set out to evaluate anesthesiologists' preference/barriers for propofol-TIVA technique. Methods: Anesthesiologists members of the SNACC were invited (between January and February 2018) to participate to an online survey previously distributed by the Australian and New Zealand College of Anaesthetists. Results: We had 15% (N= 92) response rate to the survey. Of the respondents, 42.3% provide anesthesia to >= 2 cancer patients per week and 63% used TIVA for >50% of their neurosurgical cases. The majority of the respondents (95.6%) felt that TIVA was associated with lower incidence of PONV and emergence delirium (69.5%) and improved neuroprotection (52.2%) when compared with IA. In addition, 57.6% of anesthesia providers used TIVA more frequently in patients with multiple risk factors for PONV. Barriers to using TIVA included: duration of surgery (81% of respondents used TIVA in only half of cases lasting >4 h); cost (72.8% considered TIVA more expensive); and technical difficulties (more difficult to use [85.8%], longer set-up times [67%], and more difficult to titrate [50%] when compared with than IA). Related to cancer outcomes, 52.2% were unsure whether TIVA could be beneficial for cancer patients and 40% of respondents rarely used this technique in this patient setting. Discussion: Propofol TIVA and IA may have differential pharmacodynamic effects including immunomodulation, inflammation, and neuroprotection. In the neurosurgical setting, IA is associated with lower systemic vascular resistance and promotion of cerebral oxygenation while higher cerebral perfusion pressures and lower mean intracranial pressures during elective craniotomies in patients receiving propofol-maintained anesthesia.2 Our survey indicates that TIVA is preferred over IA for neurosurgical cases and perceived to provide better neuroprotection. The majority of participants considered that TIVA is associated with lower incidence of PONV, but only about half of respondents used TIVA for patients with multiple risk factors for PONV despite the recommendation of TIVA in the guidelines for PONV.5 Conclusions: On the basis of our survey, IA continues to be the most commonly used technique among anesthesia providers. Despite the aforementioned barriers (cost, set-up times, and equipment) TIVA remains the technique of choice for neurosurgical patients and at high risk for PONV. Barriers can be overcome by increased access to Master Class educational strategies. Database: EMBASE

66. Acetaminophen does not reduce postoperative opiate consumption in patients undergoing craniotomy for cerebral revascularization Author(s): Stone S.; Burbridge M.; Jaffe R. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 459 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Postoperative management in patients undergoing craniotomy is unique and challenging. Practitioners may minimize opioid use with the result that postcraniotomy pain is often undertreated. We utilized a unique population of patients who underwent bilateral extracranial-to- intracranial (EC-IC bypass) revascularization procedures for moyamoya disease and hypothesized that 1 gram IV acetaminophen given immediately after intubation and again 45 minutes before the end of craniotomy, may be more effective in minimizing opiate consumption and decreasing pain scores in the 24-hour postoperative period. In a double-blind randomized placebo-controlled crossover study, 40 craniotomies in 20 patients were studied. A random number generator was used by the hospital pharmacy to assign patients to receive either 1 g of IV acetaminophen or an equal volume (100 mL) of normal saline immediately after intubation and again 45 minutes before the end of their first operation. For the second surgery, patients received the study drug (IV acetaminophen or normal saline) that they did not receive during their first surgery, both immediately after intubation and again 45 minutes before the end of the procedure. In the IV acetaminophen group, the average 24-hour postoperative fentanyl equivalent consumption was decreased but the difference was not statistically significant: 228 mug compared with 312 mug in the placebo group (Fig. 1; P=0.09). Pain scores did not significantly differ between the IV acetaminophen group and the placebo group in postoperative hours 0 to 12 (Fig. 2A; P=0.44) or 24 (Fig. 2B; P=0.77). Our study demonstrates that in patients receiving bilateral craniotomies for moyamoya disease, IV acetaminophen when given immediately after intubation and again 45 minutes before closure, does not significantly decrease 12 or 24-hour postoperative opiate consumption. Database: EMBASE

67. Anesthetic experience and management of awake craniotomy in a single academic center Author(s): Santos C.; Rey-Dios R.; Kurnutala L. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 426-427 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Craniotomy requiring an awake and responsive patient is often employed when brain masses are near regions of eloquent cortex, such as those involved in motor, sensory, or linguistic functioning. Proper patient selection, preparation, preoperative evaluation, and team approach are vital to the success of the procedure as the patient must be able to communicate with the anesthesiologist and surgeon during critical portions of the surgery. Intraoperative management typically falls into 2 categories; the "asleep awake asleep" technique which involves periods of general anesthesia or using monitored anesthesia care with varying depths of sedation. Material: The University of Mississippi Medical Center is located in Jackson, Mississippi and it is the only academic hospital in the state. In this article we discuss 6 awake craniotomies performed in our Medical Center from 2015 to 2018. In all cases monitored anesthesia care with bilateral scalp blocks were used. Indications for awake procedure included tumor location in eloquent areas involving speech. Two cases were low-grade gliomas, 3 high-grade gliomas, and 1 solitary fibrous tumor. In all cases maximal safe resection was achieved and patients' speech function was preserved. Conclusions: Patient selection and preparation, continuous communication with patient and neurosurgical team, and adequate levels of sedation and analgesia are all required to facilitate successful awake craniotomy. Ideally, patients should be well-motivated and able to tolerate lengthy procedures. Proper airway evaluation and anticipation of complications such as seizure, intraoperative bleeding, airway obstruction, and nausea must be considered. Database: EMBASE

68. Pilot retrospective study investigating ETCO₂ in stroke patients for emergency thrombectomy using JED (jaw elevation device) Author(s): Kramer D.; Spinelli A.; Nair S.; Chao J.; Cheng E.; Brook A.; Altschul D.; Osborn I. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 457 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: A total of 750,000 acute ischemic strokes occur annually in the United States; half of these patients have large vessel occlusion. Analyses have concluded that there is "strong evidence" that endovascular therapy in addition to IV thrombolysis improves outcome.1,2 There is greater preference for conscious sedation (CS), although it is still controversial if CS is superior to general anesthesia (GA).3 Arguments for CS include potentially better hemodynamics, lack of intracerebral steal, and prevention of cerebral perfusion derangements during GA.4 One of the challenges of managing these patients under CS is maintaining the airway during field avoidance while insuring adequate depth of anesthesia to prevent significant patient movement. Lack of adequate depth of anesthesia may result in vascular injury and intracranial hemorrhage. With these challenges in mind, our group have reviewed the outcome of patients undergoing thrombectomy for stoke with CS using the Jaw Elevation Device (JED) to maintain airway patency during thrombectomy for acute stroke. Materials and Methods: After IRB approval, all patients undergoing acute thrombectomy for stroke from January 1, 2017 through April 30, 2018 were reviewed in the EPIC EMR at our institution. Patients were segregated into GA, CS, and CS with JED groups. Both CS and JED groups received CS at discretion of attending anesthesiologist. The hemodynamic, oxygenation, and ventilatory data were obtained by using a propriety algorithm written in PHP to parse and aggregate all SBP, DBP, HR, SpO2, and ETCO2 on all patients undergoing CS or JED. The results were analyzed using a student one-sided t test with correction for unequal variance with the Microsoft Excel statistical package. On the basis of our interest in the fluctuation of the hemodynamic and ventilatory values of these parameters, we also analyzed the variances using the same student t test. P-value<0.05 was considered statistically significant. Results: There were 83 patients who underwent thrombectomy. A total of 22 underwent GA and were excluded. Fifty-three were in the CS group and 8 were in the JED group. Means of ETCO2 were significant for the JED group to P<0.05. Means of variance for the ETCO2 were significant for the ETCO2 group P<0.005. Mean SpO2 was not significant for the 2 groups, however, t test of variances for the2 groups was significant (Table 1). Hemodynamic data including SBP, DBP, and HR did not differ between the 2 groups. Conclusions: While this is a small retrospective review, it highlights that the use of the JED may provide more reliable ventilation with less fluctuation in ETCO2 and SpO2. The use of the JED may facilitate more reliable ventilation in these patients. Other factors to be explored in the future will include the ability to give a more generous sedation regimen without airway obstruction. Database: EMBASE

69. Critical, subfatal venous air embolism during ventriculoperitoneal shunt placement Author(s): Gurrieri C.; Munis J.; Abcejo A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 425-426 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Venous air embolism (VAE) is a rare but potentially lifethreatening complication. Clinical manifestations vary from clinically nonsignificant to hemodynamic catastrophe with "gas lock" effect right ventricular outflow obstruction, paradoxical embolism, pulmonary hypertension, cardiovascular collapse or death. We present a nonseated neurosurgical case complicated by VAE-associated hemodynamic collapse. Case report: We report a challenging case wherein an otherwise healthy 47-year-old male presented for laparoscopic ventricular-peritoneal shunt placement for communicating hydrocephalus. Six months prior, the patient underwent a right decompressive hemicraniectomy for traumatic epidural hematoma and subsequently a right cranioplasty for persistent craniectomy defect. He had a long hospital course complicated by severe traumatic and diffuse axonal brain injury with neurological impairment. A 3-month follow-up head computed tomography scan was performed and it revealed persistent significant ventriculomegaly necessitating ventricular- peritoneal shunt placement. After uneventful induction of general anesthesia, insufflation of the pneumoperitoneum coincided with immediate bradycardia into the 30 seconds refractory to atropine treatment. Concomitantly, he became severely hypotensive before suffering pulseless electrical activity cardiac arrest. Advanced cardiac life support was initiated. Pneumoperitoneum was immediately deflated. Intraoperative transesophageal (TEE) echocardiogram revealed massive venous air burden. Diffuse air bubbles were visible in all 4 cardiac chambers as well as the ascending aorta and hepatic veins (Figs. 1, 2). No patent foramen ovale was identified. Estimated left ventricle systolic function was ~50%. Right ventricle was within the normal size but with reduced systolic function. Return of spontaneous circulation was achieved after 10 minutes of cardiopulmonary resuscitation. The procedure was aborted and the patient was transferred to the Intensive Care Unit intubated and on vasopressors support. The patient was transitioned to comfort care and withdrawal of life-sustaining measures per family request. He expired the night of the event. Conclusions: VAE is a potentially life-threatening condition that can occur during nonsitting and routine surgery. Emphasis should be given to the prevention, early recognition, and prompt treatment of the possible cardiovascular complications with TEE remaining the most sensitive method to detect it. (Figure Presented) . Database: EMBASE

70. Institutional analysis of best practice related to usage of ASA monitors and hemodynamic changes with prone to supine emergence transition in neuroanesthesia practice: A retrospective analysis Author(s): LaGrone R.; Chakraborty I. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 455-457 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Neurosurgical cases make up a large portion of surgeries performed in the United States and its increasing every year; according to the NIH from 2006 to 2013, not only is the number of neurosurgical cases increasing but the ratio of spine to craniotomy cases is increasing as well which means more and more prone positioning. Each year at UAMS, nearly 15% of all cases are neurosurgeries. Of those, 80% require prone position or 12% of all cases (up to 10 cases requiring this positioning per day). Understandably, each of these surgeries require 2 position changes and with these transitions come hemodynamic changes and a precarious time of very little monitoring. The purpose of this study was to determine our institutional use of ASA standard monitors at UAMS during the prone/supine position change in neurosurgical cases and to note any significant hemodynamic changes at this time. Patients were selected from chart review of those cases that were performed by the neurosurgical department from 2010 to 2014 and required a position change to prone. The dataset contained 30,109 observations on 232 surgical cases from 223 patients. Note that 9 of the patients each had 2 surgeries. Cases where all monitoring devices had <7 measurements were removed from the analysis, leaving 225 surgical cases from 216 patients available for analysis. Three primary results were measured: (1) the results of a UAMS Anesthesia Staff Survey on use of ASA monitors in neuroanesthesia; (2) patient data set results showing lack of ASA monitor usage during position change; and (3) patient data set results detailing hemodynamic alterations during position change. The primary results of the UAMS Anesthesia Staff Survey were that over 92% of providers do not keep on all ASA monitors during position change, and based on self-report most providers leave 2 ASA monitors on during position change, with pulse oximetry being the favorite monitor amongst all education and experience levels. The patient dataset shows that pulse oximetry, despite being the preferred monitor, was most likely to be left off the patient long enough to miss a cycle time during transition (80% to 84% of the time) and also recorded the longest lag time before being replaced of 11 to 13 minutes. In regards to hemodynamic change, the largest significant change was seen in diastolic blood pressure with an increase of 6.87% or 3.88 points with a P-value of 0.024. With the standardization of ASA monitors, "death due to anesthesia" has become rare over the last 25 years, falling from around 2 per 10,000 anesthetics administered to 1 per 200,000 to 300,000. However, there is still potential for problems, the most common times being at induction, emergence, major surgical events, or during intraoperative position changes. With this study, providers can be more aware of the changes that can occur during this position change and become increasingly vigilant on ASA monitor usage during this time. Database: EMBASE

71. Suspected propofol infusion syndrome during intraoperative total intravenous anesthesia for anterior and posterior cervical discectomy and fusion Author(s): Kumar M.; Changyaleket B.; Banchs R. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 424 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Propofol infusion syndrome (PRIS) is a rare complication of propofol infusion. PRIS has been associated with infusions of >67 mcg/kg/min for >48 hours in the ICU; however, has also been reported intraoperatively in high-dose short-term infusions. PRIS is a poorly understood phenomenon that presents with lactic acidosis, rhabdomyolysis, elevated creatinine kinase, lipemic blood, elevated LFTs, and if progresses, bradycardia, Brugada syndrome, and myocardial failure. The incidence of PRIS estimated to be <1% with a mortality of 33% to 66%. Treatment includes discontinuing the infusion and supportive care. We report a case of possible PRIS with an 11 hours high dose infusion of propofol during an anterior cervical dissection and fusion (ACDF) and posterior cervical fusion (PCF) lasting 14 hours. The patient is a 62 year-old male with a history of HTN, TIA, severe cervical stenosis, and myelopathy who presented with neck stiffness, back pain, and LE weakness with gait instability. Anesthesia was maintained with propofol (180 to 270 mcg/kg/min) and remifentanil infusions to allow for monitoring of somatosensory and motor evoked potentials. An infusion of phenylephrine (20 to 100 mcg/min) was also required to maintain hemodynamic stability. During placement of second ACDF cage at C5, loss of motor signals in both BUE and RLE were noted. High-dose methylprednisone infusion was started. Left UE signals returned but the rest remained absent. The patient received 9 L crystalloids, 1 L albumin, and 3U PRBC with 1200 mL EBL. Three hours before the end of the case, PRIS was suspected as a progressive metabolic lactic acidosis was noted. The propofol and methylprednisone infusions was stopped as existing data suggest administration of exogenous steroids may increase the risk of developing PRIS. By the end of the surgical procedure, a pH of 7.02, BE of -18, LA of 9.9 mg/dL, and CK of 400 were recorded. Postoperative labs in the ICU were significant for CK was 4625, Troponin 2.83, and triglycerides 947. Alternative diagnosis to explain metabolic acidosis were considered. Although 4 L of NS was given, hyperchloremic metabolic acidosis is unlikely as the AG was 21. Lactic acidosis due to hypovolemia or ischemia is possible, but unlikely as the hemoglobin remained >8.9 mg/dL and hemodynamic stability was maintained. Features arguing against PRIS include a normal creatinine and LFTs. The AST was only mildly elevated to 98. The elevated CK could be due to muscle breakdown from an extended surgical time. While troponin was elevated, this could be due to demand ischemia or PRIS- induced cardiomyopathy. This case is interesting because it is an unclear example of PRIS in an intraoperative setting. The patient required a high-dose infusion for an extended surgical time. Postoperative labs were significant for elevated lactic acid, CK, troponin, and triglycerides; however, notable features such as creatinine and LFTs remained normal. It is possible there are multiple components contributing to the overall presentation which makes the case more complex. Database: EMBASE

72. Spinal cord ischemia and infarct presenting as cauda equina syndrome from disk herniation Author(s): Kramer D.; Aguirre-Alarcon A.; Kinon M.; Kim J.; Brook A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 423-424 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:A 56-year-old male presented with lower back pain, foot drop and urinary retention. MRI revealed a HNP with protrusion at L4/L5. Lower extremity examination revealed 4+/5 strength on the left leg with 3/5 strength on the right leg. He underwent MIS discectomy at L4/L5 under GA. MAP was maintained between 69 and 111mmHg (mean MAP=88.7mmHg). Positioning was without extreme lordosis. Pulse oximetry was 99% to 100% throughout. Dexamethasone was administered but antifibrinolytic agents were not given. Postoperatively he had improvement of symptoms. Twelve hours postoperatively, he walked to bathroom. While on the toilet he had severe back pain. The patient was assisted back to bed and examination revealed bilateral loss of motor function and sensation to the level of T12. Open laminectomy and decompression with bilateral foraminotomies and repeat L4/L5 discectomy was performed. The patient's examination did not improve. Neurology consult felt examination consistent with conus medullaris syndrome; high dose steroids were administered. MRI was obtained which revealed cord signal hyperintensity at the conus medullaris, with progressive hyperintensity remote from the area of the surgery (Fig. B). On follow-up MRI a new signal abnormality at the level of the conus suggestive of hemorrhage was seen. The patient was discharged from the hospital on day 28 to an rehabilitation facility without improvement in examination. Discussion: Spinal cord infarcts (SCI) are uncommon presentations of central nervous system (CNS) ischemia. They account for 0.3% to 2 % of all CNS infarcts. Many patients with SCI have vascular risk factors including hypertension, DM, PVD, and dyslipidemia. Our patient had all these risk factors. In thoracic or thoracolumbar SCI, the etiology is often idiopathic. Symptoms often develop concomitantly with sudden movements of back (such as Valsalva maneuver in our patient). While there are many etiologies for SCI, the diagnosis of occult spinal AVM is intriguing. SCI has been associated with AMVs. MRI can miss the diagnosis of spinal AVM. Should there be a concern regarding this a spinal angiogram should be considered. The most common location of dural AVMs is at the level of the conus medullaris. The symptoms have been reported often to be initiated or worsened with Valsalva maneuver. All these features are noted in our patient. During the presentation we will discuss the possibility of this patient have an occult spinal AVM as etiology of SCI. In summary, the clinician should maintain a high index of suspicion in patients presenting with acute onset of back pain, when there is sensory dysfunction in addition to motor weakness, in patients with sphincter dysfunction. While the symptoms of conus medullaris syndrome may be difficult to distinguish from cauda equina, the clinician must be vigilant, for the consequences of a missed or delayed diagnosis can be devasting. Database: EMBASE

73. The unarousable patient with nonconvulsive status epilepticus Author(s): Quast M.; Pasternak J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 423 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Nonconvulsive status epilepticus (NCSE) is persistent seizure activity in the absence of motor manifestations. NCSE can be a potential cause of delayed emergence after anesthesia. A 55- year-old male with a history of transient ischemic attacks, chronic alcohol abuse, and remote seizures underwent a right shoulder arthroplasty. He received a preoperative interscalene block with 15 mL of 0.25% bupivacaine and 30 mL of 0.5% bupivacaine with epinephrine followed by general anesthesia with isoflurane and nitrous oxide. Following surgery, he achieved extubation criteria, the tracheal tube was removed, and he was sent to the postanesthesia care unit for recovery. Upon arrival in the postanesthesia care unit, he was hemodynamically stable, breathing spontaneously, but unresponsive to both verbal and painful stimuli. His left pupil was dilated and was attributed to a Horner syndrome from his interscalene block. Routine laboratory studies were unremarkable. Bilateral erratic vertical and horizontal disconjugate ocular movements were noted along with bilateral eyelid and left hand fluttering. CT scan of the head was negative for acute pathology. NCSE was considered but electroencephalography (EEG) was not available. Lorazepam 4mg IV was administered, after which the patient opened eyes, began to respond to stimuli, and was able to appropriately answer questions. Emergent neurology consult recommended obtaining an EEG in the future; however, one was not performed while he was an inpatient. He was admitted to the intensive care unit for observation overnight, with no subsequent episodes of unresponsiveness or seizure activity throughout his 3-day hospital course. The differential diagnosis for delayed emergence after anesthesia is extensive and includes pharmacologic causes, metabolic derangements, and primary neurological disorders such as stroke or NCSE. Patients with NCSE often present with altered mental status and possibly slight motor movements such as twitches or rhythmic myoclonus. NCSE is readily diagnosed with EEG. When EEG is not available, NCSE is assumed if clinical status improves following administration of antiepileptic drugs. Database: EMBASE

74. This tube shall pass: Airway management in the setting of undiagnosed tracheal stenosis Author(s): Trousdale E.; Welch T. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 422-423 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Despite the development of numerous methods used to identify patients who are in danger of difficult intubation, unexpected airway pathology and complications still occur.1 Undiagnosed tracheal stenosis, a form of central airway obstruction, comprises a portion of unexpected difficult airways.2 While rare, this case highlights the potential fatal complications that can result in the setting of difficult intubation or ventilation secondary to undiagnosed tracheal stenosis as well as the lifesaving nature of airway algorithms.3 Case Report: A 29-year-old female with a medical history significant for asthma and drug resistant focal epilepsy presented for a Visualase laser ablation of a left amygdalohippocampal seizure focus. Following induction of anesthesia the patient was an easy mask airway. Initial attempt at intubation via direct laryngoscopy with a Miller 2 blade showed a grade 1 view of the vocal cords, but a 6.5 single-lumen endotracheal tube was unable to be passed. Despite ongoing grade 1 view of the vocal cords on subsequent laryngoscopy a 6.0, 5.5, 5.0, and 4.5 endotracheal tube were unable to be advanced. Ear nose and throat surgeons were contacted and subsequently evaluated the patient's airway while she remained anesthetized. Flexible bronchoscopy revealed grade 3 subglottic stenosis. The Visualase procedure was cancelled and the patient was woken up and taken to the postanesthesia care unit for recovery. The patient subsequently went back to the operating room later in the day for carbon dioxide (CO2) laser division of the subglottic scar. Work-up several weeks later was significant for previously undiagnosed subglottic stenosis secondary to myeloperoxidase-positive vasculitis. Following repeat CO2 laser division, the patient had significant improvement in her breathing, and ultimately underwent successful Visualase laser ablation of her seizure focus. Discussion: Tracheal stenosis can result from a variety of causes including iatrogenic, congenital, and acquired.2 Diagnosis of tracheal stenosis can be challenging as symptoms such as dyspnea, wheezing, or stridor may be mistaken for other pathologies such as cardiomyopathy or obstructive lung disease.4 Even with adherence to practice guidelines, unexpected challenges arise. In these cases, proficient use of difficult airway algorithms remains paramount and saves lives. (Figure Presented) . Database: EMBASE

75. Effect of the sitting versus the supine position on microbubble clearance times from the right atrium, right ventricle, and pulmonary artery Author(s): Nelson J.; Abcejo A.; Perkins W. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 451 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Venous air embolism (VAE) occurs in neurosurgical procedures performed in the seated position. A treatment for VAE is central venous catheter (CVC) placement with the CVC tip at the cavo-atrial junction. The rationale for CVC use is aspiration of entrained air from the right atrium with model studies suggesting the uppermost cardiac location is optimum for retrieval. This is based upon presumed bubble buoyancy, such that entrained air accumulates superiorly in the seated patient. This assumption has not been tested in human subjects. This study examines injected microbubble clearance times from the right atrium (RA), right ventricle (RV), and pulmonary artery (PA) in supine and seated positions of patients undergoing neurosurgical procedures in the seated position. Methods: An IRB-approved prospective study of 20 patients undergoing seated neurosurgical procedures. Following induction and transesophageal echo (TEE) probe placement, a Cook Bunegin-Albin Air Aspiration CVC was positioned in the low SVC. Attainment of the TEE midesophageal right ventricular inflow outflow view, displayed RA, RV, and PA simultaneously. Microbubbles formed by agitating 10 mL saline with 1mL air were injected into the CVC over 1 second. Real-time images were recorded from initial injection. Triplicate injections were obtained in supine and seated positions. TEE measured cardiac outputs were obtained. Clearance time was defined as the interval between the first appearance of microbubbles and the first bubble-free appearance at the specified location. ANOVA and t test analyses were performed. Results: Microbubbles appeared in RA during agitated saline injection. There was no measureable delay in microbubble appearance in the RV and PA compared with the RA. Within subject repeated microbubble injections had no impact on clearance times. There were no significant differences in clearance times across subjects between supine and seated positions for RA (12.4+/-1.9 vs. 10.2+/- 0.8 s), RV (13.5+/-2.1 vs. 11.5+/-0.9 s), and PA (13.7+/-2.3 vs. 12.2+/-1.2 s) or cardiac outputs (4.1+/- 0.8 vs. 4.8+/-0.9 L/min). There were no significant differences in clearance times between RA, RV, and PA. Discussion: The utility of a CVC in entrained air aspiration during VAE is contingent upon retention of a significant fraction of the air in a predictable and CVC accessible location. The suggestion that the optimum location for the CVC tip is the cavo-atrial junction implies air bubble buoyancy in the RA makes it a favorable location for retrieval. Our findings suggest microbubbles follow the bulk fluid in which they are suspended, blood, with fluid dynamic forces playing a greater role than buoyant forces. This may help explain a common observation that air retrieved from a CVC following precordial Doppler and TEE-demonstrated VAE is often <1mL and of no demonstrable clinical benefit. Conclusions: On the basis of microbubble clearance times, blood fluid dynamic forces are greater than microbubble buoyant forces, resulting in rapid passage of blood from the right heart into the pulmonary circulation. These results suggest that CVC use for neurosurgical procedures in the seated position as a standard of care deserves reconsideration and further study. Database: EMBASE

76. Effect of goal-directed intraoperative fluid therapy on hospital stay in patients undergoing excision of supratentorial tumors Author(s): Rath G.; Mishra N.; Chaturvedi A.; Bithal P. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 421-422 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Optimal fluid management in neurosurgery involves a tight balance between over-correction and under-correction. Evidences suggest that goal-directed fluid therapy (GDFT) can improve postoperative outcome in patients undergoing major non-neurosurgical surgeries. We hypothesized that the stroke volume variation (SVV) guided GDFT would improve the surgical outcome in terms of duration of hospital stay, and reduce the incidence of postoperative complications in patients undergoing craniotomy for supratentorial brain tumors. Methods: Forty patients in between the age group of 18 to 65 years with large supratentorial tumors (tumor size > 4 cm in one dimension on the radiologic scan) undergoing craniotomy and excision were prospectively randomized into 2 groups. Patients belonging to the control group received fluid regimen based on routine hemodynamic monitoring whereas those belonging to GDFT group received fluid regimen based on SVVguided GDFT (by keeping SVV <12%) using FloTrac/Vigileo system. A colloid bolus of 250 mL 6% hydroxyl ethyl starch (130/0.4) was given, if the SVV was >12% in the GDFT group. Hemodynamic parameters such as blood pressure and heart rate were recorded at baseline, 5, 10, 15, and 30 minutes postinduction and then every hourly till the end of surgery. Dynamic parameters such as cardiac index, stroke volume index, and SVV were recorded 15 and 30 minutes after induction and then every hourly till the end of surgery. Results: The total amount of fluid (crystalloid) required was significantly lower in GDFT (P=0.003) group as compared with the control group. The incidence of intraoperative complications was significantly lower in the GDFT group (P=0.005); tight brain incidence was significantly higher in the control group. The duration of hospital stay (5.05 d in the GDFT vs. 8.05 d control, P=0.07) and incidence of postoperative complications (10% in GDFT vs. 25% in control, P= 0.32) were lower in GDFT group but did not reach statistical significance. Neurological outcome in terms of Glasgow outcome score at-discharge were similar in both the groups. Conclusions: This study did not show any benefit of GDFT over conventional intraoperative fluid therapy in terms of incidence of postoperative complications, hospital and ICU stay, Glasgow outcome scores at-discharge in patients undergoing craniotomy for excision of large supratentorial tumors. Database: EMBASE

77. The impact of anesthesia and perioperative factors on postcraniotomy infection in supratentorial high-grade gliomas patients: A retrospective analysis Author(s): Dong J.; Zeng M.; Peng Y.; Han R. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 450 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Objective: To confirm the effect of anesthesia choice and perioperative factors on postcraniotomy infection in high-grade glioma patients. Methods: A total of 457 cases of HGG was collected in Beijing Tiantan Hospital from 2012 to 2016 for the analysis of incidence of postoperative infection. After exclusion criterior, 378 patients were included in the analysis. The patients age, histoty of diabetes milletus, Karnofsky performance status, World Health Organization (WHO) pathologic classification, use of methylprednisolone, duration of surgery and anesthesia, gross total resection, postoperative intracranial hematomas, perioperative blood glucose, white blood cells, incision classification, intracranial drainage tube placement were collected and analyzed. Results: The incidence of intracranial infection is similar in patients with intravenous and inhalational anesthesia, respectively, P>0.05. The total WBC is (14.7+/-4.5)x109/L and (16.3+/-4.5)x109/L in patients with intravenous and inhalational anesthesia 1 day postoperatively, respectively, P= 0.009. The count of neutrophils is (13.1+/-4.5)x109/L and (14.5+/-4.1)x109/L, respectively, P=0.017. And the count of lymphocytos is (0.9+/-0.5)x109/L and (1.1+/-0.9)x109/L, respectively, P=0.009. Although the patients with intravenous group anesthesia appeared to have lower WBC, the infection rate is similar between patients with 2 anesthesia maintenance methods (11% vs. 12%, P>0.05). The risk factors for postcraniotomy infection in high-grade glioma patients included postoperative intracranial hematoma (odds ratio=3.562; 95% confidence interval, 1.298-9.771) and drainage of intracranial tube (odds ratio = 4.439; 95% confidence interval, 1.513-13.027). Conclusions: The postoperative intracranial hematoma and drainage with the intracranial tube are risk factors of postcraniotomy infection. Although patients maintained with intravenous anesthesia had lower WBC count, the postoperatively infection with 2 anesthesia type are similar. Database: EMBASE

78. Intravenous versus inhalational anaesthesia ( IVIA) trial for outcome following intracranial aneurysm surgery Author(s): Bhagat H.; Sharma T.; Mahajan S.; Gandhi K.; Sachdeva N.; Aggarwal A.; Jangra K. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 421 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Aneursymal subarachnoid haemorrhage (aSAH) accounts for significant percentage of strokes with substantial economic burden. The major burden of patients subjected to neuroanesthesia care in our hospital are the ones who undergo microsurgical clipping following aSAH. Both the intravenous and inhalational anesthetics cause dose dependent reduction of CMRO2 which could have benefits of neuroprotection, However the longterm outcome with use of anesthetic agents is yet to be known in patients undergoing surgery for aSAH. The neurological outcome at 3 months was the primary outcome while intraoperative brain conditions, duration of hospital stay and the estimation of perioperative markers of brain injury were the secondary outcomes of the study. Methods: The prospective randomized study was conducted at PGIMER, Chandigarh, India in 106 patients who underwent neurosurgery following aSAH. The patients were randomized into 2 groups-the Propofol group and the Desflurane group. WFNS grade I-II patients of 18 to 65 years of age were included in the study. The patients were induced with fentanyl and propofol while vecuronium was used for facilitating tracheal intubation. Anesthesia was maintained with propofol infusion or desflurane titrated to BIS of 40 to 60. Fentanyl infusion was used for analgesia and vecuronium was administed as boluses for muscle relaxation.Ventilation of patients was maintained with oxygen and medical air (1:1). The anesthetics were stopped following completion of skin closure. The brain relaxation score was recorded at the time of reflection of bone flap. The intraoperative events related to hemodynamic changes, intraoperative aneurysm rupture, and temporary clipping times were noted. The IL-6 and S 100 B were measured preoperatively, intraoperatively, and postoperatively in serum samples using ELISA. The duration of hospital stay was recorded. The neurological outcome was assessed at 3 months following discharge using the Glasgow outcome scale (GOS). Results: The preliminary analysis of our results shows that 13 patients were excluded and the data was analyzed for 45 patients in propofol group and 48 patients in desflurane group. The preoperative data in terms of demography, WFNS grade, Fisher grade, and location of aneurysm were comparable among the 3 groups (P>0.05). The intraoperative characteristics including the duration of anesthesia, brain swelling, hemodynamic changes, temporary clipping time and the incidence of intraoperative rupture of aneurysm were similar among the 3 groups (P>0.05). The perioperative serum IL6 and S100B were comparable among the 3 groups (P>0.05). The duration of hospital stay was 8 (7.97 to 10.03) days in the propofol group and 8 (7 to 8.8) days in the desflurane group (P=0.26). The GOS at 3 months were 5 (3.94 to 4.77) in propofol group and 5 (4.53 to 4.93) in the desflurane group. Conclusions: The long-term neurological outcome of good grade aneurysmal SAH patients undergoing craniotomy and clipping remains similar with use of either propofol or desflurane. Database: EMBASE

79. Cardiovascular autonomic dysfunction in multiple sclerosis contributing to severe intraoperative hypotension Author(s): Srisooksai G.; Mohamed B. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 420 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Case Report: A 53-year-old women with history of multiple sclerosis (MS) was scheduled for intrathecal baclofen pump placement for severe spasticity. She was diagnosed at age 27 with primary progressive MS manifested as bilateral leg weakness and gait difficulties. Her 2014 magnetic resonance imaging (MRI) showed multiple lesions in periventricular and brainstem regions, including the pons and medulla. Her MSrelated symptoms included fatigue, diplopia, and memory deficits. She denied cardiovascular diseases or symptom, although her functional status was difficult to assess due to wheel-chair bound state. Her active medications were tizanidine and vitamin D. Preoperative vital signs and labs were normal. Shortly after uneventful IV induction and intubation, her blood pressure drastically dropped to MAP of 30 seconds, from baseline MAP in the 90 seconds. There was minimal responses to fluid boluses and high dose vasopressors, including phenylephrine up to 1 mcg/ kg/min and large boluses of ephedrine, vasopressin, and calcium. On emergence, her hemodynamics improved and she was wean off vasoactive medications. She was extubated and recovered in PACU without sequelae. Discussion: MS is an immune-mediated disease of the CNS involving inflammation and demyelination of optic nerve, brain, and spinal cord.1 Anesthetic considerations for MS patients include cautious use of neuromuscular blockers, avoidance of hyperthermia, aspiration risk, and postoperative urinary retention from neurogenic bladder.2 Cardiovascular autonomic dysfunction (AD) in MS are commonly described in neurology literature but has not been well studied in perioperative setting. This case report demonstrated possible severe cardiovascular AD presenting as intraoperative profound refractory hypotension, despite low risk procedure with little fluid shifts and common causes of hypotension ruled out. One mechanism is CNS lesions disrupting the autonomic pathway, which is radiologically supported by studies showing correlation between the severity of cardiovascular AD and location of MRI lesions including locus coeruleus and nucleus tractus solitaires in the brainstem.3 Our patient's MRI showed evidence of T2 lesions in the pons and medulla, adjacent to the fourth ventricle likely in areas of major cardiorespiratory centers. Conclusions: Formal testing for cardiovascular AD is a diagnostic challenge. Practical evaluation include obtaining preoperative orthostatic vital signs and history. One may also consider reviewing MRI lesions in regions associated with autonomic dysfunction which may help predict hemodynamic instability and need for invasive monitoring. Review of prior anesthesia records for response to specific vasopressors also can provide valuable information. Database: EMBASE

80. Intracranial aneurysms in patients under 18 years of age: Critical care experience of a tertiary care institute Author(s): Srivastava S.; Gupta D.; Mehrotra A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 449 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Objectives: Pediatric intracranial aneurysms are rare in the first 2 decades of life and have critical care considerations that are quite different from that of adult patients; this study focuses on the intensive care management of these patients and the factors affecting outcome. Methods: In 20 years, 57 patients with the age range of 4 to 18 years were operated at our centre. Their clinicoradiologic features, surgical outcome, and critical care course was assessed. Results: Pediatric patients constituted <4% to 6% of total patients operated for aneurysms. Their preanesthetic checkup showed associated anomalies like rheumatic heart disease (3) coarctation of aorta (2) hypertension. 1 There was a much higher incidence of internal carotid artery bifurcation (25%) and middle cerebral artery aneurysms (15%) causing subarachnoid hemorrhage in the pediatric population. The children had a higher incidence of hemiparesis and seizures (36%) that required anticonvulsants before surgery. Seven patients had associated ICH/IVH. A higher incidence of complex aneurysms (52%) was seen. Angiographic vasospasm was present in 40.8% and clinical vasospasm in 20% of children. Following treatment of 11 patients with vasospasm, 8 patients had complete reversal. All patients with H&H grade 3 to 5 required overnight elective ventilation. Twelve patients required long-term ventilation for which tracheostomy was needed. Transient DI occurred in 2 patients postoperatively. Five patients died in the course of study out of which 2 died due to ACA territory infarct with raised ICP. Three patients died due to septicemia (ventilator-associated pneumonia). Favorable outcome was seen in (77%) of the patients. Conclusions: Younger patients withstand aneurysmal clipping better because of better functional brain capacity and compliance, collateralization of vessels. The high incidence of complex and giant aneurysms, congenital anomalies and associated medical illnesses require specialized treatment protocols and anesthetic management. Focusing on clinical vasospasm and treating it with hypertensive, normovolemic therapy and nimodipine often helped in reversing neurological deficits. A special focus on the fluid and electrolyte balance in children was required. Database: EMBASE

81. Bioactivity of s-nitrosothiols as a novel indicator of hypoxia in brain-dead organ donors Author(s): Nazemian R.; Matta M.; Reynolds J.; Aldamouk A.; Zhu L.; Hausladen A.; Moyal A.; Colon E.; Wang J.; Armes T.; Stamler J.; Latifi S.; Lebovitz D.; Perez-Protto S. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 449 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Transplantation is the treatment of choice for many endstage organ diseases. Yet many people die before their organ need is met because of the wide gap between the number of waitlisted patients and number of available organs. The majority of transplanted organs are procured from brain dead donors. In preclinical studies we determined that brain death disrupts nitric oxide (SNO) bioactivity, notably the main regulator of tissue oxygenation (StO2) and microvascular blood flow S-nitrosohemoglobin (SNO-Hb). As a first step in translating these findings we assessed for changes in SNO-Hb and tissue oxygenation in death by neurological criteria human donors up until organ recovery. Study Design and Methods: In conjunction with Lifebanc, the North East Ohio OPO, consented DNC donors were noninvasively monitored for changes in StO2 and blood samples were procured at regular interval to quantify SNO-Hb levels. Information on organs recovered and transplanted were obtained from the medical record. R programming software was used for statistical analysis. Results: To date, 39 donors have been monitored. The subjects' median age was 43 (IQR= 25 to 56) years and the mean duration of donor support time was 39.6 hours (IQR=31.5 to 55.4). The median number of expected, recovered, and transplanted organs was 6, 4, and 3, respectively. After brain death, SNO-Hb levels were significant decreased compared with healthy humans (95% CI=0.03-2.5) and remained depressed for the monitoring period. Consistent with its role in regulating microvascular blood flow there was a positive correlation between SNOHb and StO2 (r=0.39, P=0.08). Of more importance, both StO2 and SNO-Hb levels correlated with and were prognostic for the number of organs transplanted. Conclusion: Similar to our preclinical studies we determined that NO bioactivity is disrupted following brain death as exemplified by the reduction in SNO-Hb, which is turn correlated with decreased tissue oxygenation and a lower number of transplanted organs. While the mechanism for this decline in SNO-Hb remains to be determined, the results suggest that therapies directed at maintaining or increasing NO bioactivity could improve end organ tissue oxygenation and subsequently increase the number of and quality of organs available for transplant. Database: EMBASE

82. A retrospective study comparing discrepancy between estimated and calculated blood loss and infectious complications in multilevel spinal fusion surgery Author(s): Ford K.; Uejima J.; Hemmer L.; Bebawy J.; Koht A.; Carabini L.; Moreland N.; Zeeni C.; McCarthy R. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 414-415 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Estimates of blood loss (EBL) in multilevel spine fusion surgery ranges from 50 to over 15,000 mL with greater inaccuracies associated with higher blood loss.1 While previous studies demonstrate an increased rate of surgical site infections in patients with anemia, overestimating EBL can also result in unnecessary transfusion, and thus higher morbidity and mortality.2,3 Calculated blood loss (CBL) can be derived from the hemoglobin (Hgb) lost, the volume of blood transfused, and reinfused cell salvaged blood. We hypothesized that for spinal fusions >3 bony levels, EBL would underestimate CBL, and that greater differences would be associated with infectious complications. Methods: This is a retrospective study describing the morbidity and mortality observed in a large single center cohort of patients who underwent spinal fusions of >=3 bony levels between January 2003 and September of 2013. The equation used for CBL=EBVx(Hgb initial -Hgb final/Hbg average)+500 mLxPRBC units+Cell saver (mL). The difference in CBL and EBL was assessed using the Bland Altman analysis, and then analyzed for association with postoperative infectious complications. A P< 0.05 was required to reject the null hypothesis. Results: The final cohort included 978 cases of multilevel spinal fusions. There were 10 perioperative mortalities and 349 (35.6%) cases involving a complication. The mean EBL was 2924 +/- 2388 mL and the mean CBL was 2648 +/- 2648 mL. The CBL-EBL was dependent on the average of EBL and CBL (r=0.18, P<0.001). The bias in the CBL/EBL ratio was 1.12 (95% confidence interval, -0.91 to 3.15) (Fig. 1). There were 111 (11.3%) cases with an infectious complication (bacteremia, urinary tract, pneumonia, wound, or sepsis). The difference in CBL-EBL in cases with an infectious complication was 672 mL, 95% confidence interval, 133-1210 mL, P= 0.03 (Fig. 2). Conclusions: Greater differences in calculated and EBL were observed in patients that had infectious complications. Our findings confirm the association of inaccurate EBL and a greater incidence of postoperative infections. These results are likely related to delayed resuscitation with large volume blood loss and transfusion requirements. (Figure Presented) . Database: EMBASE

83. Early cardiovascular and cerebral hemodynamics response and cardiac dysfunction following moderate-severe traumatic brain injury Author(s): Chaikittisilpa N.; Vavilala M.; Lele A.; Moore A.; Krishnamoorthy V. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 444-445 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Patients with traumatic brain injury (TBI) often develop hemodynamic instability, which leads to poor outcomes. Novel methods to detect subclinical systolic dysfunction have been described following TBI, however, the effect on cardiovascular and cerebral hemodynamics is not known. Our study aimed to describe early cardiovascular and cerebral hemodynamic responses after moderate-severe TBI and examine their association with subclinical systolic dysfunction. Methods: This is a secondary analysis of a prospective cohort study examining subclinical systolic dysfunction with echocardiographic speckle tracking analysis in patients with isolated moderate-severe TBI. Transthoracic echocardiography (TTE) was performed on day 1 and between day 5 and 7 after injury. Cardiovascular hemodynamic parameters (stroke volume [SV], stroke volume index [SVI], cardiac output [CO], cardiac index [CI], systemic vascular resistance [SVR], and systemic vascular resistance index [SVRI]) were calculated from TTE data. Systolic dysfunction was defined based on clinical criteria (ejection fraction< 50%) or subclinical criteria (global longitudinal strain [GLS] > -16%). Transcranial Doppler ultrasound (TCD) was also performed on the first day. We determined the association between systolic dysfunction and hemodynamic parameters using linear regression. Results: A total of 29 TTE and 15 TCD examinationss were performed in 15 patients. During examination, 9 (60%) patients had propofol infusion and 3 (20%) were on vasopressor. Overall, SV (median: 58.3 mL, IQR: 44.9 to 75.7), SVI (median: 29.0 mL/m2, IQR: 20.5 to 31.0), CO (median: 5.34 L/min, IQR: 4.09 to 5.75), and CI (median: 2.83 L/min/m2, IQR: 2.05 to 3.10) were within low to normal ranges, while SVR (median: 1295 dyne sec/cm-5; IQR: 1233 to 1993) and SVRI (median: 2704 dyne sec/cm-5;/m2, IQR, 2210 to 4084) were normal to high. Five 5 (33%) patients had subclinical systolic dysfunction with impaired GLS (>-16%), among which 2 patients also had low ejection fraction (< 50%). All TCD variables were normal. Linear regression analysis demonstrated an association between GLS and SVI (r? =0.274, P=0.034). However, there was no significant association between GLS and SV, CO, CI, SVR, or SVRI. Strain abnormality and hemodynamic parameters remained the same in the first week after TBI. Conclusions: This preliminary study suggests that patients with isolated moderate-severe TBI commonly develop high SVR/SVRI suggesting a catecholamine-excess state. However, the SV/SVI are in lower ranges resulting in heterogeneity in the CO/CI. Advanced hemodynamic monitoring and cardiac function evaluation may be considered for personalized hemodynamic management in TBI. Database: EMBASE

84. Predictive factors for hypotension after the supineto-prone positional change in patients undergoing spine surgery Author(s): Park H.; Hwang J.; Jeon Y. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 413 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: The supine-to-prone positional change can result in hypotension by decreasing venous return. In general, this hypotension related with positional change can be counteracted by autonomic nervous system such as baroreceptor reflex and increased sympathetic activation in unanesthetized subjects. However, in anesthetized patients, depression of cardiac contractility and blockade of the compensation mechanism by anesthetics may increase the incidence of hypotension after the supine-toprone positional change. There has been no study concerning the incidence and risk factors of hypotension after the supine-to-prone positional change in anesthetized patients until now. In this study, predictive factors for hypotension after the supine- to-prone positional change were investigated retrospectively. Methods: Demographics, current medication, hemodynamic data such as mean blood pressure (MBP) and heart rate measured before (supine position) and after (prone position) positional change, respiratory variables, and pulse pressure variation in the supine position were collected from 179 patients undergoing elective posterior spine surgery in the prone position between May in 2017 and March in 2018. Hypotension after the supine-to-prone positional change was defined as a reduction in MBP > 20% after the positional change. Results: In multivariate logistic regression analysis, preoperative use of betablocker (odds ratio [95% confidence interval], 7.64 [1.21-48.36], P=0.031), MBP measured in the supine position just before the supine-to-prone positional change (supine MBPlast, 1.04 [1.00-1.07], P=0.033) and effect-site concentrations of remifentanil (2.12 [1.51-2.96], P<0.001) were independent risk factors for hypotension after the supine-to-prone positional change. Conclusions: Preoperative use of beta-blocker, high concentrations of remifentanil, high supine MBPlast were associated with development of hypotension after the supine-to-prone positional change in patients undergoing posterior spine surgery. Database: EMBASE

85. Extubation criteria after posterior high cervical and occipital fusion: A single-center retrospective analysis Author(s): Buhl L.; Boone M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 411-413 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Ideal patient positioning for intubation depends upon range of motion in the cervical spine, particularly at the occiput-C1 and C1-C2 levels. Many patients undergoing procedures on the cervical spine have limitations in this range of motion, often necessitating advanced airway techniques. While much has been written on initial airway management in these patients, comparatively less is known about extubation criteria. We performed a retrospective analysis of posterior high cervical and occipital fusions to identify factors related to delayed extubation, postoperative airway complications, and postoperative pulmonary complications. Methods: The operating room schedule was searched from January 1, 2009 to April 30, 2018 for all posterior fusions involving the occiput, C1, or C2. Cases that ultimately did not involve instrumented fusion of the occiput, C1, or C2 were excluded. Anesthesia records were reviewed to identify patient characteristics, airway management, and complications. Patients who were already intubated on arrival to the operating room were excluded. Procedure length was measured from anesthesia induction to procedure finish. In-patient records and discharge summaries were also reviewed to assess extubation time and postoperative complications, including pulmonary complications. Results: We identified 135 cases that met the inclusion criteria. Of these, only 2 patients had airway complications in the immediate postoperative period (2/135, 1.5%). Both patients required reintubation while still in the operating room; however, this proved to be difficult in both cases, ultimately requiring emergent surgical airways. This low rate of postop airway complications did not allow for the identification of predictive factors. Of the variables analyzed, procedure duration, blood loss, intraoperative fluid administration, and highest cervical level fused were all significant predictors of delayed extubation. Patient age, ASA classification, BMI, underlying cervical spine pathology, initial airway management, number of airway attempts, and use of neurophysiological intraoperative monitoring were not significant predictors of delayed extubation. Among those patients in whom extubation was delayed, we did not see an increased risk of postoperative pulmonary complications. Conclusions: Our retrospective analysis revealed a low rate (1.5%) of postoperative airway complications in patients undergoing posterior high cervical and occipital fusions; however, both patients who required immediate postoperative reintubation required emergent surgical airways. Accordingly, although the overall rate of airway complications in this population is low, the consequences can be severe, necessitating a higher degree of scrutiny when deciding to extubate postoperatively. In our institution, factors predictive of delayed extubation were procedure duration, blood loss, intraoperative fluid administration, and highest cervical level fused. While the choice to extubate postoperatively must always be considered on a case-by-case basis, careful consideration of these factors and a recognition that airway complications in this population often have more severe consequences than in the general population can aid in decision making. (Figure Presented) . Database: EMBASE

86. Diabetes mellitus and the risk of vasospasm after aneurysmal subarachnoid hemorrhage Author(s): Athiraman U.; Tempelhoff R.; Aum D.; Vellimana A.; Karanikolas M.; Zipfel G. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 411 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Diabetes mellitus is one of the most common and known risk factor associated with increased incidence of cerebrovascular disorders. 1 Delayed cerebral ischemia (DCI) occurs in ~30% of patients, develops 4 to 12 days after subarachnoid hemorrhage (SAH), and is characterized by large artery vasospasm, distal autoregulatory dysfunction and micro vessel thrombosis.2 Cerebral vasospasm is the important component of DCI representing as the major contributor to poor outcome after SAH.2 The aim of our study is to assess the incidence of vasospasm after aneurysmal subarachnoid hemorrhage in the patients with and without diabetes. Methods: After IRB approval, data were collected retrospectively for all the patients admitted to our hospital for an aneurysmal subarachnoid hemorrhage between January 2009 and December 2014 and the patients with the history of diabetes were noted. The primary outcome is to assess the incidence of vasospasm (angiographic and symptomatic) in the diabetic versus nondiabetic patients. Univariate and logistic regression analysis were performed to identify the independent predictors of vasospasm. P<0.05 is considered statistically significant. Results: A total of 181 SAH patients were included. Factors significant in the univariate analysis are shown in the Table 1. Logistic regression analysis identified diabetes (odds ratio [OR], .221; confidence interval [CI], 0.076-0.644), Hunt and Hess grade (OR, 1.575; CI, 1.066-2.327) and the age (OR, .972; CI, 946-0.999) as the significant predictors of angiographic vasospasm outcomes. Conclusions: The data in our study indicates that the angiographic vasospasm outcomes after aneurysmal SAH depends on (1) the presence of diabetes, (2) Hunt and Hess grade, and (3) age. Larger prospective trials are needed to establish the role of the diabetes in the outcomes after SAH. Database: EMBASE

87. Impact of concussion on postoperative complications: A retrospective matched cohort study Author(s): D'souza R.; Sexton M.; Pasternak J.; Abcejo A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 411 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Concussion represents the functional manifestation of traumatic brain injury (TBI). It is estimated that millions of concussions occur each year in the United State alone with patients frequently requiring anesthesia soon after injury.1 Concussion is associated with significant changes in cerebral hemodynamics that may persist for weeks despite the resolution of clinical symptoms.2 Altered physiology that may occur in the perisurgical and anesthetic period may place the vulnerable brain following concussion at risk for secondary injury. We describe rates of postoperative complications in those with and without recent concussion. Methods: Following IRB approval, patients who had a concussion and underwent an anesthetic within 90 days between June 2005 and June 2015 were meticulously identified from subjects included in a prior investigation. 1 Patients with concussion were matched to control patients based on age, sex, date of procedure (within 1 y), surgical procedure, anesthetic type (general vs. monitored anesthetic care vs. primary regional), and ASA (American Society of Anesthesiologists) status. Matched control patients were excluded if they had a history of concussion, TBI, neurological disease, cognitive dysfunction or delay, chronic pain syndrome or previous neurosurgical intervention. Collected patient data included the following: demographics, aberrations in intraoperative vital signs (PaO2<80mmHg, systolic blood pressure<100 or > 180mmHg, temperature <35 or > 38degreeC, PaCO2>50 or <25mmHg), hospital length of stay, and postanesthesia care unit (PACU) outcomes including opioid consumption in oral morphine equivalents, postoperative nausea and vomiting (PONV), pain scores, and headache. PONV was defined as any documented nursing diagnosis of nausea and any antiemetic administration. Unpaired t test and chi2 tests were utilized for continuous and categorical variables, respectively. Results: Seventy-seven postconcussion patients were matched to 176 control patients. In patients with recent concussion, there were significantly increased rates of PONV (10.4% vs. 4.0%, P=0.047), rates of PACU pain score >=7 (26.0% vs. 14.8%, P= 0.033), and headache within 90 days of anesthesia (18.2% vs. 5.7%, P=0.002). There was no difference in hospital length of stay, intraoperative or PACU opioid consumption, and total intraoperative crystalloid. There was no difference in intraoperative or postoperative aberrant physiological variables, including hypoxic events, hypotensive or hypertensive episodes, and hypothermia or hyperthermia. There was no difference in these PACU outcomes: maximum pain score, Richmond Agitation-Sedation Scale score, or headache while in PACU. Conclusions: Compared with patients without concussion, patients with recent concussion were more likely to suffer PONV and high pain scores. Moreover, patients with recent concussion were more likely to receive a diagnosis of persistent headache following the anesthetic despite similar rates of headache while in the PACU. Database: EMBASE

88. Effects of serum sodium level on postoperative outcome in patients after neurosurgical procedures Author(s): Ikeda K.; Toda Y.; Nakatsuka H.; Hazama K. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 410-411 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Sodium disorders are often seen in patients after neurosurgical procedures. We hypothesized that sodium disorders in neurosurgical patients are associated with a poor outcome. Methods: In this single-center retrospective observational study, patients aged 18 years or older who received craniotomy or intracranial revascularization during the period from January 2016 to December 2016 were enrolled. Data were obtained from electronic medical records, and the patients were divided into 2 groups by postoperative outcome: a poor group and a good group. Patients in the poor group included patients who died, patients with consciousness disturbance of 100 or higher in the Japan Coma Scale, and patients with hemiparalysis at discharge. Data for serum sodium levels in the preoperative, intraoperative, and postoperative periods were compared in the 2 groups, and patient backgrounds, duration of anesthesia, intraoperative fluid volume, amount of bleeding, and use of hydroxyethyl starch (HES), albumin or transfusion were also compared in the 2 groups. Results: There were 84 operations in the study period. Twenty-six patients (31.0%) were in the poor group (5 patients died, 8 patients had consciousness disturbance, and 13 patients had paralysis). The patient's age, sex, BMI, and preoperative renal function did not differ significantly between the 2 groups. There were significant increases in the poor group compared with the good group in ASA-PS (P=0.0005), number of patients who underwent emergency operations (16 patients [62%] vs. 7 patients [12%], P< 0.0001) and number of patients in whom preoperative intubation was performed (9 patients [35%] vs. 6 patients [10%], P=0.01). However, the duration of anesthesia was longer in the good group than in the poor group (7.4 vs. 5.8 h, P=0.04). There was no significant difference between the 2 groups in the use of HES, albumin, or transfusion. Preoperative and intraoperative serum sodium levels did not differ between the 2 groups, but postoperative serum sodium level at day 1 was higher in the poor group than in the good group (141.9 [95% confidence interval, 139.6-144.1] vs. 139.1 mEq/L [95% confidence interval, 137.6-140.6], P=0.04). Conclusion: Serum sodium level is high in patients with a poor outcome. Hypernatremia might be a risk factor for poor outcome in neurosurgical patients. Database: EMBASE

89. Perioperative use of IV milrinone for cerebral hypoperfusion in extracranial to intracranial bypass surgery: A case series Author(s): Fenner H.; Gooderham P.; Flexman A.; Huttunen H.; McEwen J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 470 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Extracranial to intracranial (EC-IC) bypass surgery is increasingly offered to patients with Moyamoya disease as well as other cerebrovascular disorders (eg, radiation vasculopathy, tumour invasion). Despite advances in surgery, anesthesia and neuromonitoring, these patients are vulnerable to cerebral ischemia during and following surgery. The use of phosphodiesterase inhibitors, including milrinone, has been advocated in the treatment of cerebrovasospasm in the context of subarachnoid hemorrhage.1,2 Their use has not yet been described in other settings such as EC-IC bypass surgery. Our study objective was to describe a series of patients in which milrinone was used to successfully reverse symptoms of cerebral ischemia during or following cerebrovascular bypass surgery. Methods: After institutional ethical approval, we retrospectively identified all patients who underwent EC-IC or other intracranial vascular bypass surgery at our hospital and received intravenous milrinone between September 1, 2015 and April 11, 2018. Patient demographics and comorbidities, intraoperative and postoperative course, clinical indication for milrinone and neurological outcome was extracted from the medical record. Results: Five patients met the inclusion criteria: 3 male and 2 female with an average age of 42 (SD= 17) years. Three patients had EC-IC bypass surgery, 2 patients underwent encephalo-duro-arterio- synangiosis. Milrinone was commenced when there was a change in neuromonitoring (n=2) or in the presence of new postoperative nonhemorrhagic neurology (n= 3). Milrinone was used in the range of 0.125 to 1 mcg/kg/min for a variable duration (range: 4 h to 5 d). All patients were treated with norepinephrine to maintain a mean arterial pressure >100mmHg and a systolic blood pressure <160mmHg. In all cases, the patients made an almost complete recovery to baseline neurological status, including reversal of a new hemiparesis in 3 of the patients. No significant complications related to the use of milrinone were noted. Conclusions: Our case series provides a novel description of the use of intravenous milrinone to reverse vasospasm and symptoms of cerebral ischemia in the context of cerebrovascular bypass surgery in adults. Our preliminary report suggests the need for further research to define the role of intravenous milrinone to reverse cerebral vasospasm in the context of cerebrovascular bypass surgery. Database: EMBASE

90. Conscious sedation versus general anesthesia during mechanical thrombectomy: A retrospective study (our institutional experience) Author(s): Jangra K.; Bhagat H.; Khurana D.; Samagh N.; Kapil S. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 410 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Endovascular treatment (EVT) in the form of mechanical thrombectomy combined with intravenous thrombolysis has been proven to be superior to the intravenous thrombolysis alone for the management of acute ischemic stroke. The literature is quite conflicting regarding the superiority of conscious sedation (CS) or general anesthesia (GA) for outcome in stoke patients during EVT. Previous retrospective studies showed that there is better neurological outcome after CS compared with GA while a recent prospective trial showed the outcome is comparable between the groups.1?3 Hence, we present our institutional experience regarding the outcome of mechanical throbectomy in patients receiving CS and GA. Methods: After approval from the institutional review board, this retrospective study was conducted at Postgraduate Institute of Medical Education and Research, Chandigarh, from year 2015 to 2017. The data of patients who underwent mechanical thombectomy was collected retrospectively form the stroke data base. Differences in outcome between the GA and CS groups were compared by unpaired t test or Mann- Whitney U test for continuous variables and Fisher exact test for dichotomous data. The Modified Rankin Scale (mRS) scores 3 months after the stroke were compared using 2-tailed chi2 test. Statistical significance was set to P<0.05. Results: In GA group 11 patients and in CS group 40 patients were analyzed. Baseline parameters including National Institutes of Health Stroke Scale (NIHSS) on arrival was comparable between the group (P= 0.030). Other stroke parameters such as degree of recanalization (P= 0.408), postprocedural NIHSS (P=0.193), NIHSS at discharge (P= 0.922), complications during the procedure (P=0.214), major postoperative complications (P=0.845), duration of hospital stay (P= 0.821) and mRS at 3 months (P=0.540) were comparable between the groups. Conclusions: We observed that during mechanical thrombectomy for acute ischemic stroke, there was no difference found between general anaesthesia and conscious sedation for major in- hospital complications and neurological outcome 3 months after stroke. Database: EMBASE

91. Exercise mediates anesthetic recovery in diabetic and control rats Author(s): Sinon C.; Ottensmeyer A.; Garcia P.; Slone A.; Pardue M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 438 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Type 2 diabetes mellitus is the most prevalent metabolic disease worldwide. Diabetes is associated with decreases in cortical volume and an increased risk for experiencing cognitive impairments. It has been previously reported that diabetic patients experience impaired cognitive function following cardiac surgery, especially on speed-related tasks. In an animal model of type 1 diabetes, exposure to isoflurane anesthesia without surgery is sufficient to cause memory problems. Exercise is often prescribed for diabetic patients and regular physical activity is hypothesized to decrease the risk of postoperative cognitive impairments. This study presents the first results of our investigation into the effects of diabetes and of exercise on recovery from isoflurane anesthesia in a type 2 diabetes rat model. Methods: Wistar (n=32) and Goto-Kakizaki (GK) type 2 diabetes (n=32) rats between 3 and 4 months old underwent forced treadmill exercise or remained idle on a stationary treadmill for 10 days. Rats then received either a 2-hour exposure to 1.5% to 2% isoflurane in oxygen at 1 L/min or oxygen. At 2 hours, rats were removed and placed into a recovery chamber. Time to appearance of postanesthetic milestones were recorded for 30 minutes, after which the rat was moved to a video-monitored rodent cage environment for 1 hour to record postanesthesia behavior. Preanesthesia and Postanesthesia Y-maze spatial alternation was recorded to determine cognitive performance on a spatial memory task. Results: At baseline, diabetic rats show a decrease in spontaneous alternation behavior (P=0.0291) and in maze exploration (P<0.0001). Rats receiving 10 days of forced treadmill exercise displayed no difference from idle rats in their emergence times from isoflurane general anesthesia (return of righting reflex, P=0.9259), but exercise hastened the appearance of our general recovery marker (Sticky Dot) post anesthesia for both Wistar and GK rats (P=0.0079). Rats that underwent exercise and isoflurane treatment display a decrease in spatial working memory compared with other experimental groups, as revealed by a significant main effect for anesthetic treatment and activity on a postanesthesia Y- maze test. Discussion: At baseline, we found the diabetic rats were less active and showed decreased spatial working memory compared with Wistar rats in the Y-maze. Forced exercise training before general anesthesia resulted in hastened recovery from isoflurane regardless of the presence of metabolic syndrome. Despite the lack of an effect of diabetic status on postanesthesia behavioral outcomes, these results suggest a need for further study of the interaction between exercise and recovery from anesthesia. Database: EMBASE

92. Noninvasive intraoperative cerebral autoregulation: Monitoring and retrospective calculation of optimal arterial blood pressure in elective neurosurgical patients Author(s): Valero R.; Lopez-Mock C.; De Riva N.; Fabregas N.; Belda I.; Gracia I.; Garcia-Orellana M.; Hurtado P. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 469-470 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background and Objectives: Cerebral autoregulation (CA) may be assessed with the cerebral oximetry index (COx) that correlates a surrogate marker of the cerebral blood flow (regional saturation of oxygen, rSO2) with either cerebral perfusion pressure (CPP) or arterial blood pressure (ABP).1 An automated curve fitting method with specific software (ICM +) calculates the "optimal ABP" (ABPOPT), defined as the ABP level where COx reaches its lowest value in an individual patient.2 Besides the technical challenges, we hypothesized that on-line monitoring of the COx index in patients undergoing long neurosurgical procedures allows a retrospective definition of their intraoperative ABPOPT. Measurements and Main Results: Retrospective analysis of prospectively collected data in the neurosurgical theater at Hospital Clinic de Barcelona. A total of 66 patients with continuous (> 2 h) intraoperative monitoring of invasive ABP and rSO2 with ICM+ software were included. COx was calculated online as the correlation between 10-second averaged values of rSO2 and mABP over a 300 seconds period (30 values). CA was considered intact for COx< 0.3 and impaired for COx>= 0.3. ABPOPT could be calculated in 49 (74%) of the 66 patients analyzed. The relationship between the baseline ABP value at admission (ABPBV), ABPOPT and the average "real" intraoperative ABP (ABPR) in these patients was also studied. Ten patients (20.41%) kept their average ABPR below 20% of their ABPBV. In 30 patients (61.22%) the average ABPR was lower than the ABPOPT. Conclusions: On-line CA monitoring with noninvasive COx index is feasible and allows a retrospective calculation of the ABPOPT values in most of the patients of the study. The fact that ABPR was below calculated ABPOPT in a significant number of patients deserves further analysis. Database: EMBASE

93. Multimodal intraoperative management for severe carotid occlusion during spine surgery: A case report Author(s): Myers J.; Sharma D.; Luk K. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 438 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Case Description: Anesthetic management of complex patients is often multifaceted, frequently requiring monitoring beyond ASA standards. In particular, carotid stenosis may necessitate attempts to assure brain perfusion, with many modalities studied but often with difficulty in interpretation or application. We present here a case report of a 64-year-old with a history of severe bilateral carotid occlusion and stroke who presented for resection of a progressively symptomatic thoracic intramedullary spinal cord mass. The patient's right carotid was stented after a stroke in 2015, from which she had some residual weakness. In addition, the patient had peripheral vascular disease, hypertension and endometrial cancer status posthysterectomy. Preoperative transcranial Doppler (TCD) showed a completely occluded left carotid and right to left flow dependence. To monitor collateral flow during surgery, we used intraoperative TCD as well as somatosensory evoked potentials, motor evoked potentials, and EEG, in addition to standard ASA monitoring. After a typical induction and intubation, anesthesia was maintained with propofol and remifentanil, blood pressure was supported with a phenylephrine infusion and ephedrine boluses. Early in the case, once TCD monitors were in place and before incision, it was noted that the patient had reduced flows in her MCAs bilaterally, left worse than right. It was also noted that her EEG signals were depressed and there were signs of slowing and amplitude loss on her somatosensory evoked potentials and motor evoked potentials. Raising the patient's MAP to 90 to 95mmHg (5% to 10% higher than her baseline of 85mmHg) proved to ultimately best support blood flow as measured by TCD in her bilateral MCAs and perfusion as measured by neuromonitoring methods. Subsequent periodic dips in her blood pressure resulted in similar changes, which were managed without additional agents or infusions. The surgery was completed without complication and the patient was extubated at the end of surgery. In the immediate postoperative period, she did not show any new neurological deficits. At 3 months the patient had returned to baseline functional status and was undergoing chemotherapy for a local, limited recurrence of her endometrial cancer. Discussion: Delivery of an appropriate anesthetic can be a careful balancing act, given that many patients have significant comorbidities whose management is more difficult than their presenting complaint. In this case, multimodal intraoperative neuromonitoring assisted us in relieving the new-onset spinal cord compression she had and preventing further injury from her neurological frailty. The periodic dips in the patient's blood pressure were most likely secondary to ongoing blood and fluid losses, phenylephrine tachyphylaxis, potential accumulation of anesthetic given propofol's context sensitive half-time, and surgical manipulation. The striking feature was the patient's sensitivity to small decreases in MAP, underlining the critical dependence of her left cortex on right cerebral blood flow. Although this degree of monitoring is not appropriate for many cases, in patients with severe comorbidities multiple efforts to reduce risk are worth the investment of time and attention. Database: EMBASE

94. Intraoperative measurement of regional cerebral blood flow by near-infrared spectroscopy in patients undergoing superficial temporal artery to middle cerebral artery bypass surgery for moyamoya disease Author(s): Tsukinaga A.; Yoshitani K.; Kato S.; Ohnishi Y. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 469 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Superficial temporal artery to middle cerebral artery (STAMCA) bypass surgery developed for prevention of stroke in patients with Moyamoya disease (MMD). However, there has been no quantitative evaluation whether STA-MCA bypass increases regional cerebral blood flow (rCBF) intraoperatively to date. Recently advanced near-infrared spectroscopy (NIRS) has enabled to measure relative change in rCBF following injection of indocyanine green (ICG).1 On the basis of that technology, we developed a quantitative method measuring rCBF. The purpose of this study was to examine whether STA-MCA bypass graft increases rCBF by measuring rCBF intraoperatively by our novel technology of NIRS and ICG. Method: Thirteen patients undergoing elective STA-MCA bypass surgery for MMD were enrolled. We measured rCBF pre and post bypass intraoperatively by using NIRS and intravenous injection of ICG. rCBF was calculated by using the maximum gradient model combining the change of arterial blood concentration (i) and maximum arterial blood concentration of ICG in the brain tissue (ii).2 First, the curve of the change in ICG concentration in the brain tissue was drawn using the software, NIRO ICG (Hamamatsu Photonics, Japan). The original curve includes both arterial and venous components of the brain tissue. The curve of ICG concentration of arterial blood was separated by applying the frequency filter to pulse wave component in the curve of ICG concentration (i). Second, the maximum blood concentration of ICG was obtained by DDG analyzer (Nihon Kohden, Japan) (ii). Combining the 2 results [(i) and (ii)], rCBF was calculated. rCBF measured by NIRS (rCBF-N) at pre and post bypass was compared with preoperative and postoperative rCBF measured by Positron emission tomography (rCBF-P) of the anterior cerebral artery area corresponding to the measurement site by NIRS. We used paired t test in statistical analysis. Results: rCBF-N was significantly increased in the operated side (pre: 25.5+/-12.5 mL/100 g/min, post: 32.7+/-11.5 mL/100 g/min, P=0.04), but not in the nonoperated side (pre: 25.5+/-10.9 mL/100 g/min, post: 25.7+/-13.7 mL/100 g/min, P=0.51). Postoperative rCBF-P was significantly increased in the both side compared with preoperative rCBF-P (operated side; pre: 30.7+/-5.4 mL/100 g/min, post: 37.5+/-9.3 mL/100 g/ min, P=0.01; nonoperated side; pre: 31.4+/-0.6 mL/100 g/min, post: 39.4+/-11.7 mL/100 g/min, P=0.01) (Fig.). Conclusions: Intraoperative rCBF-N pre and post STA-MCA bypass surgery were significantly increased similarly with rCBF-P. rCBF-N could be a quantitative assessment of STA-MCA bypass surgery. Database: EMBASE

95. Inadvertent burst suppression in a case series of 130 spine patients under total intravenous anesthesia Author(s): Myers J.; Sharma D.; Hecker J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 438 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: The electroencephalography (EEG) pattern called burst suppression is well characterized but poorly understood. Described as a generally pathologic state of low cortical activity, the signal is straightforward to identify and amenable to quantification. In patients undergoing surgery, it is a marker for a deeply anesthetized state and has been utilized as a neuroprotective intervention in cerebral vascular procedures. However, recent emerging evidence indicates it may be a potential factor in the development of postoperative delirium and the frequency of unintended suppression during major surgery is largely unexplored. Here we describe the incidence and degree of burst suppression among 130 spine patients undergoing surgery at Harborview Medical Center. Methods: Patients were selected from department-maintained case lists for spine surgery patients from January to February of 2016. EEG was visually assessed in 1 minute epochs for the presence and degree of burst suppression over the course of the case by a qualified and experienced EEG technician. EEG monitoring was applied after induction, measures reported here are postinduction. Burst suppression was recorded in percentiles with the amount of time in burst suppression noted in minutes, as well as objective notes about the point in time of the surgery. Results: We analyzed the EEG of 130 patients undergoing spine surgery at HMC between January and February of 2016. We report that 91 of 130 patients experienced some degree of inadvertent burst suppression. The degree of burst suppression could be very high: twenty-three of these cases showed 90% to 100% burst suppression for at least 10 minutes, 15 for over 60 minutes. In addition, the time spent in suppression spanned the entirety or near-entirety of the procedure for 34 of the 91 patients. Conclusions: The impact of changes in EEG activity under anesthesia are beginning to be characterized, but the importance of particular changes are still poorly defined. In this study, we identify a surprisingly high incidence of inadvertent burst suppression at some point during a typical intravenous anesthetic at our institution. Not only was the degree of burst suppression quite high, 90% to 100% in one quarter of the patients who experienced suppression, but burst suppression was experienced across the near-entirety of the procedure in over one third of those 91 patients. Recent data has indicated a possible link between intraoperative burst suppression and postoperative delirium, thus the data presented here may indicate the potential for refinement in anesthetic management with regard to monitored EEG activity. Database: EMBASE

96. The risk factor of postoperative transient neurological events in pediatric patients of moyamoya disease: A retrospective study Author(s): Matsuura H.; Yoshitani K.; Ohnishi Y. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 468-469 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Moyamoya disease (MMD) is a cerebrovascular disease characterized by bilateral stenosis of the intracranial internal carotid arteries and an abnormal collateral vascular network at the base of the brain. Previous studies indicated that postoperative stroke and cerebral hyperperfusion had occurred 27.5% to 50% of patients (1 to 4) per surgery. Particularly, the pediatric patients with MMDare exposed to the risk of transient neurological events (TNE), such as emergence delirium, dehydration, and anxiety, but to our knowledge, there have been few studies that identified the risk factors of postoperative TNE in pediatric cases. Therefore we investigated the incidence and the risk factors of TNE in pediatric patients with superficial temporal artery-middle cerebral artery (STA-MCA) bypass procedure retrospectively. Method: After Institutional Review Board approval, we retrospectively reviewed medical records of MMD patients younger than 15 years old with STA-MCA bypass surgery under general anesthesia at one cerebrovascular center in Japan between January 1999 and March 2016. The primary outcome was TNE. Candidates of risk factors of TNE, age, sex, anesthetic agent (propofol or sevoflurane), premedications, sedation (propofol or dexmedetomidine), and crying, were examined by multivariable logistic regression analysis. Results: A total of 277 cases of 154 pediatric patients received STA-MCA bypass surgery, and 154 cases (39%) suffered TNE within 1 week after operation. Crying (odds ratio, 3.4; 95% confidence interval, 1.87-6.18; P<0.001) was an independent risk factor of TNE, and sedation protected incidence of TNE (odds ratio, 0.50; 95% confidence interval, 0.28-0.89; P=0.018), but there was no significant difference in propofol or dexmedetomidine. Conclusions: In pediatric patients of MMD, crying induced postoperative TNE and the sedatives reduced the risk of TNE. Database: EMBASE

97. A rare and unexpected cause of acute unilateral loss of transcranial motor evoked potential signal during posterior thoracic spine surgery Author(s): Simmons C.; Clavijo C. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 437 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Intraoperative neurophysiological monitoring (IOM), including somatosensory evoked potentials (SSEPs), transcranial motor evoked potential (TcMEP), and electromyography (EMG) are commonly used in spinal fusion procedures and have been shown to decrease the incidence of neurologic injury, improve outcomes1 and subsequently lower cost.2 Intraoperative loss of signal requires immediate assessment and efforts to identify causality, as signal loss without return is a poor prognostic indicator.3 A systematic approach to identifying and correcting signal loss is imperative. Here, we present a case of TcMEP signal loss not previously reported at our institution and the related unique interventions utilized to resolve concerns. Case Presentation: A 23-year-old previously healthy male, status post Motor Vehicle Crash and subsequent T5 burst fracture, presented for posterior spinal fusion at T2-T9. At surgeon request, neuromonitoring was utilized and included: SSEP, TcMEP, spontaneous EMG. Patient arrived to the operating room (OR) intubated and under sedation. After induction of general anesthesia, placement of intravenous and arterial catheters, and before final positing, baseline signals were obtained. Largesized, polyphasic responses at the expected latency were present in left and right upper extremities and bilateral adductor hallucis muscles. Signals were not obtained in the bilateral tibialis anterior. After prone positioning, responses were again obtained, and no significant changes were detected. Patient anesthesia was maintained with infusions of propofol, sufentanil, and ketamine. Signals were followed throughout the procedure with no significant changes noted. At completion of instrumentation and at start of wound closure, TcMEP responses were undetectable at the left adductor hallucis. Attending surgeon was informed immediately and was concerned with overcorrection of deformity and considered reopening wound to assess. During this time technical aspects and anesthesia were ruled out as a possible cause. At this time, physical examination of the extremities was undertaken resulting in discovery of a left foot that was cool and pale. The left foot was the location of intra-arterial catheterization and was thought to be contributing to physiological derangements noted. Vascular surgery was consulted and after obtaining dorsalis pedis pulses via doppler, recommended to discontinue the arterial line and observe. At case completion patient was transported to the intensive care unit. Immediate neurological examination was not possible; however, follow-up examination indicated 4/5 strength testing at all major lower extremity muscle groups. Discussion: A standardized approach to acute unilateral loss of intraoperative TcMEPs includes immediate communication with surgical and anesthesia teams, investigation of possible sources of vascular occlusion or nerve compression, evaluation of patient positioning, and technical considerations including electrode placement, circuit integrity, and machine malfunction. In this case, a systematic approach was followed and led to timely discovery of a rare complication. As a result of adherence to protocols and prompt corrective measures, this patient sustained no permanent neurological injury. Database: EMBASE

98. Incidence of post-operative visual dysfunction after robot-assisted laparoscopic radical prostatectomy Author(s): Kitaguchi M.; Egawa J.; Kinomoto A.; Kawanishi H.; Inoue S.; Kawaguchi M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 408 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Robot-assisted laparoscopic radical prostatectomy (RALP) is a widely performed minimally invasive surgical technique used to treat prostate cancer. RALP has several advantages in comparison with conventional open prostatectomy, including reduced need for blood transfusion, less postoperative pain, and fewer surgical complications. During a RALP procedure, a steep Trendelenburg position and abdominal carbon dioxide gas insufflation are required. This procedure can induce a significant increase in intraocular pressure and optic nerve ischemia. A previous study reported that 28% of patients showed transient visual field deficit after RALP.1 However, no evidence regarding visual outcomes after RALP is available. The National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) is a self-completion questionnaire addressing visual function and assesses vision-related quality of life (QOL). The NEI-VFQ was translated into Japanese, and the reliability and validity of the Japanese version has been verified.2 The current study investigated the incidence of postoperative visual dysfunction after RALP using the Japanese version of the NEI-VFQ. Methods: After obtaining approval of the ethics committee of our institution, written informed consent was obtained from all patients. Thirty-two patients undergoing RALP were included in the study. Visual function was assessed one day before surgery, 5 days after surgery, and 1 month after surgery using the Japanese version of the NEI-VFQ. A higher score in the NEI-VFQ (score range, 0 to 100) indicates better vision-related QOL. Postoperative visual dysfunction (POVD) was defined as a 40-point decrease in the preoperative NEI-VFQ score in at least one of 8 subscales comprising general health (GH), general vision (GV), near vision (NV), distance vision (DV), social function (SF), mental health (MH), role limitation (RL), and dependency (DP). The total VFQ score was calculated as the average score of 7 subscales (GV, NV, DV, SF,MH, RL, and DP).2 Results: Of the 32 patients recruited in this study, 3 patients were excluded 5 days after surgery and 1 patient was excluded 1 month after surgery due to incomplete data. Of the remaining 28 patients, 4 patients (14.3%) showed POVD 5 days after surgery and no patient showed POVD 1 month after surgery. There was no significant difference between preoperative, 5-day postoperative, and 1-month postoperative total VFQ scores (85, 83, and 83, respectively; P=0.20). The average age of the patients was 70+/-6 years in the non-POVD group and 68+/-5 years in the POVD group. The duration of intraoperative hypertension (sBP> 160mmHg) was 2 +/-5 minutes in the non-POVD group and 4+/-6 minutes in the POVD group. The duration of intraoperative hypercarbia (EtCO2>43mmHg) was 30+/-52 minutes in the non-POVD group, and 5 +/-7 minutes in the POVD group. Conclusions: POVD was observed in 4 of 28 patients 5 days after RALP, all of whom recovered 1 month after the procedure. The total number of patients who showed POVD was low. Therefore, further studies are needed to identify the factors associated with POVD post-RALP. Database: EMBASE

99. Effect of fosaprepitant on EEG, SSEP, and tcmep neuromonitoring under general anesthesia Author(s): Burbridge M.; Lopez J.; Shah A.; Jaffe R. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 437 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Fosaprepitant (Emend) is an intravenous neurokinin type-1 receptor antagonist which inhibits the binding of substance P and attenuates its central nervous system functions. Substance P and the neurokinin type-1 receptor are found in high concentrations in the medulla vomiting center. Fosaprepitant is superior to both ondansetron1 and droperidol2 in preventing postoperative nausea and vomiting (PONV) after craniotomy in adult patients. Craniotomy has been shown to be a risk factor for PONV, and can cause potentially catastrophic complications.3 In addition to the medulla, neurokinin type-1 receptors and substance P are found in numerous other sensory pathways. We therefore sought to determine if fosaprepitant administration intraoperatively would interfere with electroencephalogram (EEG), somatosensory evoked potential (SSEP), and transcranial motor evoked potential (TcMEP) monitoring in patients undergoing general anesthesia. We enrolled 5 adult patients who presented for interventional neuroradiology procedures under general anesthesia. Patients with preexisting sensory or motor deficits, diabetes mellitus, peripheral neuropathy, and those on hormonal- based medications such as the oral contraceptive pill were excluded. Our anesthetic protocol included premedication with 2mg midazolam, and patients were induced with 3mcg/kg fentanyl, 1 to 2 mg/kg propofol and 1 mg/kg succinylcholine. All patients were intubated with a 7.0 cuffed endotracheal tube. Patients were maintained on propofol (100mcg/kg/min) and remifentanil (0.05 to 0.1 mcg/kg/min) infusions. Fosaprepitant 150mg IV was administered after induction of general anesthesia, but after sufficient and reproducible baseline EEG, SSEP, and TcMEP were obtained before the surgical procedure. EEG and evoked potential amplitudes, latencies, and morphologies were analyzed at baseline following anesthetic induction. These electrophysiological responses were then continuously monitored throughout the duration of the case. SSEP's were run at least every 5 minutes. The average duration of EEG, SSEP, and TcMEP monitoring was 165 minutes after fosaprepitant administration. Results show that fosaprepitant does not have a significant effect on the amplitude, latency, or morphology of SSEP monitoring, or on EEG or TcMEP morphologies obtained using our anesthetic protocol. This preliminary data demonstrates that fosaprepitant can be administered during neurosurgical cases under general anesthesia without interfering with EEG, SSEP or TcMEP neuromonitoring. Database: EMBASE

100. Predictive factors of unpredicted movement in motor evoked postential during intraoperative neurophysiologic monitoring in adult patients undergoiing brain surgery Author(s): Lee S.; Jeon Y.; Hwang J.; Park H. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 436-437 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: During transcranial motor evoked potential monitoring, electrical stimuli activates peripheral muscles and can cause bite injuries, excessive surgical field movement, and movement induced injury. The aim of this study was to identify risk factors associated with unexpected movements by motor evoked potential stimulation. Methods: In this retrospective observational study, 464 patients undergoing brain surgery were enrolled. Demographic data and intraoperative laboratory data including arterial blood gas analysis, hematocrit, sodium, potassium, glucose, ionized calcium, ionized magnesium, and lactate were collected. We retrospectively compared the data of patients with and without unexpected movement during surgery. Results: Among the 464 patients, unexpected movements were observed in 174 patients (38%). Age (odds ratio, 0.98; 95% confidence interval, 0.96-0.99; P=0.022) and ionized calcium (odds ratio, 244.21; 95% confidence inetravl, 4.96-12015.33; P=0.006) were independent risk factors for unexpected intraoperative movement. Conclusions: Age and ionized calcium concentration may be associated with unexpected movement during motor evoked potential monitoring for the brain surgery. Database: EMBASE

101. Shaking spell during a repeat epidural blood patch: Convulsive syncope, epileptic seizure, or local anesthetic toxicity? A diagnostic dilemma Author(s): Dahl A.; Warner N.; Watson J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 466-467 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Distinguishing convulsive syncope from seizures related to epilepsy or local anesthetic toxicity can be a diagnostic challenge. While there are many shared clinical signs including shaking, loss of consciousness, and incontinence, management strategies are unique and hence, it is crucial to obtain an accurate and prompt diagnosis. Case Description: A 37-year-old gentleman with a history of chronic headaches, hemicrania continua with chronic cerebrospinal fluid (CSF) leak, congenital scoliosis status postextensive hardware instrumentation, familial connective tissue disorder status post aortic root replacement with aortic valve replacement on chronic anticoagulation presented to the Pain Clinic for consideration of repeat lumbar epidural blood patch to ameliorate symptoms related to his CSF leak. An epidural blood patch was performed 10 days previously, utilizing a right paramedian interlaminar approach, resulting in 30% pain reduction in his frontal headache. His INR was within normal limits and a repeat epidural blood patch was scheduled. The patient was brought to the procedure room. He was conversant throughout the procedure. The epidural space was accessed at L4-L5 on the first pass without difficulty utilizing the same approach and epidural contrast spread was consistent with the previous technique and images. After slow injection of 13 mL of autologous blood, the patient complained of nausea. He became diaphoretic, lightheaded, and bradycardic into the 40 seconds. The procedure was paused for 1 minute with modest symptomatic relief. When continuation was attempted, he began feeling worse. The procedure was immediately aborted; however, the patient promptly lost consciousness followed by nonrhythmic shaking of his upper extremities and upwardly directed movement of both eyes. He was diaphoretic and pale. The spell lasted 15 seconds in duration. The patient spontaneously regained consciousness. He was hot and flushed. He was able to answer questions appropriately but did not recall the spell. His bradycardia and modest hypotension improved over the next 10 minutes. Discussion: Epileptic seizure triggers can include flashing lights, lack of sleep, and fever, and are associated with rhythmic movements, tongue biting, incontinence, and prolonged recovery of mental status. Local anesthetic seizures have similar clinical appearance, occur during or following local anesthetic injection (often in highly vascular regions), and may be accompanied by brief prodromal symptoms. Increased heart rate is often detected if epinephrine is present. Convulsive seizures typically have a clinical prodrome where the patient feels poorly and may be accompanied by evolving hemodynamic change (eg, bradycardia, hypotension). Triggers include vasovagal stimulation, pain, and exercise. Loss of consciousness, tongue biting, and incontinence may occur, though body movements are nonrhythmic in nature. Rapid recovery of mental status after the event is the best discriminatory feature from epileptic seizures. Psychogenic nonepileptic seizures are also possible, and a brief review of differential diagnoses and accompany features is provided in the accompanying table. Database: EMBASE

102. Dermatomal somatosensory evoked potential (SSEP) monitoring using a novel automated SSEP deivce: A feasibility study Author(s): Chui J.; Fujii S.; Freytag A.; Murkin J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 435-436 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Mixed nerve somatosensory evoked potential (SSEP) monitoring is commonly used to monitor spinal cord function but inaccurate in detecting nerve root injury.1 Dermatomal SSEP has been used for nerve root monitoring in lumbosacral spine surgery.2 However, recording dermatomal SSEP is technically challenging because of the smaller amplitude than mixed nerve SSEP. As the recent introduced automated SSEP device (EPAD) incorporates a proprietary artificial rejection and signal optimization system, we hypothesized that the EPAD automated SSEP device might provide an enhanced dermatomal SSEP signal. This study aimed to assess the feasibility of using this automated SSEP device to record dermatomal SSEP during noncardiac and nonneurological surgery. Method: After Ethics Board approval and written consent, study participants were monitored using the EPAD automated SSEP device intraoperatively. The stimulating surface electrodes were applied to palmar side of thumb (C6 dermatome) and middle finger (C7 dermatome) bilaterally. Subcortical dermatomal SSEP were monitored. The recording surface electrodes were placed to the posterior neck at the fifth cervical spine level (C5) and referenced to the forehead electrode (Fz). Results: Nine patients were consented and included. No technical issue was encountered. All patients were successfully monitored with satisfactory dermatomal SSEP signals (Fig. 1). The mean impedance was 2309 Ohm. The amplitude and latency of C6 SSEP were 0.6 +/- 0.3mA and 16.0 +/- 4.7 ms. The amplitude and latency of C7 SSEP were 0.63 +/- 0.4mA and 19.3 +/- 4.4 ms, respectively. The smallest amplitude of recordable dermatomal SSEP signal was 0.3mA. Conclusions: We found that small amplitude dermatomal SSEP signals (of C6 and C7 dermatomes) could be consistently obtained from an automated SSEP device. This finding might facilitate the development a nerve root specific monitoring strategy for spine surgery. Further studies are required to evaluate the diagnostic accuracy and the application in spine surgery. Figure 1. Dermatomal somatosensory evoked potential from 2 patients. A, The dermatomal SSEP signals obtained from stimulation of left C6 dermatome of a patient. The baseline amplitude and latency of C6 dermatomal SSEP were 0.5mA and 19.8ms. B, A very small dermatomal SSEP signal obtained from stimulation of right C7 dermatome of a patient. The baseline amplitude was only 0.3mA. The scales of are 1 and 5 ms/Div. (Figure Presented). Database: EMBASE

103. Phenylephrine modulates CSF IL-6 concentration in a sex dependent manner to protect cerebral autoregulation and reduce hippocampal necrosis after traumatic brain injury in newborn pigs Author(s): Armstead W.; Curvello V.; Hekierski H.; Pastor P.; Vavilala M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 434-435 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Hypotension and low cerebral perfusion pressure are associated with low cerebral blood flow, cerebral ischemia, and poor outcomes after traumatic brain injury (TBI). TBI is the leading cause of death in children, and boys and younger children have particularly poor outcomes compared to girls and older children. Cerebral autoregulation is impaired after TBI, contributing to poor outcome. Cerebral perfusion pressure is often normalized by use of vasoactive agents to increase mean arterial pressure and optimize cerebral blood flow. Clinically, current vasoactive agent use is variable, empiric, and may be related to variability in mortality. As ethical considerations constrain mechanistic studies in children, we use an established porcine model of fluid percussion brain injury (FPI) to understand this pathology. In prior studies of newborn pigs, Phenylephrine (Phe) prevents impairment of cerebral autoregulation and histopathology in female but potentiated such injury in males via modulation of ERK mitogen-activated protein kinase. Prior unrelated studies indicated an association between upregulation of ERK mitogenactivated protein kinase with increased cerebrospinal fluid (CSF) IL-6 after FPI. However, the role of IL-6 in CNS pathology is not well understood. We presently investigated whether Phe protects autoregulation and limits histopathology after FPI in pigs due to a sex dependent modulation of brain injury associated upregulation of IL-6. Methods: Lateral FPI was produced in anesthetized pigs. Pial artery reactivity was measured via a closed cranial window. IL-6 was quantified by ELISA. Data (n=5) were analyzed by repeated measures ANOVA, with significance determined at P<0.05. Results: Results show that CSF IL-6 was increased by FPI, release potentiated by Phe in the male but blocked in the female. The IL-6 antagonist LMT-28 prevented impairment of cerebral autoregulation and hippocampal CA1 and CA3 neuronal necrosis after FPI in untreated and Phe-treated male and female pigs. Papaverine induced dilation was unchanged by FPI and LMT-28, indicating that impairment of vascular reactivity was not an epiphenomenon. Discussion: These data indicate that Phe modulates CSF IL-6 concentration in a sex dependent manner to protect cerebral autoregulation and reduce hippocampal necrosis after traumatic brain injury in newborn pigs. Database: EMBASE

104. Cardiomyopathy in limb-girdle muscular dystrophy: A case presentation and perioperative implications Author(s): Feldheim T.; Mohamed B. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 465 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Patients with neuromuscular disorders present a myriad of concerns for the anesthesiologist.1 One such set of disorders are the Limb- Girdle Muscular Dystrophies (LGMD); a group of at least 15 genotypic muscular dystrophies that cause an analogous phenotypic expression.2 Certain subtypes are at risk for delayed recovery from residual neuromuscular blockade, cardiovascular collapse, postoperative respiratory failure, and malignant hyperthermia. We present a case of an adult patient with LGMD requiring a total abdominal hysterectomy. Case Presentation: A 69-year-old female presented with a 6-month history of postmenopausal bleeding and pelvic mass scheduled for open total abdominal hysterectomy. She had a past medical history of hypertension and chronic kidney disease. She endorsed bilateral lower extremity weakness which got progressively worse limiting her activity. Preliminary neurology diagnosis was LGMD. Preoperative evaluation included transthoracic echocardiogram which showed cardiomyopathy with left ventricular ejection fraction of 35%. Cardiology was consulted and left heart catheterization showed normal coronary arteries. Anesthetic plan was to avoid triggers for malignant hyperthermia, careful use of neuromuscular blockade, judicious use of intravenous fluids and other implications for cardiomyopathy. Her perioperative course was uneventful and she was successfully extubated. Discussion: LGMD is a neuromuscular disease that encompasses different heterogenetic mutations. There are variabilities in phenotypes based on the subtype but almost all LGMD have proximal limb weakness of the thighs and shoulders, elevated CK, and eventually cardiovascular and respiratory weakness.4 Cardiac workup including evaluation for cardiomyopathy and dysrhythmia is warranted.3,4 LGMD patients are at risk of post-operative respiratory depression secondary to diaphragmatic weakness; thus, shorter acting agents such as propofol and remifentanil are recommended.3,4 Judicious use of short-acting neuromuscular blocking agents (NMB) is also recommended. The use of Sugammadex has made it easier to utilize nondepolarizing NMB agents.3 Several subtypes of LGMD are associated with malignant hyperthermia-like reactions and rhabdomyolysis when exposed to succinylcholine as well as volatile anesthetics; it is recommended to avoid these medications.1,3,4 Furthermore, succinylcholine use can lead to severe hyperkalemia.4 Conclusions: Perioperative considerations for patients with LGMD should focus on the possibility of cardiomyopathy, dysrhythmia, respiratory muscle weakness, and malignant hyperthermia-like reactions. Database: EMBASE

105. Clinical utility of intraoperative cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic and thoracoabdominal aneurysm repair: An audit of the Japanese association of spinal cord protection in aortic surgery database Author(s): Uranaka M.; Yoshitani K.; Kato S.; Ohnishi Y.; Nakai M.; Nishimura K. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 433-434 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy (ACC/AHA Class I, Level B) in open and endovascular thoracic aortic repair. However, the small studies support the evidence of CSFD, large scale study is needed.1 We previously conducted a retrospective large-scale study to investigated whether motor evoked potentials was effective to reduce the incidence of motor deficits in open and endovascular thoracic aortic repair. We use the same database to examine whether the CSFD reduce the motor deficits after open and endovascular thoracic aortic repair. Methods: Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated clinical utility of CSFD in open and endovascular thoracic aortic repair for decrease the incidence of postoperative motor deficits. We also used propensity score matching CSFD versus not-CSFD to adjust potential confounders. Results: We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). CSFD was performed in 417 patients, and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge had a significant association with CSFD (adjusted odds ratio [OR]=2.14, 95% confidence interval [CI], 1.32-3.47, P=0.002) (Table 1), and with other factors: history of neural deficits (adjusted OR=6.08; 95% CI, 3.10- 11.91; P<0.001) (Table 1), and endovascular procedure (adjusted OR=0.45; 95% CI, 0.27-0.76; P= 0.003) (Table). After propensity score matching (n= 819), CSFD had a significant association with postoperative motor deficits at discharge (OR= 4.624; 95% CI, 2.37-9.04; P< 0.001). Conclusions: CSFD in thoracic and thoracoabdominal aortic repair was a risk factor of postoperative motor deficits. CSFD may be used in high risk patients and less useful. (Table Presented) . Database: EMBASE

106. Ultra-low tidal volume ventilation (ULTVV) reduces neuroinflammation after experimental cardiopulmonary resuscitation Author(s): Ruemmler R.; Kuropka F.; Ziebart A.; Dnges B.; Mllmann C.; Kamuf J.; Garcia-Bardon A.; Hartmann E. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 432-433 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Lung-protective ventilation strategies are a well-developed, highly researched topic in critical care medicine. However, the optimal ventilation method for patients receiving cardiopulmonary resuscitation (CPR) still remains elusive and highly controversial. In this study, we tried to apply a new protective ventilation scheme during mechanical CPR in swine, which is derived from "lung-rest" ventilation known during ECMO therapy on intensive care units. Methods: A total of 30 male German landrace pigs were anesthetized and instrumented with intravascular catheters. After a stabilisation phase (Vt, 8 mL/kg; FiO2, 0.4, PEEP, 5mbar), base line measurements were taken and ventricular fibrillation was then induced via an intravenous stimulation probe. The animals were left untreated and without ventilation for 4 minutes. The pigs were randomized into 3 groups, group 1 receiving standard IPPV (Vt, 8 to 9mL/kg; FiO2, 1.0; RR, 10/min; PEEP, 5mbar), group 2 receiving modified chest-compression only resuscitation with 10l per minute passive oxygen insufflation (CCO) whereas group 3 was treated with ultra-low tidal volume ventilation (ULTVV) (2 to 3 mL/kg; FiO2, 1.0; RR, 50/min; PEEP, 5 mbar). During interventional ventilation, mechanical cardiopulmonary resuscitation was performed using a LUCAS-2 device. After 5 minutes, blood gas analyses were taken and advanced life support was commenced including up to 4 full cycles of CPR, rhythm analyses and defibrillations as well as administration of adrenaline and vasopressin. In case of ROSC, blood gas, and mass spectrometry analyses were performed and the animals were then monitored for 6 hours before being euthanized according to German animal care law. Brain tissue samples were collected and analyzed for IL-6 and TNF-alpha expression via PCR. Results are displayed in mean difference/95% CI of difference. Statistical analysis was performed via 2-way ANOVA inter-group analysis with GraphPad Prism 5 software. P-values <0.05 were considered significant. Results: IL-6 and TNF-alpha concentrations in hippocampus samples were significantly lower in ULTVV and CCO animals (IL-6: ULTVV [-7,91/-1,68 to -14,14, P< 0,05], CCO [-8,94/-2,71 to -15,17, P<0,01] [all *10-6 relative to PPIA] TNFa: ULTVV [-2,8/-0,6 to -5,0, P<0.05] CCO [-4,12/-1,99 to -6,38, P<0,001] [all *10- 5 relative to PPIA]). Cortex samples showed no significant differences. Decarboxylation was more efficient in ULTVV than in CCO animals during CPR. Discussion: Our data suggest benefits of lung- protective ventilation during CPR. Lower ventilation pressures combined with sufficient ventilation with ULTVV could provide better circulation and thus lead to increased cerebral perfusion and less cerebral tissue damage in the most oxygen-dependent regions. In addition, ULTVV provides better decarboxylation and might be sustained longer without substantial acidosis which usually limits CCO use. Conclusions: ULTVV offers a novel treatment option under cardiac arrest receiving CPR. Lower driving pressures might increase venous return, thus providing better circulation and less neuroinflammation, possibly ameliorating outcomes. Database: EMBASE

107. Trans-odontoid screw migration and airway management in the neurosurgical patient Author(s): Nookala A.; Welch T. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 464 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: The most common second body cervical spine fracture is the odontoid fracture. Odontoid fractures have a biphashic age distribution that peaks at ages 20 to 30 (trauma) and in the elderly 70-80 years old. Many odontoid fractures are treated surgically.1 Case Description: A 59-year-old male with a past medical history of hypertension and gastroesophageal reflux disease presented to an outside emergency room after a mountain bike accident. The patient was the helmeted and fell off his bike over the handle bars. Computerized topography (CT scan) of his cervical spine showed a mildly displaced odontoid fracture. The patient was placed in a C-collar and transferred to our institution for surgical intervention. The patient was taken to the operating room for odontoid screw placement and anterior fusion. The patient had an uncomplicated induction with an easy indirect laryngoscopy with a video laryngoscope. The patient had an uncomplicated postoperative course and was discharged on postoperative day 1. He continued to have interval follow up with Neurosurgery. At the 3-month follow-up the patient complained of difficulty swallowing and a scratchy throat. He was found to have anterior migration of the transodontoid screw into the retropharyx with a thin layer of mucosa overlying the mass (Fig. 1). The patient returned to operating room for removal of the transodontoid screw and posterior cervical spine fusion. The patient's preanesthetic evaluation revealed aMallampatti II, small mouth opening, and decreased neck mobility. There was significant concern of the screw eroding into the retropharynx, and potential to rupture overlying mucosa upon any trauma from airway instrumentation. The anesthetic plan included an IV induction with a vidoelaryngoscope intubation and a fiberoptic scope available. Otolaryngology and Neurosurgery were in the operating room available during induction and intubation. Standard ASA monitors and an arterial line were placed. Induction was uncomplicated, and the airway was secured with a videolaryngoscope without trauma to the overlying mucosa of the migrated screw. Discussion: Transodontoid screw complications can include dysphasia, nonunion, screw breakout, and screw migration. Close follow-up is suggested to monitor for common complications.2 It is important to communicate with the surgical service, and have multiple resources available when securing an airway after anterior screw migration. Database: EMBASE

108. Delayed onset macroglossia after posterior fossa surgery requiring enteral feeding tube Author(s): Patel J.; Willett P. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 463 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Macroglossia following posterior fossa surgery in children can be a life threatening complication requiring emergent intervention. While the etiology of macroglossia is uncertain, we report an unusual case of delayed onset macroglossia following posterior fossa surgery. Case Presentation: An otherwise healthy 6-year-old male with cerebellar mass underwent a suboccipital craniotomy for tumor resection. Induction and intubation were uneventful. The patient was prone with a soft bite block in place for intraoperative neuromonitoring. The case lasted for 8 hours and the intraoperative course was unremarkable. On emergence there was no evidence of airway edema or trauma, he was extubated awake without any complications. On postoperative day (POD) 1 the patient underwent an uneventful postoperative MRI brain. Prior airway examination noted a Mallampati class 1 airway. The MRI noted anterior tongue edema and hyperemia extending to sublingual glands. Upon emergence, patient noted to have edematous tongue with protrusion out of oral cavity, with no visible abrasions or lacerations on tongue and no evidence of airway obstruction. ENT and Dental were consulted and recommended conservative management. The tongue edema intensified through POD 5 resulting in visible abrasions and ulcerations on ventral surface of tongue and preventing oral intake requiring nasogastric tube placement. By POD 10 the tongue was improving with cold saline gauze wrapping and by POD 13 the patient could retract tongue into oral cavity. The patient was discharged to inpatient rehab with nasogastric tube still in place. Discussion: Macroglossia after neurosurgical procedures is a known but poorly understood phenomenon, more notably described in adult patients. 1 The onset ranges from intraoperative to delayed up to 36 hours; while the duration can last >2 weeks causing potentially devastating airway compromise requiring tracheostomy.2 There are 3 proposed mechanisms: mechanical trauma from neuromonitoring, obstruction of venous drainage due to positioning, and neurogenic vasodilation.3 This case presented well after any intraoperative mechanical trauma or venous obstruction was relieved. Given these factors we feel this case likely represents a neurogenic cause. Our patient never developed respiratory distress and imaging showed the edema was limited to the anterior tongue. There is at least one similar case report of delayed onset anterior tongue edema with no respiratory compromise. 4 There is also a case report of immediate onset macroglossia that was determined to be isolated to the tongue and was successfully extubated at 72 hours, well before resolution of the macroglossia.5 This may suggest that patients with isolated tongue edema may be managed without advanced airways and that imaging may help guide management. Database: EMBASE

109. Effect of anesthetic choice on hemodynamics and vasopressor use after mechanical thrombectomy for acute ischemic stroke Author(s): Whalin M.; Moran T.; Levey N.; Haussen D.; Grossberg J.; Nogueira R.; Ratcliff J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 462-463 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: New Guidelines extending the thrombectomy treatment window for acute stroke will lead to an increase in the volume of cases. As hospitals and providers prepare for this growth, they must consider how periprocedural management might impact post-thrombectomy care. Some patients require vasopressors after thrombectomy to meet blood pressure goals but the characteristics of this population have not been well-described. We hypothesized that the type of anesthesia used during thrombectomy would be associated with the use of vasopressors during the following 3 days. Methods: We reviewed our institutional thrombectomy database from 2013 to 2017 and extracted hemodynamic data for the 3 days after thrombectomy. Continuous and categorical data were summarized using medians/interquartile ranges and percentages/95% confidence intervals, respectively. Predictors of vasopressor use were evaluated using logistic regressions. Results: We obtained detail postprocedure hemodynamic data for 360 patients treated during the study period. Fourteen percent of patients received general anesthesia with sevoflurane and 86% of patients received MAC with dexmedetomidine. The overall rate of vasopressor use in this population was 15% during the 3 days following thrombectomy, with phenylephrine being the most common agent (Fig. 1). As shown in Table 1, patient demographics, comorbidities, and stroke features were not associated with vasopressor use. The maximum systolic blood pressure on the day of thrombectomy was higher on the day of thrombectomy in the patients who received general anesthesia (median difference 8.1mmHg, 95% confidence interval, 0.2-16.0mmHg) but no association was seen between anesthetic choice and postprocedure vasopressor use. Conclusions: We failed to identify variables associated with postthrombectomy vasopressor use in this population. Future study is needed to determine if vasopressor use after thrombectomy is associated with long-term outcomes. Database: EMBASE

110. Variability in cerebral oxygen extraction fraction during anesthesia: Luxury and misery perfusion patterns Author(s): Mahanna-Gabrielli E.; Bergonzi K.; Yodh A.; Kofke W.; Baker W. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 399 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Anesthesia providers rely on indirect information from blood pressure and SaO2 to infer adequate oxygen delivery to the brain. Without direct measurement of changes in cerebral blood flow (rCBF) and cerebral metabolic rate of oxygen consumption (rCMRO2), it is impossible to predict oxygen extraction fraction (rOEF). A continuous measurement of rOEF would allow assessment of intraoperative autoregulation. Lack of autoregulation has been associated with paradoxical uncoupling of CBF from CMRO2 leading to either luxury or misery perfusion with the risk of hyperemia or ischemia, respectively. A recently developed Noninvasive Neurometabolic Optical Monitoring (NNOM) (Arjun Yodh et al, USPatent 8082015), provides continuous measurement of rCBF, rCMRO2, and rOEF by a scalp near-infrared light optode patch and Diffuse Correlation Spectroscopy and Diffuse Optical Spectroscopy.1,2We aimed to determine the feasibility of using NNOM in older patients under general and regional anesthesia to determine rOEF variability and the presence of misery or luxury perfusion. Methods: Prospective study of NNOM in 4 elderly patients undergoing total hip arthroplasty (1 general, 3 spinal anesthetics). Data were collected at t=0 (2 to 3 min awake before anesthesia) until emergence. Changes of rCBF, rOEF, and rCMRO2 were continuously recorded from baseline with each patient serving as their own control. OEF was calculated as 1-ScO2 and CMRO2 as CBFxOEF. Misery perfusion was defined as >10% increase in OEF (rOEF>1.1). Luxury perfusion was defined as >10% decrease (rOEF<0.9). Intact CBF autoregulation occurred when rOEF remained constant during perturbations in rCBF or rCMRO2. Results: Monitoring was feasible in all subjects. All monitored cases showed periods of loss of autoregulation leading to changes in rOEF. Figure 1 shows an example of the intraoperative NNOM. Misery perfusion occurred in 1 subject for 33 minutes. Luxury perfusion occurred in 3 subjects, ranging from 17 to 59 minutes. Periods of intact autoregulation during 10% or greater changes in rCBF or rCMRO2 occurred in all subjects (Fig. 2). Conclusions: Intraoperative noninvasive monitoring of rOEF and rCBF is feasible during both general and spinal anesthesia. Episodes of luxury and misery perfusion were recorded in all patients suggesting alteration of cerebral autoregulation. Future directions of intraoperative NNOM will be to correlate rOEF patterns with perioperative cognitive disturbances and continuously assess neuropharmacological effects of anesthetics and vasoactive drugs. (Figure Presented) . Database: EMBASE

111. Case series: A novel approach to maintaining normothermia in major spinal deformity surgery Author(s): Mazal A.; Davenport O.; Davies M.; Bagley C.; McDonagh D. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 430 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Maintenance of intraoperative normothermia is of paramount importance during major spine deformity cases. Intraoperative hypothermia can lead to coagulopathy and may contribute to perioperative morbidity and mortality by increasing the risk of postoperative shivering, cardiac events, and surgical site infections. Heat loss occurs during major spine cases due to large body surface exposure to ambient temperatures. During these cases only the upper and lower extremities and head can be covered with an external warming device and actively warmed. We explored the feasibility of using a novel esophageal warming device (EWD) in 3 patients undergoing major spinal deformity surgery. Methods: After induction of general anesthesia and endotracheal intubation, the EWD was lubricated and inserted into the esophagus (Fig. 1). The EWD is composed of a nonpermeable, silicone triple lumen system consisting of a fluid intake lumen, fluid return/output lumen, and separate central orogastric tube (for suction of gastric secretions). The device transfers heat to the body from the esophagus to closely apposed vascular structures such as the vena cava, aorta, and left atrium. The device is connected to a Norm-O-Temp fluid warmer (Cincinnati Sub-Zero, Cincinnati, OH) and run at 42degreeC throughout the case. Core temperature is monitored with a bladder probe (embedded in a urinary catheter). A lower body forced air warmer and IV fluid warmer were also used to avoid hypothermia. Results: Case 1: patient is a 71-year-old female who presented to neurosurgical attention secondary to a severe lumbar scoliotic deformity with associated progressive low back and leg pain. T6-S1 fusion and L2-L3 laminectomies were performed with no significant intraoperative or postoperative complications. Intraoperative temperature was maintained between 35.5 and 35.8degreeC. Case 2: patient is a 77-year-old female who presented to neurosurgical attention for correction of a flat back deformity with associated low back pain and postural difficulties. Fusion from T10-pelvis, with pedicle screw fixation, and L3 pedicle subtraction osteotomy was performed without complication. Intraoperative temperature range was maintained between 36.7 and 36.9degreeC. Case 3: patient is a 77-year-old female who presented to neurosurgical attention for correction of a lumbar scoliotic deformity with associated severe L2-L4 stenosis and progressive low back and leg pain. Fusion from T10-pelvis with pedicle screw fixation, L3-L4 laminectomies, and L5-S1 transforaminal interbody fusion were performed without complication. Intraoperative temperature range was maintained between 35.4-36.2degreeC. Conclusions: Patient warming with an EWD is feasible in major spine deformity surgery. Internal warming is a novel approach that will need to be formally tested against other methods of intraoperative temperature control. (Figure Presented) . Database: EMBASE

112. Delivering anesthesia for emergent neurosurgery in the parturient Author(s): Saasouh W.; Mathews L.; Rajan S. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 462 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: A parturient admitted for neurosurgery presents a unique set of challenges. Such scenarios are likely under-documented leading to a lack of practice guidelines for the proper anesthetic care. We present 3 such cases and the decision-making process involved in each. Description of cases: Case 1: A-37-year-old primigravida at 26 WGA presented with a symptomatic AVM and scheduled for emergent delivery followed by embolization. The patient was premedicated with sodium citrate, metoclopramide, and metoprolol, and an arterial line and external subdural bolt were placed under mild sedation. Rapid-sequence induction of general anesthesia was performed (fentanyl, lidocaine, propofol, succinylcholine, esmolol) and anesthesia was maintained with propofol and sevoflurane (< 0.5 MAC). C-section was performed without complications and patient was extubated uneventfully. Angiography and embolization were carried the next day under general anesthesia (rapidsequence induction) which was maintained with sevoflurane, remifentanil, and rocuronium without any untoward events. Case 2: A 21-year-old G1P0 at 19 WGA presented with a symptomatic large CPA mass. Decision was to hold surgery until 24 WGA but she presented at 23 WGA with severe nausea and vomiting and was admitted to the NICU where an EVD was placed and high-risk obstetrics were consulted. Rapid sequence induction (propofol, rocuronium, fentanyl) was performed and FHR monitoring was performed throughout the case. Anesthesia was maintained with sevoflurane (0.5 MAC), propofol, and dexmedetomidine with phenylephrine for hemodynamic support. EVD was used for intermittent CSF drainage and mannitol and dexamethasone were administered after induction. Tumor resection was performed in the park bench position and lasted 14 hours after which patient was transferred to the NICU under sedation to be extubated the next morning. FHR remained normal throughout the procedure. Case 3: A 37-year-old G4P3 with history of opioid dependence on suboxone presented at 32 WGA with basal ganglia hemorrhage and HELLP syndrome. She was admitted to NICU where FHR monitoring showed fetal bradycardia necessitating emergent C-section. Anesthesia was maintained with propofol and remifentanil and she received mannitol and hypertonic saline to treat intracranial hypertension. A nicardipine infusion was used to maintain blood pressure <140mmHg. Delivery was completed with minimal neonatal support. Her postoperative course was complicated with prolonged ventilation, HELLP, cerebral edema, and required tracheostomy and gastrostomy placement. Discussion: Multiple dilemmas are presented in the parturient undergoing emergent neurosurgery. Care must be taken to manage the pregnancy, delivery (if any), as well as the complex neurological status. The choice of delivering a premature baby must be weighed against the risks of performing the neurological intervention without delivery. Safe administration of anesthesia is paramount to the health and wellness of parturient and neonate alike. A multidisciplinary approach is ideally performed at a health care facility capable of managing potential complications. Database: EMBASE

113. Spontaneous oscillation in brain electroencephalography, hemodynamics and metabolism: An opportunity to evaluate neurovascular coupling? Author(s): Highton D.; Phan P.; Elwell C.; Smith M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 398-399 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Neurovascular coupling (NC) matches cerebral oxygen delivery to demand in response to changes in neuronal activity. In health this is observed as task evoked functional hyperemia. Impaired NC is implicated in cerebral energy failure following acute brain injury (ABI), but its evaluation using functional activation experimental paradigms is not feasible in unconscious patients. Spontaneous oscillations which might reflect NC are observed in neuromonitoring modalities, including electroencephalography (EEG), and near infrared spectroscopy (NIRS) derived cerebral haemoglobin oxygenation and cytochrome c oxidase. Considerable interest surrounds the physiological origins of these oscillations because they might associate the hemodynamic and metabolic response of the brain to energy demand.1 We hypothesize that slow EEG oscillations (representing neuronal activity) are associated with NIRSderived hemodynamic signals (oxy/deoxyhemoglobin) and mitochondrial oxidation (cytochrome c oxidase) following ABI. Methods: We investigated 20 patients with ABI following ethics approval and representative consent. Frontal multimodal neuromonitoring included: EEG (BIS-X, Philips) and a broadband NIRS system optimized for the monitoring of oxy/deoxy-hemoglobin and cytochrome c oxidase in adults.2 The wavelet transform was used to extract a continuous time series for EEG beta wave power and this was compared with several NIRS-derived variables using wavelet coherence as previously described.3 These were cerebral tissue oxygenation index (oxyhemoglobin/total hemoglobin), Hbdiff (oxyhemoglobin-deoxyhemoglobin), a marker of oxygen delivery, and cytochrome c oxidase oxidation (oxCCO). Results: Figure 1A demonstrates significant coherence between NIRS and EEG beta power within the slow wave band 0.1 to 0.01 Hz. Two individual patient examples demonstrate variation in this relationship: a normal haemodynamic response to increased EEG power (Fig. 1B), and inversion of the normal response characterized by a fall in cerebral oxygen delivery associated with increased EEG activity (Fig. 1C). Conclusions: We have demonstrated an association between EEG and NIRS hemodynamic and metabolic oscillations which is consistent with NC: neuronal activity (EEG) is significantly correlated to a hemodynamic and metabolic response function (NIRS). Individual patient datasets reveal variation in this response function including a normal response (functional hyperemia) and inverted response consistent with known pathophysiology following ABI. Although further work is required to correlate these changes with cerebral energy failure, the combination of EEG and NIRS may have unique potential as a noninvasive bedside marker of NC following ABI. Database: EMBASE

114. Loss of motor evoked potentials before posterior cervical fusion and return with subtle head manipulation Author(s): Kramer D.; Ferastraoaru V.; Zhang L.; Legatt A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 397-398 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:A 77-year-old woman with cervical spondylosis and previous ACDF at C3-C5 presents with severe right arm and hand weakness and bilateral leg weakness. GA was induced and intubation was easily achieved with #3 Glidecope, keeping the head in neutral position. The patient was maintained initially on desflurane and converted to TIVA. Mean arterial pressure was maintained at 80mmHg. SEPs, motor evoked potential (MEPs), TOF, and EMG were utilized. SEPs were recorded following stimulation of either posterior tibial nerve and of the right ulnar nerve; and remained stabler during the operation. SEPs to left ulnar nerve stimulation were intermittently identifiable and thus were not adequate for intraoperative monitoring. MEPs were initially present in the left deltoid, biceps and EDC muscles and small MEPs were present in the right deltoid and EDC muscles. There were no monitorableMEPs in the right biceps muscle or in either APB muscle. Twenty minutes after induction, with the patient supine, end tidal desflurane at 0%, mean arterial pressure was 80mmHg, and TOF 4/4 twitches, the MEPs that had been present in arm muscles disappeared bilaterally and were reproducibly absent (Fig. 1). There was no indentifiable technical cause of the change; no anesthetic boluses, inhalational agents, or additional paralytic drugs had been given. The anesthesiologist gently lifted the patient's occiput resulting in 1/2 inch of elevation. Immediate return of the MEPs (Fig. 1) with the recovery to amplitudes that was comparable to baseline. A wake-up test was performed. TIVA was reinduced. MEPs were still present on the left and small MEPs were present in the right deltoid and EDC muscles, and did not change with prone positioning. The patient underwent decompression at C3-C6 and fusion at C2-T2. MEPs that were monitorable at baseline levels with no significant changes. At the end of procedure, the patient was extubated. Her arm and hand strength was markedly improved from her preoperative examination. Discussion: In a patient with severe cord compression, small alterations in the positioning of the head and neck can cause compromise. MEP loss in our patient's arms was most likely due to small alterations in her neck position. This is confirmed by reappearance of the MEPs following small readjustment of the head. If MEPs are suddenly lost in a patient with spinal compression, gentle adjustment of the patient's head may be performed to relieve increased cord compression.3 MEP monitoring should be initiated early and recorded frequently. This case illustrates that cooperative interaction between neuromonitoring, anesthesiologists, and surgeons, with rapid intervention in the event of loss of neuromonitoring signals, can result in excellent neurological outcome.4 (Table Presented) . Database: EMBASE

115. Anesthetic management of awake craniotomy under intraoperative MRI versus traditional operating room setup Author(s): Saasouh W.; Ahuja S.; Lee B.; Avitsian R.; Rajan S. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 461 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Intraoperative MRI (IMRI) has been gaining popularity for more precise tumor resection and decreased residual tumor. The anesthetic management of a patient in the IMRI suite presents a particular set of challenges that require appropriate preparation. Here we compare the use of IMRI to routine operating room procedures in terms of anesthetic management. This is an ongoing analysis and the data shall be available before abstract presentation. Methods: After Institutional Review Board (IRB) approval data from the medical records of all Cleveland Clinic adult patients who underwent awake craniotomy under IMRI (December 2012 to December 2016) was reviewed. These patients were paired with non-IMRI awake craniotomy procedures in an observational cohort. The aim was to highlight the main differences in anesthetic management such as airway management, anesthetic medications, and intraoperative seizures. Results: Most patients in the cohort received propofol with or without dexmedetomidine for maintenance of anesthesia. Airway management differed in that patients in the IMRI suite had an LMA in most of the cases. Intraoperative airway interventions were limited in the IMRI suite owing to the bulky head gear patients had to have. The management of intraoperative seizures was especially challenging in the IMRI suite due to limitations in allowed equipment. The cases were generally similar in terms of hemodynamics and postoperative recovery. Further numerical details to follow. Conclusions: Intraoperative MRI adds a layer of complexity to an already demanding anesthetic management in awake craniotomy. We present our observational data comparing the anesthetic management of patients in the IMRI suite versus a traditional operating room setup. The data will be updated as it becomes available prior to the date of abstract presentation as this is an ongoing analysis. Database: EMBASE

116. Descriptive analysis of quality improvement reporting patterns in neuroanesthesia Author(s): Slade I.; Yang J.; Boggia S.; Sharma D.; Brown M. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 428 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: This project describes quality improvement (QI) reporting patterns in neuroanesthesia cases at a single academic institution with 2 major hospital-based practice sites. Categorizing reported event types by major domains provides hospital-specific data to prioritize future QI initiatives tied to these domains. Methods: This is a retrospective, descriptive analysis of QI reports from the institutional anesthesiology QI databases for neuroanesthesia cases conducted from 2013 to 2017. Neuroanesthesia cases included craniotomies of all types, neuroradiology, and neurosurgeon-performed spine surgery. Cases were identified in each hospital's QI database based on keywords and manual review. This subset of cases had further manual review to categorize event reports into domains, defined by the QI team, based on primary event characteristics. Each domain was summarized proportionally to the total reported neuroanesthesia QI events and the total neuroanesthesia cases at the respective hospitals. Results: For the 2013 to 2017 review period, at hospital A, there were 3870 neuroanesthesia cases and 152 QI events reported (3.9% of all neuroanesthesia cases). At hospital B, there were 10,878 neuroanesthesia cases and 280 QI events reported (2.6% of cases). The top 5 event domains reported at hospital A were drug error (27 events, 17.8% of all QI reports), communication/ documentation (18 events, 11.8%), vascular catheter dislodgement (15 events, 9.9%), skin injury (15 events, 9.9%), and equipment/device failure (12 events, 7.9%). The top 5 event domains reported at hospital B were communication/ documentation (93 events, 33% of all QI reports), equipment/ device failure (39 events, 13.9%), vascular catheter dislodgement (28 events, 10%), drug error (17 events, 6.1%), and skin injury (17 events, 6.1%). Each hospital's primary QI event domain was further subcategorized. At hospital A, the primary domain of drug errors included drug not given/not infusing (12 events, 7.9% of QI reports), wrong dose (6 events, 3.7%), incorrect infusion duration (3 events, 1.9%), unintentional administration (3 events, 1.9%), wrong route (2 events, 1.2%), and drug stocking error (1 event, 0.6%). At hospital B, the primary domain of communication/documentation issues included preoperative or postoperative handoffs (34 events, 12.1%), transfusion- related (24 events, 8.6%), documentation (17 events, 6.1%), intraoperative communication (6 events, 2.1%), and patient placement/bed availability (6 events, 2.1%). Discussion: This is the first neuroanesthesia-specific QI event analysis in this academic institution. There are no known similar analyses reported in the neuroanesthesia literature. Although the QI event databases are subject to reporting bias, the events reported are likely reflective of issues that providers thought were of sufficient significance to voluntarily submit in the interest of system improvement and patient safety. Therefore, despite this inherent bias, the information learned can reflect hospitalspecific needs to help inform and prioritize quality domains for future QI interventions at the respective hospitals. Postintervention analysis of subsequent QI data may provide a mechanism for ongoing monitoring of effectiveness of such initiatives over time. Database: EMBASE

117. Unilateral, lower extremity loss of somatosensory evoked potential in a patient undergoing general anesthesia for spine surgery Author(s): George A.; Koht A.; Bebawy J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 395-396 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:A 67-year-old female patient was undergoing a staged procedure for correction of scoliosis with an anterior lumbar interbody fusion (ALIF) at the levels L5-S1, followed by a posterior spinal fusion (PSF) of T10 to ileum. The ALIF was uneventful and 2 days later the patient was under general anesthesia for the PSF surgery with an IV infusion of Propofol (40 mug/kg/min) and Sufentanil (0.3 mug/kg/h) and inhalational Sevoflurane to maintain half or less MAC of anesthesia. Neuromonitoring was done throughout the surgery measuring motor evoked potentials (MEP), somatosensory evoked potentials (SSEP) and EMG's. Following rod placement and pulse lavage of the surgical site, a complete loss of the SSEP's from the right posterior tibial nerve was noted. The SSEP's from bilateral upper extremities, and the left lower extremity in addition to the MEP's from all extremities remained at baseline. We systematically excluded technical error, limb compression, perfusion, anesthetic and surgical causes. Mean arterial pressure (MAP) was raised to 90mmHg and surgery was stopped for about 45 minutes to resolve the situation but without success, at which point a senior anesthesiologist was consulted. Taking into consideration the sequence of events and proximity in time from the pulse lavage to complete loss of signal (7 min) we presumed the probable cause of the SSEP loss would be local irritation leading to vasospasm from the pulse lavage. A warm saline irrigation was started and the MAP's were further raised to around 105mmHg. Seven minutes after warm saline irrigation and increasing the MAP, signs of reproducible SSEP recovery was noted and it completely recovered to baseline within 30 minutes. (Figure Presented) . Database: EMBASE

118. Attainment of neuromonitoring signals using long subdermal needle electrodes in a morbidly obese patient Author(s): Mirkin E.; Koht A. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 395 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Somatosenory evoked potential (SSEP) and motor evoked potential (MEP) monitoring are commonly used techniques in neurosurgery to detect central and peripheral nerve dysfunction.1 SSEPs directly monitor the dorsal column-medial meniscus pathway, and are usually elicited by stimulation of a peripheral nerve at a distal site.2 These sites typically involve the median or ulnar nerves at the wrist for upper extremities, and the posterior tibial or peroneal nerves in the lower extremities. Bar electrodes, EEG metal disc electrodes, adhesive surface electrodes, and subdermal needle electrodes can be used for SSEP monitoring.MEPs monitor the corticospinal tract and can be obtained via transcranial electrical stimulation to the scalp utilizing needle electrodes or by magnetic stimulation. Neuromonitoring is dependent on these electrodes being secured in place. Case Presentation: A 63-year-old male with a history of metastatic prostate cancer of C2 causing subluxation of C1-C2 and occiput cervical instability, cervical spondylosis from C2-C6, moderate central stenosis from C3-C6, and right foraminal stenosis at C4-C5 presented for an occiput to T2 posterior spinal fusion, C2-C6 decompression, and right C4-C5 foraminotomy. The patient's comorbidities included morbid obesity (BMI: 48, 179 kg), obstructive sleep apnea, knee arthritis, and urinary incontinence. The prostate cancer was initially treated with chemical castration, seeding, and maintained on a nonsteroidal antiandrogen, enzulutamide. The patient's airway was graded as a Mallampati IV. He had significantly limited neck movement and a TMD of 4 cm. He was intubated uneventfully via an awake nasal fiberoptic technique using a low dose IV remifentanil infusion. Lines were placed, and anesthesia was maintained via TIVA using remifentanil, propofol, and ketamine infusions. Standard 13mm long subdermal electrodes (Rhythm link) for neuromonitoring were placed. SSEPs and MEPs were obtained in the upper extremities, and MEPs were present in the lower extremities. However, no SSEPs could be acquired in the lower extremities. The needles were repositioned multiple times and replaced with a new set of electrodes, but SSEPs remained undetectable in the lower extremities. When the subdermal needles were applied to the lower extremities, edematous fluid was noted after puncture sites in the ankles rather than blood. Longer subdermal needles of 5 cm length (Ambu Neuroline Monopolar) were then placed in the lower extremities, and SSEPs were finally elicited. The case proceeded with 2 surgeons due to the patient's difficulty anatomy. No adverse intraoperative events occurred. The patient was extubated and transferred to the NSICU for postoperative monitoring. Discussion: This case highlights how subdermal needle length was key in SSEP signal capture in a morbidly obese patient. Edema versus expected blood was observed at the puncture sites in the lower extremities when the shorter needles were applied. This alerted us that the absence of SSEPs could be due to distance from the nerve or electrical shunting. Database: EMBASE

119. Intraoperative pulmonary embolism during craniotomy: A case report Author(s): Joseph K.; Uejima J. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 460 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: Acute intraoperative pulmonary embolism (PE) is a serious, yet rare, life- threatening event that requires swift diagnosis and intervention. Rudolf Virchow first described his famous triad of risk factors for venous thromboembolism (VTE) >100 years ago and it remains relevant today: venous stasis, endothelial damage, and hypercoagulable state.1 Further, there is up to a 5-fold increase in the incidence of PE in the perioperative period.1 We present a case of intraoperative pulmonary embolism in a patient with known risk factors while undergoing craniotomy for tumor resection for recurrent malignancy. Case Presentation: A 52-year-old male with a history of recurrent glioblastoma multiforme (GBM) status post prior resection, chemotherapy, and radiation, GERD, HTN, and obesity presented for tumor resection. Per clinical trial, patient could not receive any medications that affected CYP3A4. Twenty minutes after induction, patient started to display hemodynamic instability and had hypoxemic episodes that responded, initially, to recruitment breath maneuvers. At that time, a baseline ABG was drawn that revealed a large PaCO2 end-tidal CO2 gradient, which raised suspicion for an acute pulmonary embolus. Shortly thereafter, hemodynamic instability ensued, and patient was up-titrated on vasopressors: phenylephrine, then norepinephrine and epinephrine. Surgery was aborted before entering the cranial vault, and interventional radiology (IR) was contacted. Patient was transported to IR for catheterization of pulmonary arteries and was found to have massive bilateral pulmonary embolisms and subsequently systemically heparinized. Infusion catheters were placed in bilateral arteries, and tPa boluses were started for clot lysis. After boluses, patient regained some hemodynamic stability, but remained on high-dose vasopressor infusions. Bilateral infusion catheters were left in place, patient was transported to neurosurgical ICU on norepinephrine, epinephrine, and vasopressin infusions, and nitric oxide was started. Overnight, patient was weaned off norepinephrine, and oxygenation and ventilation improved. He remained on nitric oxide and catheter-directed thrombolysis. Despite cardiopulmonary improvement, patient's family elected to withdraw care given his poor prognosis with or without tumor resection. Discussion: An increase in alveolar dead space is associated with pulmonary thromboembolism with high sensitivity and specificity in surgical patients,1 in addition to cardiopulmonary compromise. Studies have shown a statistically significant reduction in mortality in patients with major PE who received directed thrombolysis compared with systemic heparin alone.1 Regardless of intervention, mortality in hemodynamically unstable patients with PE remains as high as 30%.2. Database: EMBASE

120. Protocolized perioperative care for complex spine surgeries and the resulting reduction in ICU/hospital length of stay Author(s): Ayrian E.; Tran T.; Laney J.; Roffey P.; Sugeir S.; Hsieh P.; Liu J.; Varner C.; Arnaudov D.; Arakelyan A.; Zelman V. Source: Journal of Neurosurgical Anesthesiology; Oct 2018; vol. 30 (no. 4); p. 428 Publication Date: Oct 2018 Publication Type(s): Conference Abstract Abstract:Background: In April 2015, we implemented a new perioperative protocol for patients undergoing complicated spinal procedures. The implementation of our protocol involved the combined efforts of providers in the Anesthesiology/Neurosurgery/Orthopedic spine/ICU departments. Biweekly preoperative meetings amongst providers were established to discuss high risk cases and plan of care; the preoperative and intraoperative management of the protocol then ensued. Immediately proceeding the procedures, patients were transferred to the ICU and intensivists continued to implement a protocolized postoperative management strategy. As the implementation of our new perioperative protocol we have observed the reduction in both ICU and hospital length of stay (LOS), in addition to a decrease in postoperative complications. Methods: Patients that were selected for the study included those who were scheduled for complicated spine surgeries, which we defined as including any one of the following criteria: surgery involving >6 levels, surgical timeline >6 hours, predicted blood loss >2 L, combined anterior and posterior approach, staged procedure, classified as high risk by the spine surgeon, patients with significant comorbidities and are of advanced age. Preoperative strategies involved outpatient clinic assessments from both anesthesiolgists and surgeons, as well as any necessary consultants, to establish thorough optimization. Providers convened preoperatively at conference to discuss upcoming cases and strategies/goals of care. Intraoperative management aimed at emphasizing frequent communication between anesthetic and surgical providers, in conjunction with strict monitoring, hemodynamic and resuscitation strategies. Standardized handoff between anesthetic/surgical staff and ICU providers was enforced postoperatively. Neuro ICU providers abided by structured resuscitation and weaning strategies. Results: A total of 201 cases were reviewed. A total of 94 cases were treated under the new complex spine surgery protocol, while 107 cases were treated under the old protocol. The mean ICU LOS for patients cared for under the old and new protocol decreased from 6.3 to 4.2 days, respectively (P=0.011). The mean hospital LOS for patients treated under the old and new protocol decreased from 14.8 to 10.0 days, respectively (P<0.001). Postoperative complicaitons decreased with patients treated under the new protocol as well, from 0.7 to 0.4 (P=0.187). This analysis was completed under the exclusion of one of the patients after protocol implementation, who developed an unusual complication of pseudomonas aspiration pneumonia and was held in ICU for 56 days and in the hospital for 85 days, the mean length of ICU stay after implementing the protocol decreased from 7.58 to 5.03 with an 85% confidence level. Conclusions: Protocolized perioperative care pathways, with emphasis on multidisciplinary care and efficatious communication strategies, safely and effectively enhance patient recovery in complex spine surgeries. The implementation of our protocol led to significant reductions in ICU LOS and hospital LOS, along with decreased postoperative complications. Database: EMBASE

121. Bias in before?after studies: Narrative overview for anesthesiologists Author(s): Ho A.M.H.; Phelan R.; Mizubuti G.B.; Murdoch J.A.C.; Shyam V.; Gilron I.; Wickett S.; Ho A.K. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1755-1762 Publication Date: May 2018 Publication Type(s): Review Abstract:Before-after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before- after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test-retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before-after studies. (Anesth Analg 2018;126:1755-62.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

122. American college of surgeons children's surgery verification quality improvement program: What anesthesiologists need to know now Author(s): Houck C.S.; Deshpande J.K.; Flick R.P.; Peterson M.B. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1624-1632 Publication Date: May 2018 Publication Type(s): Article Abstract:A task force of pediatric surgical specialists with the support of The American College of Surgeons recently launched a verification program for pediatric surgery, the Children's Surgery Verification quality improvement program, with the goal of improving pediatric surgical, procedural, and perioperative care. Included in this program are specific standards for the delivery of pediatric anesthesia care across a variety of practice settings. We review the background, available evidence, requirements for verification, and verification process and its implications for the practice of pediatric anesthesia across the country. In addition, we have included a special roundtable interview of 3 recently Children's Surgery Verification-verified program directors to provide an up-to-date real- world perspective of this children's surgery quality improvement program. (Anesth Analg 2018;126:1624-32.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

123. Occupational and ergonomic factors associated with low back pain among car-patrol police officers Author(s): Benyamina Douma N.; Cote C.; Lacasse A. Source: Clinical Journal of Pain; Oct 2018; vol. 34 (no. 10); p. 960-966 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: Low back pain (LBP) is frequent and burdensome among police officers, but occupational and ergonomic factors associated with LBP and its chronic symptoms have never been studied among these workers using a biopsychosocial model. This study aimed at exploring such factors associated with acute or subacute LBP and chronic low back pain (CLBP) among car-patrol police officers. Methods: A web-based cross-sectional study was conducted among car-patrol officers working in the province of Quebec (Canada). Factors associated with acute or subacute LBP and CLBP (as opposed to absence of LBP) were studied using a multivariate multinomial regression model. Results: A total of 2208 car-patrol officers composed the study population. Statistically significant occupational/ergonomic determinant for higher prevalence of acute or subacute LBP was more frequent discomfort in the lower back when sitting in the patrol car as a driver (adjusted odds ratio [OR], 3.008; 95% confidence interval [CI], 2.170-4.168). More frequent posttraumatic interventions was associated with lower prevalence of acute or subacute LBP (adjusted OR, 0.609; 95% CI, 0.410-0.907). Occupational and ergonomic factors associated with higher prevalence of CLBP were greater seniority (adjusted OR, 1.061; 95% CI, 1.007-1.118) and more frequent discomfort in the lower back when sitting in the patrol car as a driver (adjusted OR, 7.546; 95% CI, 5.257-10.831). Discussion: Few occupational and ergonomic factors that police organizations could use to better tailor prevention were found to be associated with acute or subacute LBP and CLBP. This cross- sectional study is an efficient first investigation for screening hypotheses that should be confirmed in further cohort studies. ©Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

124. Association between the 2011 Fibromyalgia Survey Criteria and Multisite Pain Sensitivity in Knee Osteoarthritis Author(s): Neville S.J.; Clauw A.D.; Moser S.E.; Clauw D.J.; Brummett C.M.; Harte S.E.; Urquhart A.G. Source: Clinical Journal of Pain; Oct 2018; vol. 34 (no. 10); p. 909-917 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: The present study evaluated the relationship between the 2011 American College of Rheumatology fibromyalgia (FM) survey criteria and quantitative sensory testing (QST). Materials and Methods: Patients with knee osteoarthritis scheduled to undergo knee arthroplasty completed the FM survey criteria and self-report measures assessing clinical symptoms. Patients also underwent a battery of QST procedures at the surgical knee and remote body sites, including pressure algometry, conditioned pain modulation, and temporal summation. All assessments were completed before surgery. FM survey criteria were used to calculate a continuous FM score indicating FM severity. Results: A total of 129 patients were analyzed. Of these, 52.7% were female, 93.8% were Caucasian, and 3.8% met the FM survey criteria for FM classification. Mean age for females (63.6 y) and males (64.7 y) was similar. Females and males differed significantly in nearly every outcome, including FM severity, clinical pain, anxiety, depression, and pressure pain sensitivity. In females, FM scores significantly correlated with pressure pain sensitivity, but not conditioned pain modulation or temporal summation, such that increased sensitivity was associated with greater FM severity at all body sites examined. In addition, as FM scores increased, the association between pain sensitivity at the surgical knee and pain sensitivity at remote body sites also increased. No relationship between FM score and QST was observed in males. Discussion: We demonstrated an association between diffuse hyperalgesia as measured by QST and FM severity in females with knee osteoarthritis. These results suggest that the FM survey criteria may represent a marker of pain centralization in females with potential utility in clinical decision making. ©Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

125. Back to living: Long-term functional status of pediatric patients who completed intensive interdisciplinary pain treatment Author(s): Randall E.T.; Smith K.R.; Conroy C.; Smith A.M.; Sethna N.; Logan D.E. Source: Clinical Journal of Pain; Oct 2018; vol. 34 (no. 10); p. 890-899 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: To provide a descriptive account of long-term functioning (>=5 y posttreatment) among youth who completed intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain conditions. Materials and Methods: A total of 95 patients (mean age at follow- up=20.0 y) treated at least 5 years previously at a single IIPT program completed questionnaires assessing pain, functional disability, health care utilization, academic/career achievement, and quality of life. Data analyses focused on pain, functioning, and progress toward developmental goals at long-term follow-up. Results: The majority of respondents report significant reduction in pain compared with preadmission (P<0.001). Five years posttreatment, average functional disability scores were in the minimal range, with statistically significant decrease in functional disability from time of admission (P<0.001). Nearly 80% of respondents characterized themselves as having no functional difficulties at follow-up. Clinically significant improvement was established for both pain and function. Respondents generally reported developmentally appropriate status, with 89% graduating high school on schedule. Discussion: Results show long-term positive functioning among individuals who underwent intensive rehabilitation treatment for chronic pain as children or adolescents. Despite experiencing one or more pain flares at some point after treatment, most former IIPT patients report minimal to no ongoing functional disability, complete or partial resolution of pain symptoms, and developmentally appropriate progress toward goals (eg, school completion, independent living). ©Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

126. Effect of stellate ganglion block on the regional hemodynamics of the upper extremity: A randomized controlled trial Author(s): Kim M.K.; Yi M.S.; Park P.G.; Kang H.; Shin H.Y.; Lee J.S. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1705-1711 Publication Date: May 2018 Publication Type(s): Article Abstract:BACKGROUND: The success of stellate ganglion block (SGB) is traditionally determined on the basis of findings such as Horner's syndrome, temperature rise in the face, hyperemia of the tympanic membrane, and nasal congestion. However, decreases in vascular resistance and increases in blood flow in the arm may be more meaningful findings. To date, the effect of SGB on the regional hemodynamics of the arm has not been evaluated using pulsed-wave Doppler ultrasound. METHODS: A total of 52 patients who were to undergo orthopedic surgery of the forearm were randomly assigned to either the mepivacaine group (SGB with 5 mL of 0.5% mepivacaine) or the saline group (SGB with 5 mL of normal saline). Before surgery, a single anesthesiologist performed a SGB under ultrasound guidance. The temperature of the upper extremity and the resistance index and blood flow in the brachial artery were measured before SGB, 15 and 30 minutes after SGB, and 1 hour after surgery. The severity of pain, requirement for rescue analgesics, and side effects of the local anesthetic agent were all documented. RESULTS: After SGB, the resistance index decreased significantly and the blood flow increased significantly in the brachial artery of members of the mepivacaine group (15 minutes: P = .004 and P < .001, respectively; 30 minutes: P < .001 and P < .001, respectively). However, these values normalized after surgery. The severity of pain, need for rescue analgesics, and incidence of adverse effects were not significantly different between the 2 groups. CONCLUSIONS: Although SGB did not decrease the pain associated with forearm surgery, ultrasound-guided SGB did increase blood flow and decrease vascular resistance in the arm. Therefore, pulsed-wave Doppler may be used to monitor the success of SGB. (Anesth Analg 2018;126:1705-11.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

127. Peripheral nerve blocks for hip fractures: A cochrane review Author(s): Guay J.; Parker M.J.; Griffiths R.; Kopp S.L. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1695-1704 Publication Date: May 2018 Publication Type(s): Review Abstract:BACKGROUND: This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic. METHODS: Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale. RESULTS: Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, -1.41 (95% confidence interval [CI], - 2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I2 statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used (P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38-1.27; I2 statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19-0.89; I2 statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 [95% CI, 5-72]; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, -11.25 hours (95% CI, -14.34 to -8.15 hours; I2 statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, -3.48 (95% CI, -4.23 to -2.74; moderate quality of evidence). CONCLUSIONS: There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks). (Anesth Analg 2018;126:1695- 704.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

128. Teaching medical students clinical anesthesia Author(s): Curry S.E. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1687-1694 Publication Date: May 2018 Publication Type(s): Article Abstract:There are many reasons for evaluating our approach and improving our teaching of America's future doctors, whether they become anesthesiologists (recruitment) or participate in patient management in the perioperative period (general patient care). Teaching medical students the seminal aspects of any medical specialty is a continual challenge. Although no definitive curricula or single clinical approach has been defined, certain key features can be ascertained from clinical experience and the literature. A survey was conducted among US anesthesiology teaching programs regarding the teaching content and approaches currently used to teach US medical students clinical anesthesia. Using the Accreditation Council for Graduate Medical Education website that lists 133 accredited anesthesiology programs, residency directors were contacted via e-mail. Based on those responses and follow-up phone calls, teaching representatives from 125 anesthesiology departments were identified and asked via e-mail to complete a survey. The survey was returned by 85 programs, yielding a response rate of 68% of individuals contacted and 63% of all departments. Ninety-one percent of the responding departments teach medical students, most in the final 2 years of medical school. Medical student exposure to clinical anesthesia occurred as elective only at 42% of the institutions, was requirement only at 16% of responding institutions, and the remainder had both elective and required courses. Anesthesiology faculty at 43% of the responding institutions reported teaching in the preclinical years of medical school, primarily in the departments of pharmacology and physiology. Forty-five percent of programs reported interdisciplinary teaching with other departments teaching classes such as gross anatomy. There is little exposure of anesthesiology faculty to medical students in other general courses. Teaching in the operating room is the primary teaching method in the clinical years. Students are allowed full access to patient care, including performing history and physical examinations, participating in the insertion of IVs and airway management. Simulation-based teaching was used by 82% of programs during medical student anesthesia clerkships. Sixty-eight percent of respondents reported that they have no formal training for their anesthesiology faculty teachers, 51% stated that they do not receive nonclinical time to teach, and 38% of respondents stated that they received some form of remuneration for teaching medical students, primarily nonclinical time. This article presents a summary of these survey results, provides a historical review of previous evaluations of teaching medical students clinical anesthesia, and discusses the contributions of anesthesiologists to medical student education. (Anesth Analg 2018;126:1687-94.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

129. Delineating the trajectory of cognitive recovery from general anesthesia in older adults: Design and rationale of the TORIE (Trajectory of recovery in the elderly) project Author(s): Mincer J.S.; Sano M.; Baxter M.G.; Deiner S.G.; Sewell M.C.; Kundu P.; Tang C.Y.; Allore H.G.; Delman B.N.; McCormick P.J.; Schwartz A.E.; Brallier J.W.; Sanchez A. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1675-1683 Publication Date: May 2018 Publication Type(s): Article Abstract:BACKGROUND: Mechanistic aspects of cognitive recovery after anesthesia and surgery are not yet well characterized, but may be vital to distinguishing the contributions of anesthesia and surgery in cognitive complications common in the elderly such as delirium and postoperative cognitive dysfunction. This article describes the aims and methodological approach to the ongoing study, Trajectory of Recovery in the Elderly (TORIE), which focuses on the trajectory of cognitive recovery from general anesthesia. METHODS: The study design employs cognitive testing coupled with neuroimaging techniques such as functional magnetic resonance imaging, diffusion tensor imaging, and arterial spin labeling to characterize cognitive recovery from anesthesia and its biological correlates. Applying these techniques to a cohort of age-specified healthy volunteers 40- 80 years of age, who are exposed to general anesthesia alone, in the absence of surgery, will assess cognitive and functional neural network recovery after anesthesia. Imaging data are acquired before, during, and immediately after anesthesia, as well as 1 and 7 days after. Detailed cognitive data are captured at the same time points as well as 30 days after anesthesia, and brief cognitive assessments are repeated at 6 and 12 months after anesthesia. RESULTS: The study is underway. Our primary hypothesis is that older adults may require significantly longer to achieve cognitive recovery, measured by Postoperative Quality of Recovery Scale cognitive domain, than younger adults in the immediate postanesthesia period, but all will fully recover to baseline levels within 30 days of anesthesia exposure. Imaging data will address systems neuroscience correlates of cognitive recovery from general anesthesia. CONCLUSIONS: The data acquired in this project will have both clinical and theoretical relevance regardless of the outcome by delineating the mechanism behind short-term recovery across the adult age lifespan, which will have major implications for our understanding of the effects of anesthetic drugs. (Anesth Analg 2018;126:1675-83.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

130. Reduction in operating room plasma waste after evidence-based quality improvement initiative Author(s): Meyer M.J.; Dzik W.H.; Levine W.C. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1662-1665 Publication Date: May 2018 Publication Type(s): Article Abstract:Anesthesiologists request units of plasma in anticipation of transfusion. The amount of plasma transfused intraoperatively is less than that issued (requested, thawed, and sent). We presented institutional-specific data on plasma usage including anesthesiologist-specific ratios of plasma issued-to-transfused. In month-to-month comparisons from the year before the presentation (June-December 2015) to 7 months after (June-December 2016), plasma issued to the operating room was reduced from 434.9 +/- 81 to 327.3 +/- 65 units, a change of 107.6unitspermonth(95%confidenceinterval[CI],22-193);plasmadiscardedbythebloodbank wasreducedfrom109.7+/-48unitsto69.1+/-9units,achangeof40.6unitspermonth(95%CI,0.2- 81);andplasmatransfusedwentfrom188.4+/-42unitsto160.7+/-52units,anonsignificantchangeof 27.7 units per month (95% CI, -27 to 83). (Anesth Analg 2018;126:1662-5.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

131. Validation of a new method to automatically select cases with intraoperative red blood cell transfusion for audit Author(s): Epstein R.H.; Ledolter J.; Dasovich S.M.; Herman J.H.; Maga J.M.; Schwenk E.S.; Dexter F. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1654-1661 Publication Date: May 2018 Publication Type(s): Article Abstract:BACKGROUND: Hospitals review allogeneic red blood cell (RBC) transfusions for appropriateness. Audit criteria have been published that apply to 5 common procedures. We expanded on this work to study the management decision of selecting which cases involving transfusion of at least 1 RBC unit to audit (review) among all surgical procedures, including those previously studied. METHODS: This retrospective, observational study included 400,000 cases among 1891 different procedures over an 11-year period. There were 12,616 cases with RBC transfusion. We studied the proportions of cases that would be audited based on criteria of nadir hemoglobin (Hb) greater than the hospital's selected transfusion threshold, or absent Hb or missing estimated blood loss (EBL) among procedures with median EBL <500 mL. This threshold EBL was selected because it is approximately the volume removed during the donation of a single unit of whole blood at a blood bank. Missing EBL is important to the audit decision for cases in which the procedures' median EBL is <500 mL because, without an indication of the extent of bleeding, there are insufficient data to assume that there was sufficient blood loss to justify the transfusion. RESULTS: Most cases (>50%) that would be audited and most cases (>50%) with transfusion were among procedures with median EBL <500 mL (P < .0001). Among cases with transfusion and nadir Hb >9 g/dL, the procedure's median EBL was <500 mL for 3.0 times more cases than for procedures having a median EBL =500 mL. A greater percentage of cases would be recommended for audit based on missing values for Hb and/or EBL than based on exceeding the Hb threshold among cases of procedures with median EBL =500 mL (P < .0001). There were 3.7 times as many cases with transfusion that had missing values for Hb and/or EBL than had a nadir Hb >9 g/dL and median EBL for the procedure =500 mL. CONCLUSIONS: An automated process to select cases for audit of intraoperative transfusion of RBC needs to consider the median EBL of the procedure, whether the nadir Hb is below the hospital's Hb transfusion threshold for surgical cases, and the absence of either a Hb or entry of the EBL for the case. This conclusion applies to all surgical cases and procedures. (Anesth Analg 2018;126:1654-61.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

132. Physiology and role of intraocular pressure in contemporary anesthesia Author(s): Kelly D.J.; Farrell S.M. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1551-1562 Publication Date: May 2018 Publication Type(s): Article Abstract:More than 26 million Americans suffer with cataracts, and with 3.6 million cataract extractions performed annually in the United States, it is the most common surgical procedure. The integrity of the delicate structures of the eye that mediate vision is dependent on the intraocular pressure (IOP). Yet, IOP acts to compress the vessels within the globe-akin to a Starling resistor-and is a key component that determines the ocular perfusion pressure, defined as the difference between arterial pressure and IOP. The retina is one of the most metabolically active tissues in the body, and its functional integrity is dependent on an adequate blood supply, with retinal function linearly related to the ocular perfusion pressure. Retinal cell death has been demonstrated at low perfusion pressures (below 50 mm Hg). Modern ophthalmic surgery involves globe irrigation, manipulation, and instrumentation, resulting in dynamic pressure fluxes within the eye. Marked elevations of IOP (up to 4-5 times the normal value) with consequent borderline retinal and optic disk perfusion pressures occur for prolonged periods during many ophthalmic procedures. General surgeries, including laparoscopic, spinal, and cardiac procedures, especially, with their demand for steep Trendelenburg or prolonged prone positioning and/or hypotensive anesthesia, can induce IOP changes and ocular perfusion imbalance. These rapid fluctuations in IOP, and so in perfusion, play a role in the pathogenesis of the visual field defects and associated ocular morbidity that frequently complicate otherwise uneventful surgeries. The exact etiology of such outcomes is multifactorial, but ocular hypoperfusion plays a significant and frequently avoidable role. Those with preexisting compromised ocular blood flow are especially vulnerable to intraoperative ischemia, including those with hypertension, diabetes, atherosclerosis, or glaucoma. However, overly aggressive management of arterial pressure and IOP may not be possible given a patient's comorbidity status, and it potentially exposes the patient to risk of catastrophic choroidal hemorrhage. Anesthetic management significantly influences the pressure changes in the eye throughout the perioperative period. Strategies to safeguard retinal perfusion, reduce the ischemic risk, and minimize the potential for expulsive bleeding must be central to the anesthetic techniques selected. This review outlines: important physiological principles; ophthalmic and general procedures most likely to develop damaging IOP levels and their causative factors; the effect of anesthetic agents and techniques on IOP; recent scientific evidence highlighting the significance of perfusion changes during surgery; and key aspects of postoperative visual loss and management approaches for high- risk patients presenting for surgery. (Anesth Analg 2018;126:1551-62.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

133. Preventing adverse events in cataract surgery: Recommendations from a Massachusetts expert panel Author(s): Nanji K.C.; Roberto S.A.; Morley M.G.; Bayes J. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1537-1547 Publication Date: May 2018 Publication Type(s): Review Abstract:Massachusetts health care facilities reported a series of cataract surgery-related adverse events (AEs) to the state in recent years, including 5 globe perforations during eye blocks performed by 1 anesthesiologist in a single day. The Betsy Lehman Center for Patient Safety, a nonregulatory Massachusetts state agency, responded by convening an expert panel of frontline providers, patient safety experts, and patients to recommend strategies for mitigating patient harm during cataract surgery. The purpose of this article is to identify contributing factors to the cataract surgery AEs reported in Massachusetts and present the panel's recommended strategies to prevent them. Data from state-mandated serious reportable event reports were supplemented by online surveys of Massachusetts cataract surgery providers and semistructured interviews with key stakeholders and frontline staff. The panel identified 2 principal categories of contributing factors to the state's cataract surgery-related AEs: systems failures and choice of anesthesia technique. Systems failures included inadequate safety protocols (48.7% of contributing factors), communication challenges (18.4%), insufficient provider training (17.1%), and lack of standardization (15.8%). Choice of anesthesia technique involved the increased relative risk of needle-based eye blocks. The panel's surveys of Massachusetts cataract surgery providers show wide variation in anesthesia practices. While 45.5% of surgeons and 69.6% of facilities reported increased use of topical anesthesia compared to 10 years earlier, needle-based blocks were still used in 47.0% of cataract surgeries performed by surgeon respondents and 40.9% of those performed at respondent facilities. Using a modified Delphi approach, the panel recommended several strategies to prevent AEs during cataract surgery, including performing a distinct time-out with at least 2 care-team members before block administration; implementing standardized, facility-wide safety protocols, including a uniform site- marking policy; strengthening the credentialing and orientation of new, contracted and locum tenens anesthesia staff; ensuring adequate and documented training in block administration for any provider who is new to a facility, including at least 10 supervised blocks before practicing independently; using the least invasive form of anesthesia appropriate to the patient; and finally, adjusting anesthesia practices, including preferred techniques, as evidence-based best practices evolve. Future research should focus on evaluating the impact of these recommendations on patient outcomes. (Anesth Analg 2018;126:1537-47.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

134. The technology of video laryngoscopy Author(s): Berkow L.C.; Morey T.E.; Urdaneta F. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1527-1534 Publication Date: May 2018 Publication Type(s): Article Abstract:Tracheal intubation via laryngeal exposure has evolved over the past 150 years and has greatly expanded in the last decade with the introduction and development of newer, more sophisticated optical airway devices. The introduction of indirect and video-assisted laryngoscopes has significantly impacted airway management as evidenced by the presence of these devices in the majority of published difficult airway algorithms. However, it is quite possible that many airway managers do not have a thorough comprehension of how these devices actually function, an understanding that is vital not only for their use but also for assessing the devices' limitations. This article discusses the development of video laryngoscopy, how the video laryngoscope works, and the impact of video laryngoscopy on difficult airway management. (Anesth Analg 2018;126:1527- 34.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

135. Usefulness of basophil activation tests for diagnosis of sugammadex-induced anaphylaxis Author(s): Horiuchi T.; Orihara M.; Saito S.; Yokohama A.; Tomita Y.; Tomioka A.; Yoshida N.; Takahashi K.; Takazawa T. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1509-1516 Publication Date: May 2018 Publication Type(s): Article Abstract:BACKGROUND: Sugammadex is used to reverse the effects of neuromuscular blocking agents in many cases of general anesthesia. However, there are several reports of anaphylaxis after its use. Skin testing is the gold standard for detecting the causative agent of anaphylaxis. However, due to the lack of validated protocols for skin testing with sugammadex, the diagnostic accuracy might be inadequate. Recently, the basophil activation test (BAT) has been established as a tool to detect the causative agent of anaphylaxis with high sensitivity and specificity. However, few studies have investigated the utility of the BAT for sugammadex-induced anaphylaxis. METHODS: Eight patients who presented with immediate hypersensitivity to sugammadex during general anesthesia were included in this study. We conducted skin tests to confirm the diagnosis of sugammadex- induced anaphylaxis. Twenty-one sugammadex-naive individuals who had a negative skin test for allergy to this drug were enrolled as controls. Basophils were selected on a CD3-/CRTH2+ gate and labeled with CD63 and CD203c. RESULTS: The ratios of activated basophils in the patients were much higher than those in controls: the median values of areas under the curves in the patients and controls for CD203c were 1,265,985 (95% confidence interval [CI], 77,580-5,040,270) and 116,325 (95% CI, -268,605 to 232,690), respectively (Mann-Whitney U test, P < .01), and the areas under the curves in the patients and controls for CD63 were 788,647 (95% CI, 120,285-3,523,410) and 220,005 (95% CI, -50,346 to 404,680), respectively (Mann-Whitney U test, P < .01). The patients, but not controls, demonstrated clear dose-dependent CD203c upregulation. This was also true for CD63. In the case of CD203c, the sensitivity of the BAT for sugammadex was 88% (95% CI, 47%-100%), and specificity was 100% (95% CI, 84%-100%), while sensitivity and specificity for CD63 were 75% (95% CI, 35%-97%) and 100% (95% CI, 84%-100%), respectively. CONCLUSIONS: The BAT seems to have comparable accuracy to skin tests for the diagnosis of sugammadex-induced anaphylaxis. For this purpose, both CD203c and CD63 can be used to detect activated basophils. (Anesth Analg 2018;126:1509-16.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

136. Section editor: Tong j. Gan intensive care unit enhanced recovery pathway for patients undergoing orthotopic liver transplants recipients: A prospective, observational study Author(s): Kensinger C.D.; Karp S.J.; Kelly Wright J.; Shi Y.; Shotwell M.S.; King A.B.; Pandharipande P.P.; Weavind L.M. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1495-1503 Publication Date: May 2018 Publication Type(s): Review Abstract:BACKGROUND: Liver transplant recipients continue to have high perioperative resource utilization and prolonged length of stay despite improvements in perioperative care. Enhanced recovery pathways have been shown in other surgical populations to produce reductions in hospital resource utilization. METHODS: A prospective, observational study was performed to examine the effect of an enhanced recovery pathway for postoperative care after liver transplantation. Outcomes from patients undergoing liver transplantation from November 1, 2013, to October 31, 2014, managed by the pathway were compared to transplant recipients from the year before pathway implementation. Multivariable regression analysis was used to assess the association of the clinical pathway on clinical outcomes. RESULTS: The intervention and control groups included 141 and 106 patients, respectively. There were no demographic differences between the control and intervention group including no differences between the length of surgery and cold ischemic time. Median intensive care unit length of stay was reduced from 4.4 to 2.6 days (P < .001). The intervention group had a higher likelihood of earlier discharge (hazard ratio [95% CI], 2.01 [1.55-2.62]; P < .001), and a 69% and 65% lower odds of receiving a plasma (P < .001) or packed red blood cell (P < .001) transfusion. There was no significant effect on hospital mortality (P = .40), intensive care unit readmission rates (P = .75), or postoperative infections (urinary traction infections: P = .09; pneumonia: P = .27). CONCLUSIONS: An enhanced recovery pathway focused on milestone-based elements of intensive care unit management and predetermined management triggers including hemodynamic goals, fluid therapy, perioperative antibiotics, glycemic control, and standardized transfusion triggers led to reductions in intensive care unit length of stay without an increase in perioperative complications. (Anesth Analg 2018;126:1495-503.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

137. Section editor: Roman m. Sniecinski no significant association between the transfusion of small volumes of leukocyte-depleted red blood cells and mortality over 7 years of follow-up in patients undergoing cardiac surgery: A propensity score matched analysis Author(s): Koster A.; Zittermann A.; Borgermann J.; Gummert J.F. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1469-1475 Publication Date: May 2018 Publication Type(s): Article Abstract:BACKGROUND: The impact of red blood cell (RBC) transfusion on long-term clinical outcome is controversial. METHODS: We prospectively recorded follow-up data of 6124 cardiac surgical patients who received no transfusion (RBC- group) or 1-2 units of leukocyte-depleted RBC (RBC+ group) at our institution. The primary end point was overall mortality up to 7 years after cardiac surgery; secondary end point was coronary artery revascularization during follow-up. To correct for nonrandomized group assignment, propensity score (PS) matching was performed. A subgroup analysis was also performed in patients with preoperative anemia. RESULTS: PS matching was possible in 4118 patients. During a mean follow-up of 4.05 years (range, 0.0-7.3 years), 140 patients (14.6%) died in the RBC- group and 173 (17.2%) died in the RBC+ group. The hazard ratio for the RBC+ group versus the RBC- group was 1.00 (95% confidence interval, 0.79-1.25; P = .969). The number of revascularizations was 96 (9.9%) and 125 (10.6%), respectively, with a hazard ratio of 1.21 (95% confidence interval, 0.92-1.58; P = .166) for the RBC+ group. Preoperative anemia was not a risk factor for postoperative mortality, even when patients were transfused. CONCLUSIONS: This PS- matched analysis does not provide evidence for an association of the transfusion of small volumes of leukocyte-depleted RBCs with an increased postoperative mortality in cardiac surgical patients. Moreover, preoperative anemia could not be identified as a risk factor for increased postoperative mortality. (Anesth Analg 2018;126:1469-75).Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

138. The American college of surgeons children?s surgery verification and quality improvement program: Be careful what you wish for! Author(s): DiNardo J.A.; Davis P.J. Source: Anesthesia and Analgesia; May 2018; vol. 126 (no. 5); p. 1438-1440 Publication Date: May 2018 Publication Type(s): Review Database: EMBASE

139. Pain reconceptualisation after pain neurophysiology education in adults with chronic low back pain: A qualitative study Author(s): King R.; Robinson V.; Elliott-Button H.L.; Watson J.A.; Ryan C.G.; Martin D.J. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Available at Pain research & management - from PubMed Central Abstract:Pain neurophysiology education (PNE) is an educational intervention for patients with chronic pain. PNE purports to assist patients to reconceptualise their pain away from the biomedical model towards a more biopsychosocial understanding by explaining pain biology. This study aimed to explore the extent, and nature, of patients' reconceptualisation of their chronic low back pain (CLBP) following PNE. Eleven adults with CLBP underwent semistructured interviews before and three weeks after receiving PNE. Interviews were transcribed verbatim and thematically analysed in a framework approach using four a priori themes identified from our previous research: (1) degrees of reconceptualisation, (2) personal relevance, (3) importance of prior beliefs, and (4) perceived benefit of PNE. We observed varying degrees of reconceptualisation from zero to almost complete, with most participants showing partial reconceptualisation. Personal relevance of the information to participants and their prior beliefs were associated with the degree of benefit they perceived from PNE. Where benefits were found, they manifested as improved understanding, coping, and function. Findings map closely to our previous studies in more disparate chronic pain groups. The phenomenon of reconceptualisation is applicable to CLBP and the sufficiency of the themes from our previous studies increases confidence in the certainty of the findings.Copyright © 2018 Richard King et al. Database: EMBASE

140. The MitraClip Procedure-A Comprehensive Review for the Cardiac Anesthesiologist Author(s): Wu I.Y.; Barajas M.B.; Hahn R.T. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

141. Although female patients with ankylosing spondylitis score worse on disease activity than male patients and improvement in disease activity is comparable, male patients show more radiographic progression during treatment with TNF-alpha inhibitors Author(s): Spoorenberg A.; Bootsma H.; Maas F.; Arends S.; Wink F.; Bos R.; van der Slik B. Source: Seminars in Arthritis and Rheumatism; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: The clinical presentation of ankylosing spondylitis (AS) differs between genders. Our aim was to investigate differences in disease activity, disease outcome and treatment response between male and female AS patients before and after starting tumor necrosis factor (TNF)-alpha inhibitors in daily clinical practice. Methods: Patients from the Groningen Leeuwarden AS (GLAS) cohort who started TNF-alpha inhibitors and who had visits at baseline and after 3 months and/or 2 years of follow-up were included. Results: Of 254 included AS patients, 69% were male. At baseline, female patients scored significantly higher on BASDAI, ASDAS, and tender entheses than male patients. In contrast, CRP, swollen joints, and history of extra-articular manifestations were comparable between genders. Women experienced significantly worse physical function and QoL, whereas men showed significantly more kyphosis and spinal radiographic damage. After 3 months and 2 years of follow-up, all clinical assessments improved significantly, with comparable mean change scores for female and male patients; mean 2-year change in BASDAI -2.7 vs. -2.7, ASDAS - 1.50 vs. -1.68, tender entheses -2.4 vs. -1.4, CRP -8 vs. -8, BASFI -2.2 vs. -2.1 and ASQoL -5 vs. -4, respectively. Radiographic progression was significantly higher in male patients. Female patients switched more frequently to another TNF-alpha inhibitor during 2 years of follow-up (32% vs. 14%). Conclusion: Although female patients experienced higher disease activity, worse physical function and quality of life, and switched TNF-alpha inhibitors more often, clinical improvement during treatment with TNF-alpha inhibitors was comparable between genders. However, male patients showed more radiographic spinal damage after 2 years.Copyright © 2018 Database: EMBASE

142. Validation of a Limitations in Daily Activities Scale for Chronic Pain Author(s): Wilson K.G.; Castillo D.; Kowal J.; Yong A.G.; McWilliams L.A. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Limitations in physical function and participation are important domains of assessment in chronic pain. In 1995, the International Association for the Study of Pain distributed a self-report measure of functional limitations. Although the questionnaire has been used in research studies, it has never been subjected to a thorough investigation of its measurement properties. In this study, 941 patients with chronic pain completed the 16-item Limitations in Daily Activities Scale (LIDAS) at 2 pretreatment and 1 post-treatment assessment points. Individual item analysis favored a 13-item scale. This 13-item LIDAS had a confirmed 3-factor structure consisting of limitations in personal care, global participation, and specific tasks. Reliability analyses for the total scale (alpha = .90), as well as for each factor individually (alphas = .82-.84), indicated good internal consistency, test-retest reliability (intraclass correlations = .65-.88 over varying time intervals), and responsiveness to change with treatment. LIDAS scores correlated as expected with measures of pain intensity, pain cognitions, and depression, as well as with other self-report and clinician-administered measures of functional performance. Using patient global ratings as anchors, a minimal clinically important difference of 5 points was established as a criterion for meaningful individual improvement after treatment. In conclusion, the LIDAS is a reliable, valid, and clinically relevant option for assessing limitations in physical function and participation in patients with chronic pain. Perspective: Physical function and participation comprise a core dimension in the assessment of chronic pain. This study demonstrates that the LIDAS is a reliable and valid measure of this dimension, with good applicability for documenting clinically important change with treatment.Copyright © 2018 the American Pain Society Database: EMBASE

143. Quality improvement studies - pitfalls of the before and after study design Author(s): Choi S.W.; Wong G.T.C. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Database: EMBASE

144. Machine learning based framework to predict cardiac arrests in a paediatric intensive care unit: Prediction of cardiac arrests Author(s): Matam B.R.; Duncan H.; Lowe D. Source: Journal of Clinical Monitoring and Computing; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:A cardiac arrest is a life-threatening event, often fatal. Whilst clinicians classify some of the cardiac arrests as potentially predictable, the majority are difficult to identify even in a post-incident analysis. Changes in some patients' physiology when analysed in detail can however be predictive of acute deterioration leading to cardiac or respiratory arrests. This paper seeks to exploit the causally- related changing patterns in signals such as heart rate, respiration rate, systolic blood pressure and peripheral cutaneous oxygen saturation to evaluate the predictability of cardiac arrests in critically ill paediatric patients in intensive care. In this paper we report the results of a framework constituting feature space embedding and time series forecasting methods to build an automated prediction system. The results were compared with clinical assessment of predictability. A sensitivity of 71% and specificity of 69% was obtained when the maximum value of Anomaly Index (12) in the 50 min (starting one hour and ending 10 min) before the arrest was considered for the case patients and a random 50 min of data was considered for the control set patients. A positive predictive value of 11% and negative predictive value of 98% was obtained with a prevalence of 5% by our method of prediction. While clinicians predicted 4 out of the 69 cardiac arrests (6%), the prediction system predicted 63 (91%) cardiac arrests. Prospective validation of the automated system remains.Copyright © 2018, Springer Nature B.V. Database: EMBASE

145. Assessment of central hemodynamic effects of phenylephrine: an animal experiment Author(s): Wodack K.H.; Graessler M.F.; Nishimoto S.A.; Behem C.R.; Punke M.A.; Trepte C.J.C.; Pinnschmidt H.O.; Monge-Garcia M.I.; Reuter D.A. Source: Journal of Clinical Monitoring and Computing; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Phenylephrine is an alpha1-adrenergic receptor agonist widely used to treat perioperative hypotension. Its other hemodynamic effects, in particular on preload and contractility, remain controversial. We, therefore, investigated the effect of continuously applied phenylephrine on central hemodynamics in eight mechanically ventilated domestic pigs. Mean arterial pressure (MAP) was increased in steps by 50%, and 100% using phenylephrine. Besides stroke volume (SV), cardiac output (CO), and MAP, mean systemic vascular resistance (SVR) and dynamic arterial elastance (Eadyn) were assessed for characterization of afterload. Changes in preload were assessed by central venous pressure (CVP), global end-diastolic volume (GEDV), mean systemic filling pressure analog (Pmsfa), pulse pressure variation (PPV), and stroke volume variation (SVV). Further, cardiac function index (CFI), global ejection fraction and dPmax were measured as markers of preload dependent contractility. MAP, SV, and CO significantly increased following both interventions, as did SVR. In contrast, Eadyn did not show significant changes. Although the volumetric preload variable GEDV increased after the first step of phenylephrine, this was not reflected by significant changes in CVP or Pmsfa. CFI and dPmax significantly increased after both steps. Phenylephrine does not only affect cardiac afterload, but also increases effective preload. In contrast to CVP and Pmsfa, this effect can be monitored by GEDV. Further, phenylephrine affects contractility.Copyright © 2018, Springer Nature B.V. Database: EMBASE

146. Identify and monitor clinical variation using machine intelligence: a pilot in colorectal surgery Author(s): Maheshwari K.; Cywinski J.; Mathur P.; Cummings K.C.; Avitsian R.; Ruetzler K.; Kurz A.; Crone T.; Liska D.; Campion F.X. Source: Journal of Clinical Monitoring and Computing; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Standardized clinical pathways are useful tool to reduce variation in clinical management and may improve quality of care. However the evidence supporting a specific clinical pathway for a patient or patient population is often imperfect limiting adoption and efficacy of clinical pathway. Machine intelligence can potentially identify clinical variation and may provide useful insights to create and optimize clinical pathways. In this quality improvement project we analyzed the inpatient care of 1786 patients undergoing colorectal surgery from 2015 to 2016 across multiple Ohio hospitals in the Cleveland Clinic System. Data from four information subsystems was loaded in the Clinical Variation Management (CVM) application (Ayasdi, Inc., Menlo Park, CA). The CVM application uses machine intelligence and topological data analysis methods to identify groups of similar patients based on the treatment received. We defined "favorable performance" as groups with lower direct variable cost, lower length of stay, and lower 30-day readmissions. The software auto-generated 9 distinct groups of patients based on similarity analysis. Overall, favorable performance was seen with ketorolac use, lower intra-operative fluid use (< 2000 cc) and surgery for cancer. Multiple sub-groups were easily created and analyzed. Adherence reporting tools were easy to use enabling almost real time monitoring. Machine intelligence provided useful insights to create and monitor care pathways with several advantages over traditional analytic approaches including: (1) analysis across disparate data sets, (2) unsupervised discovery, (3) speed and auto-generation of clinical pathways, (4) ease of use by team members, and (5) adherence reporting.Copyright © 2018, Springer Nature B.V. Database: EMBASE

147. Evaluation of the Neuropathic Component of Chronic Low Back Pain Author(s): Andrasinova T.; Kalikova E.; Kopacik R.; Srotova I.; Vlckova E.; Bednarik J.; Adamova B.; Dusek L. Source: Clinical Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Assessment of neuropathic pain in chronic low back syndromes is important. However, there is currently no gold standard for its diagnosis. The aim of this observational cross- sectional study was to assess the neuropathic component of pain in various chronic low back pain syndromes using a range of diagnostic tests. Methods: Included in this study were 63 patients with chronic axial low back pain (ALBP), 48 patients with chronic radicular syndromes (CRS) comprising 23 with discogenic compression (CDRS) and 25 with lumbar spinal stenosis (LSS), and 74 controls. PainDETECT (PD-Q), quantitative sensory testing (QST) and skin biopsy with evaluation of intraepidermal nerve fiber density (IENFD) were used to assess the neuropathic pain component. Results: Positive PD-Q (>=19) was obtained more frequently in patients with CDRS and LSS (26.1% and 12.0% respectively) compared to patients with ALBP (1.6%, P<0.001). The proportion of patients with sensory loss confirmed by QST was lowest in the ALBP subgroup (23.8%) compared to CDRS (47.8%), and LSS (68.0%) subgroups (P<0.001). A reduction in IENFD was disclosed in a proportion of up to 52.0% of affected roots in patients with CRS. Discussion: Neuropathic pain is quite frequent in CRS, and QST reveals sensory loss as a frequent abnormality in patients with CRS. Using a cut-off value of 19, PD-Q identified a neuropathic component in a relatively low proportion of patients with CRS. CRS may be associated with a reduction in IENFD.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

148. Staircase-evoked Pain may be More Sensitive than Traditional Pain Assessments in Discriminating Analgesic Effects: A Randomized, Placebo-controlled Trial of Naproxen in Patients with Osteoarthritis of the Knee Author(s): Treister R.; Suzan E.; Lawal O.D.; Katz N.P. Source: Clinical Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Analgesic trials often fail to show a significant effect even when medications with known efficacy are tested. This could be attributed to insufficient assay sensitivity of analgesic trials, which may be due, in part, to the insensitivity of pain-related outcome measures. The aim of this methodological study was to assess the responsiveness of evoked pain generated by the staircase procedure compared to other commonly used pain outcomes in knee osteoarthritis. Methods: This was a randomized, double-blind, placebo-controlled, cross-over trial of 1-week treatment of naproxen versus placebo. Participants were assigned to one of the two treatment sequences (naproxen-placebo or placebo-naproxen). Pain-at-rest, evoked pain using the Staircase- Evoked Pain Procedure (StEPP), pain diary, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) data were collected before and at the end of each treatment sequence. Results: Fifty-five osteoarthritis patients (30M, 25F) completed the study. Among all pain assessments, evoked pain was the most sensitive outcome to detect treatment effects, with Standardized Effect Size (SES) of 0.47 followed by the WOMAC and pain at-rest with SES of 0.43 and 0.36 respectively Sample size calculations demonstrated that compared to spontaneous pain, the evoked pain model reduces required number of subjects by 40%. Discussion: Study results support our hypothesis that evoked pain using the StEPP may demonstrate greater responsiveness to treatment effects compared to traditional pain-related outcome measures. Accordingly, these results may facilitate development and validation of other chronic-pain-related evoked pain models, which could contribute to future research and development of new analgesics treatments.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

149. Intraoperative hypotension is not associated with postoperative cognitive dysfunction in elderly patients undergoing general anesthesia for surgery: results of a randomized controlled pilot trial Author(s): Langer T.; Zadek F.; Chiodi M.; Pugni P.; Cordolcini V.; Valenza F.; Pesenti A.; Gattinoni L.; Santini A.; Marenghi C.; Bonanomi B.; Rosini F.; Marcucci M.; Inglese S. Source: Journal of Clinical Anesthesia; Feb 2019; vol. 52 ; p. 111-118 Publication Date: Feb 2019 Publication Type(s): Article Abstract:Study objective: To assess the effect of different intraoperative blood pressure targets on the development of POCD and test the feasibility of a larger trial. Design: Randomized controlled pilot trial. Setting: Perioperative care in a tertiary care teaching hospital with outpatient follow-up. Patients: One hundred one patients aged >=75 years with ASA physical status <4, undergoing elective, non-cardiac surgery under general anesthesia and 33 age-matched healthy controls. Interventions: Randomization to a personalized intraoperative blood pressure target, mean arterial pressure (MAP) >= 90% of preoperative values (Target group), or to a more liberal intraoperative blood pressure management (No-Target group). Strategies to reach intraoperative blood pressure target were at discretion of anesthesiologists. Measurements: An experienced neuropsychologist performed a validated battery of neurocognitive tests preoperatively and 3 months after surgery. Incidence of POCD at three months and postoperative delirium were assessed. Intraoperative time spent with MAP >= 90% of preoperative values, recruitment and drop-out rate at 3 months were feasibility outcomes. Main results: The Target group spent a higher percentage of intraoperative time with MAP >=90% of preoperative values (65 +/- 25% vs. 49 +/- 28%, p < 0.01). Incidence of POCD (11% vs. 7%, relative risk 1.52; 95% CI, 0.41 to 6.3; p = 0.56) and delirium (6% vs. 14%, relative risk, 0.44; 95% CI, 0.12 to 1.60; p = 0.21) did not differ between groups. No correlation was found between intraoperative hypotension and postoperative cognitive performance (p = 0.75) or delirium (p = 0.19). Recruitment rate was of 6 patients/month (95% confidential interval (CI), 5 to 7) and drop-out rate at 3 months was 24% (95% CI, 14 to 33%). Conclusions: Intraoperative hypotension did not correlate with postoperative cognitive dysfunction or delirium occurrence in elderly patients undergoing general anesthesia for non-cardiac surgery. A multicenter randomized controlled trial is needed in order to confirm the effect of intraoperative blood pressure on the development of POCD. Trial registration number: NCT02428062 www.clinicaltrials.gov.Copyright © 2018 Database: EMBASE

150. Intraoperative Transesophageal Echocardiography and Right Ventricular Failure After Left Ventricular Assist Device Implantation Author(s): Silverton N.A.; Patel R.; Zimmerman J.; Morrissey C.K.; Ma J.; Stoddard G.; Selzman C.H. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2096-2103 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objective: To determine whether intraoperative measures of right ventricular (RV) function using transesophageal echocardiography are associated with subsequent RV failure after left ventricular assist device (LVAD) implantation. Design: Retrospective, nonrandomized, observational study. Setting: Single tertiary-level, university-affiliated hospital. Participants: The study comprised 100 patients with systolic heart failure undergoing elective LVAD implantation. Interventions: Transesophageal echocardiographic images before and after cardiopulmonary bypass were analyzed to quantify RV function using tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (S'), fractional area change (FAC), RV global longitudinal strain, and RV free wall strain. A chart review was performed to determine which patients subsequently developed RV failure (right ventricular assist device placement or prolonged inotrope requirement >=14 days). Measurements and Main Results: Nineteen patients (19%) subsequently developed RV failure. Postbypass FAC was the only measure of RV function that distinguished between the RV failure and non-RV failure groups (21.2% v 26.5%; p = 0.04). The sensitivity, specificity, and area under the curve of an abnormal RV FAC (<35%) for RV failure after LVAD implantation were 84%, 20%, and 0.52, respectively. No other intraoperative measure of RV function was associated with subsequent RV failure. RV failure increased ventilator time, intensive care unit and hospital length of stay, and mortality. Conclusion: Intraoperative measures of RV function such as tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and RV strain were not associated with RV failure after LVAD implantation. Decreased postbypass FAC was significantly associated with RV failure but showed poor discrimination.Copyright © 2018 Elsevier Inc. Database: EMBASE

151. Successful Rescue Utilization of Intraoperative Tissue Plasminogen Activator in the Setting of Massive Thrombosis of Avalon Catheter and Patient in Extremis with Refractory Hypoxemia Author(s): Martin A.K.; Allen W.L.; Diaz-Gomez J.L.; Fritz A.V. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2278-2281 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

152. Acute Kidney Injury After Total Arch Replacement Combined With Frozen Elephant Trunk Implantation: Incidence, Risk Factors, and Outcome Author(s): Zhou H.; Wang G.; Yang L.; Shi S.; Li J.; Wang M.; Zhang C.; Li H.; Qian X.; Sun X.; Chang Q.; Yu C. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2210-2217 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: Acute kidney injury (AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality. Total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation has been reported to produce satisfactory clinical outcomes, whereas several features of the surgical procedure may induce postoperative AKI. The authors aimed to clarify the incidence of and risk factors for postoperative AKI and the association of AKI with short-term outcomes. Design: This study was a retrospective analysis of a prospectively collected cohort. A multivariate logistic regression model was used to identify predictors of postoperative AKI. Setting: Single center. Participants: Clinical data were analyzed for 553 consecutive patients who underwent TAR combined with FET implantation between 2013 and 2016. Interventions: None Measurements and Main Results: Postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Postoperative AKI occurred in 77.6% of the whole cohort. Patients in stage 3 AKI were associated with a higher incidence of major adverse events and in-hospital and 90-day mortality (p < 0.001, p < 0.05, p < 0.01, respectively). In the multivariate analysis, male sex (odds ratio [OR] 1.94; 95% confidence interval [95% CI] 1.22-3.18; p = 0.005); older age (per 10 years) (OR 1.37; 95% CI 1.14-1.67; p = 0.001); elevated body mass index (per 5 kg/m2) (OR 1.41; 95% CI 1.08-1.87; p = 0.01); and prolonged cardiopulmonary bypass duration (per 30 minutes) (OR 1.17; 95% CI 1.01-1.37; p = 0.03) were identified as independent predictors of postoperative AKI. Conclusion: TAR combined with FET implantation carries a high-risk for postoperative AKI compared with other types of thoracic aortic surgeries. Cardiopulmonary bypass duration was identified as the only modifiable predictor of AKI, and patients may benefit from moderate hypothermic circulatory arrest instead of deep hypothermic circulatory arrest.Copyright © 2018 Elsevier Inc. Database: EMBASE

153. Cardiopulmonary Bypass and Malaria Relapse Author(s): Abrard S.; Cousin B.; Fleury C.; Beydon L.; Fouquet O. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2282-2285 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

154. Cardiovascular Collapse During Liver Transplantation-Echocardiographic-Guided Hemodynamic Rescue and Perioperative Management Author(s): Gold A.K.; Patel P.A.; Lane-Fall M.; Gutsche J.T.; Lauter D.; Zhou E.; Guelaff E.; MacKay E.J.; Weiss S.J.; Baranov D.J.; Valentine E.A.; Feinman J.W.; Augoustides J.G. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2409-2416 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

155. Preoperative Intra-Aortic Counterpulsation in Cardiac Surgery: Insights From a Retrospective Series of 588 Consecutive High-Risk Patients Author(s): Gatti G.; Morra L.; Castaldi G.; Maschietto L.; Gripshi F.; Fabris E.; Perkan A.; Benussi B.; Sinagra G.; Pappalardo A. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2077-2086 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objective: To support a rational use of preoperative intra-aortic balloon pump (IABP) in cardiac surgery. Design: Retrospective, observational study. Setting: Single university hospital. Participants: The study included 588 (mean age 68.5 +/- 9.6 yr) consecutive patients who received IABP before cardiac surgery from 1999 to 2016. Interventions: Coronary surgery was performed in 573 (97.4%) cases. IABP indications were prophylaxis (n = 147), unstable angina (n = 239), and rapid worsening of hemodynamics (n = 202). Baseline characteristics of patients were analyzed with multivariable methods. Comparison of outcomes postsurgery between 74 patients undergoing IABP because of left main coronary artery disease (LMCAD) (stenosis >= 50%) and a new series of 1,360 patients experiencing LMCAD but who did not receive an IABP using propensity-score matching. Measurements and Main Results: Throughout the study period, the rate of IABP use for prophylaxis and unstable angina increased (p = 0.0029) despite reduction in patient surgical risk (p = 0.0051). Early period of surgery (p = 0.032), rapid worsening of hemodynamics in the operating room (p = 0.0029), renal impairment (p < 0.0001), and ventilation before surgery (p = 0.0032) were predictors of in-hospital mortality. The cumulative rate of IABP-related complications was 6.8%. Current smoking (p = 0.025) and the use of a 9 Fr catheter (p = 0.0017) were predictors of IABP-related vascular complications. No difference was found regarding outcomes postsurgery for 43 pairs of IABP/non-IABP matched patients with LMCAD, even though preoperative IABP was associated with an increased use of bilateral internal thoracic artery grafting. Conclusions: Preoperative use of IABP in cardiac surgery was shown in this study to be safe, even for high-risk patients. LMCAD is not by itself a sufficient indication for prophylactic IABP.Copyright © 2017 Elsevier Inc. Database: EMBASE

156. Heart Failure With Preserved Ejection Fraction-A Systematic Review and Analysis of Perioperative Outcomes Author(s): Mohananey D.; Heidari-Bateni G.; Villablanca P.A.; Iturrizaga Murrieta J.C.; Vlismas P.; Agrawal S.; Bhatia N.; Mookadam F.; Ramakrishna H. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2423-2434 Publication Date: Oct 2018 Publication Type(s): Review Database: EMBASE

157. Comparison of Levosimendan and Milrinone for ECLS Weaning in Patients After Cardiac Surgery-A Retrospective Before-and-After Study Author(s): Jacky A.; Rudiger A.; Kruger B.; Spahn D.R.; Bettex D.; Wilhelm M.J.; Paal S.; Seifert B. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2112-2119 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objectives: Pharmacodynamics suggests that levosimendan might be a valuable inotrope for weaning from extracorporeal life support (ECLS). As there is a paucity of evidence regarding the effectiveness and safety of such an approach, the aim was to report the authors' experiences in ECLS weaning before and after the implementation of levosimendan in clinical practice. Design: Retrospective before-and-after study. Setting: Cardiac intensive care unit of a university hospital. Participants: A total of 64 patients under ECLS for postcardiotomy cardiac failure, who underwent an ECLS weaning trial. Intervention: Group comparisons between patients treated with levosimendan and patients treated with milrinone were made with the Mann-Whitney U test or the Pearson chi- squared test. Results are given as median (interquartile range) or numbers (percentages). Measurements and Main Results: Of 64 patients, 26 (41%) received levosimendan. Successful ECLS weaning was achieved in 24 (92%) and 30 patients (79%) in the levosimendan and milrinone group, respectively (p = 0.18). In the levosimendan group, fewer patients had an intra-aortic balloon pump for weaning (2 [7.7%] v 15 [40%], p = 0.008). The support with norepinephrine was similar in the levosimendan and milrinone groups at the time of ECLS removal (0.06 [0.01-0.11] v 0.07 [0.01-0.16] micro g/kg/min, p = 0.64) and 24 hours later (0.06 [0.04-0.09] v 0.04 [0.00-0.09] micro g/kg/min, p = 0.15). Twenty-eight days (9/26 (35%) v 14/35 (40%), p = 0.28) and 180 days (13/26 [50%] v 15/34 [44%], p = 0.80) mortalities after ECLS removal were similar in the levosimendan and the milrinone groups. Conclusion: Levosimendan enabled ECLS weaning without increasing norepinephrine requirements when compared to a control group receiving milrinone.Copyright © 2018 Elsevier Inc. Database: EMBASE

158. A Diastolic Murmur and the Mitral Valve Author(s): Gao Z.; Bortman J.; Mahmood F.; Khabbaz K.R. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2455-2456 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

159. Chronic Lung Disease and Mortality after Cardiac Surgery: A Prospective Cohort Study Author(s): Ponomarev D.; Kamenskaya O.; Vedernikov P.; Kornilov I.; Shmyrev V.; Lomivorotov V.; Klinkova A.; Loginova I.; Chernavskiy A.; Karaskov A. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2241-2245 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objective: To investigate the 1-year survival in cardiac surgical patients with lung disease, including previously undiagnosed cases. Design: Prospective cohort study. Setting: Tertiary hospital. Participants: Patients scheduled for elective coronary artery bypass graft (CABG) surgery. Interventions: None. Measurements and Main Results: Pulmonary function tests (PFTs) were performed in 454 patients before surgery. Abnormal respiratory patterns were defined as follows: obstructive (forced expiratory volume in 1 second/forced vital capacity <0.70), restrictive (forced expiratory volume in 1 second/forced vital capacity >=0.70 and forced vital capacity <80% of predicted), and mixed. Overall 1-year mortality was 3.3%. Among 31 patients with documented chronic obstructive pulmonary disease (COPD), mortality was 9.6%, hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.02-12.80, p = 0.04. Of 423 patients without history of COPD, 57 obstructive, 46 restrictive, and 4 mixed abnormal patterns were identified. Of a total of 72 with obstructive lung disease confirmed by PFT (ie, 15 of COPD patients and 57 newly identified cases), 6.9% died, HR 2.75, 95% CI 0.98-8.07, p = 0.06. When combined with cases of COPD where a respiratory abnormality was confirmed (26 patients), newly diagnosed obstructive lung disease (57 patients) was significantly associated with 1-year mortality, HR 4.13, 95% CI 1.50-11.42, p = 0.006. The adjustment for EuroSCORE II did not change the results. Conclusions: Combination of confirmed preexisting lung disease and newly diagnosed cases provides a clear link to mid-term mortality.Copyright © 2017 Elsevier Inc. Database: EMBASE

160. Serratus Anterior Plane Block for Apical TAVR in an Awake Patient Author(s): Berthoud V.; Ellouze O.; Bievre T.; Konstantinou M.; Girard C.; Bouhemad B.; Jazayeri S.; Bouchot O. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2275-2277 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

161. Alkaptonuric Ochronosis and the Failure of Regional Cerebral Tissue Oxygen Saturation Monitoring by Two Different Near-infrared Spectroscopy Devices Author(s): Namekawa M.; Kimura M.; Fujii C.; Yamashita S.; Ishida K. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2286-2288 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

162. Unexpected Findings in a Man with a Repaired Type A Aortic Dissection and a New Stroke Author(s): Pagel P.S.; Hendrix W.A.; Cain M.T.; Ali A.K.Y.; Muscato G.; Mungara C.; Rokkas C. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2451-2454 Publication Date: Oct 2018 Publication Type(s): Article Database: EMBASE

163. Six-Month Outcomes After High-Risk Coronary Artery Bypass Graft Surgery and Preoperative Intra-aortic Balloon Counterpulsation Use: An Inception Cohort Study Author(s): Litton E.; Hillis G.; Bass F.; Delaney A.; Marasco S.; Myles P.S.; McGuinness S.; Reid C.M.; Smith J.A. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2067-2073 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objective: To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS). Design: Inception cohort study. Setting: A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom. Participants: Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina). Interventions: Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5- dimensional questionnaire (EQ5D). Measurements and Main Results: The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes. Conclusions: The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research.Copyright © 2018 Elsevier Ltd Database: EMBASE

164. Association of Oral Intake and Transient Mixed Venous Oxygen Desaturation in Patients Undergoing Fast-Track Postoperative Care After Open-Heart Surgery Author(s): Maki Y.; Toyoda D.; Tomichi K.; Onodera J.; Kotake Y. Source: Journal of Cardiothoracic and Vascular Anesthesia; Oct 2018; vol. 32 (no. 5); p. 2236-2240 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Objective: The impact of early resumption of oral intake after cardiac surgery on hemodynamics has not been characterized. The authors examined the effects of early oral intake on the oxygen supply-demand relationship in patients undergoing on-pump cardiac surgery in an early recovery after surgery program. Design: Prospective data were collected in postcardiac surgical patients in a multidisciplinary intensive care unit (ICU) during an 18-month period. Setting: Single institution study. Participants: Forty-three patients who underwent either mitral or aortic valve repair and were successfully liberated from ventilatory support within 10 hours after surgery. Interventions: Patients were either allowed to resume oral intake on the morning of the first postoperative day or not at the discretion of the surgical team after extubation. Measurements and Main Results: The oxygen supply-demand relationship was assessed continuously with cardiac index and mixed venous oxygen saturation (SvO2). Among the subjects, 22 patients were allowed to eat, and transient SvO2 decrease was noted in 13 patients. All transient SvO2 decreases occurred in the patients with early oral intake. The hemodynamic status and oxygen supply-demand relationship did not differ between the patients with and without transient SvO2 decrease. All the subjects were discharged successfully from the ICU on the first postoperative day, and the length of hospital stay was similar irrespective of SvO2 decrease after early oral intake. Conclusions: Early oral intake shortly after extubation was associated with transient but significant SvO2 decrease in patients who underwent fast-track recovery after open-heart surgery. Because this phenomenon did not negatively affect the postoperative outcome, early oral intake may not be harmful.Copyright © 2017 Elsevier Inc. Database: EMBASE

165. A Peculiar Radial Artery Pressure Waveform After Aortic Valve Replacement Author(s): Garg M.; Rijvi S.; Garg S.; Arora S.; Sharma S.; Sharma A. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

166. Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project Author(s): Jooste R.; Roberts F.; O'Sullivan E.P.; Mndolo S.; Chikumbanje S.; Mabedi D.; Whitaker D.K. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia, but is rarely available in low-income countries. The aim of this study was twofold: to measure the prevalence of capnography in the operating theatres and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low-income country. This is the first project to do this. Forty capnographs were donated to eight hospitals in Malawi. Thirty-two anaesthesia providers received a 1-day capnography training course with pre- and postcourse knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow-up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating theatre had a capnograph. Overall, 97% and 100% 'capnography gaps' were identified in the theatres and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed that capnography had saved lives. This study has shown it is feasible to introduce capnography in a low-income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low-income countries in 2007, we believe this is one of the most important projects in anaesthesia safety in the last decade.Copyright © 2018 Association of Anaesthetists Database: EMBASE

167. The effect of the volume of supra-inguinal injected solution on the spread of the injectate under the fascia iliaca: a preliminary study Author(s): Vermeylen K.; Soetens F.; Leunen I.; Hadzic A.; Van Boxtael S.; Pomes J.; Prats-Galino A.; Van de Velde M.; Neyrinck A.; Sala-Blanch X. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:The fascia iliaca compartment is the compartment confined by the fascia iliaca (FI) and a muscular layer formed by the iliac- and psoas muscle. This compartment creates a virtual tunnel that contains the femoral nerve (FN), the obturator nerve (ON), and the lateral femoral cutaneous nerve (LFCN) of the lumbar plexus. In this pilot study, we aimed to determine the suggested volume needed to reach the three target nerves of the lumbar plexus (FN, ON, and LFCN) with a single- injection ultrasound-guided supra-inguinal fascia iliaca compartment (S-FICB). A computer tomography (CT scan)-guided step-up/step-down sequence was used to determine the suggested injection volume to target all three nerves. Subsequently, an anatomist blinded for the injected volume and CT findings, dissected the cadavers, and evaluated the spread of dye underneath the fascia iliaca. In total, seven pelvic areas of four cadavers were evaluated on CT scan and dissected. Distribution of dye underneath the FI in relation to the FN, ON, and the LFCN was recorded in all dissected cadavers. Combining CT and dissection findings, the suggested volume to reach the FN, ON, and LFCN with an S-FICB was 40 mL.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

168. Establishment of Predictive Models for Nonocclusive Mesenteric Ischemia Comparing 8,296 Control with 452 Study Patients Author(s): Bomberg H.; Karrenbauer K.; Schafers H.-J.; Groesdonk H.V.; Stroeder J.; Bucker A.; Minko P.; Wagenpfeil S.; Klingele M. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: The aim of this study was to develop clinical preoperative, intraoperative, and postoperative scores for early identification of patients who are at risk of nonocclusive mesenteric ischemia (NOMI). Design: A retrospective analysis. Setting: Single center. Participants: From January 2008 to December 2014, all patients from the Department of Thoracic and Cardiovascular Surgery were included on the basis of the hospital database. Interventions: All mesenteric angiographically identified NOMI patients were compared with non-NOMI patients. Measurements and Main Results: The study population of 8,748 patients was randomized into a cohort for developing the scores (non- NOMI 4,214 and NOMI 235) and a cohort for control (non-NOMI 4,082 and NOMI 217). Risk factors were identified using forward and backward Wald test and were included in the predictive scores for the occurrence of NOMI. C statistic showed that the scores had a high discrimination for the prediction of NOMI preoperatively (C statistic 0.79; p < 0.001), intraoperatively (C statistic 0.68; p < 0.001), and postoperatively (C statistic 0.85; p < 0.001). A combination of the preoperative, intraoperative, and postoperative risk scores demonstrated the highest discrimination (C statistic 0.87; p < 0.001). The combined score included the following risk factors: renal insufficiency (preoperative); use of cardiopulmonary bypass and intra-aortic balloon pump support (intraoperative); and reexploration for bleeding, renal replacement therapy, and packed red blood cells >= 4 units (postoperative). The results were similar in the control group. Conclusions: These scores could be useful to identify patients at risk for NOMI and promote a rapid diagnosis and therapy.Copyright © 2018 Elsevier Inc. Database: EMBASE

169. Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles Author(s): ter Woorst J.F.; Hoff A.H.T.; van Straten A.H.M.; Soliman-Hamad M.A.; Houterman S. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: The aim of this study was to compare the patient profiles and outcomes of men and women undergoing isolated aortic valve replacement. Design: Patient data were analyzed retrospectively. Setting: This single-center study was performed at Catharina Hospital in Eindhoven, the Netherlands. Participants: The study comprised 2,362 patients, of whom 1,040 (44%) were women and 1,322 were men (56%). Interventions: Isolated aortic valve replacement was performed between January 1998 and December 2016. Measurements and Main Results: The mean follow-up was 8.3 +/- 5.1 years. Women were relatively older (69.9 years v 64.6 years; p < 0.001); more of them were underweight, obese, and diabetic; and they had lower hemoglobin values and worse renal function than did men. However, fewer women than men experienced chronic obstructive pulmonary disease, aortic regurgitation, left ventricular dysfunction, and endocarditis. Early mortality did not differ significantly between men and women (p = 0.238). Overall survival was worse in women (p < 0.001). After correction for potential risk factors, female sex was not associated with worse survival. During the study period, the mean age of patients undergoing aortic valve replacement increased. In addition, the mean age at the time of death increased, following the trend of national statistics. Conclusions: Although women undergoing aortic valve replacement have relatively more risk factors than do men, early mortality in women is not significantly higher than in men. Overall survival is worse in women than in men; however, after adjustment for preoperative risk factors, there is no difference in overall survival between women and men.Copyright © 2018 Elsevier Inc. Database: EMBASE

170. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: renal endpoints Author(s): McIlroy D.R.; Myles P.S.; Bellomo R.; Billings F.T.; Karkouti K.; Prowle J.R.; Shaw A.D. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Renal injury is a common perioperative complication. The adoption of renal endpoints, standardised and valid for use in perioperative clinical trials, would enhance the quality of perioperative clinical research. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive standardised endpoints for use in perioperative clinical trials. Methods: A systematic review was conducted to identify renal endpoints currently reported in perioperative clinical trials. In parallel, an initial list of candidate endpoints was developed based on renal theme group expertise. A multi-round Delphi consensus process was used to refine this list and produce a suite of recommended perioperative renal outcome measures. Results: Based on our systematic review, 63 studies were included for analysis. Marked heterogeneity and imprecision of endpoint definitions were observed. Our initial list of candidate endpoints included 10 endpoints for consideration. The response rates for Delphi rounds 1, 2, and 3 were 89% (n=16), 90% (n=75), and 100% (n=6), respectively. A final list of four renal endpoints was identified: acute kidney injury defined by the Kidney Disease: Improving Global Outcomes (KDIGO) consensus criteria, acute kidney disease defined by >=30% decline in estimated glomerular filtration rate from baseline at 30 days after operation in patients meeting the acute-kidney-injury criteria within 7 days of surgery, the composite of death or renal replacement therapy, and the Major Adverse Kidney Events (MAKE) composite. Conclusions: We identified four key renal outcome measures that should be considered for use in perioperative clinical trials. Using standardised definitions to capture and report these endpoints will facilitate improved benchmarking and meta-analysis of future trials.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

171. Pulmonary-Systemic Pressure Ratio Correlates with Morbidity in Cardiac Valve Surgery Author(s): Schubert S.A.; Mehaffey J.H.; Yarboro L.T.; Kern J.A.; Ailawadi G.; Booth A.; Kennedy J.L.W.; Mazimba S. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Pulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients' global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery. Design: Retrospective cohort study. Setting: Single academic hospital. Participants: The study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization. Interventions: None. Measurements and Main Results: The pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk- adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, p = 0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, p = 0.011, Wald 6.5). Conclusions: The pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery.Copyright © 2018 Elsevier Inc. Database: EMBASE

172. Minute ventilation assessment in the PACU is useful to predict postoperative respiratory depression following discharge to the floor: A prospective cohort study Author(s): Schumann R.; Zahedi F.; Bonney I.; Harvey B. Source: Journal of Clinical Anesthesia; Feb 2019; vol. 52 ; p. 93-98 Publication Date: Feb 2019 Publication Type(s): Article Abstract:Study Objective. Reliably identifying patients at risk for postoperative respiratory depression (RD) remains an unmet need. We hypothesized that defined low minute ventilation events (LMVe) near the end of the post-anesthesia care unit (PACU) stay identifies patients at RD risk on the general hospital floor (GHF). Design: Prospective observational study. Setting: Tertiary care, urban academic medical center. PACU and GHF during the first postoperative night. Patients: One hundred-and-nineteen adult, ASA I - III patients undergoing elective surgery under general anesthesia completed the study. Interventions: Data collection from a non-invasive respiratory volume monitor and the patients' medical record perioperatively through the first postoperative night. Measurements: Minute ventilation (MV), tidal volume (TV) and respiratory rate (RR) were measured continuously in the PACU and on the GHF. MV was counted as the percent of individual predicted MV (MVPRED), and RD was defined as >=1 LMVe/h on the GHF. Based on the number of LMVes within 30 min before PACU discharge, patients were grouped into A, 'Not-At-Risk': 0 LMVe and B, 'At-Risk': >=1 LMVes. Unpaired t-test, Mann-Whitney U test, ANOVA, Kruskal-Wallis test, Fisher's exact test, sensitivity and specificity and ROC curve analyses were applied as appropriate. Main results: One hundred-and-six (89%) and 13 (11%) patients met Group A and B criteria respectively. The latter had more LMVe/h on the GHF (median 0.81 vs 0, p <= 0.001), and their MVPRED was significantly less. Following opioid administration, the LMVe likelihood was 43% in Group B and 5.6% in Group A. As a predictor for RD on the GHF, the number of LMVe in the last 30 min of PACU, had positive and negative predictive values of 61.5% and 90.6%, respectively. Conclusion: Minute ventilation assessment in the PACU as described in this study can be useful to identify patients at risk for postoperative respiratory depression.Copyright © 2018 Elsevier Inc. Database: EMBASE

173. Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update Author(s): Barazanchi A.W.H.; MacFater W.S.; Rahiri J.-L.; Tutone S.; Hill A.G.; Joshi G.P.; Kehlet H.; Schug S.; Van de Velde M.; Vercauteren M.; Lirk P.; Rawal N.; Bonnet F.; Lavand'homme P.; Beloeil H.; Raeder J.; Pogatzki-Zahn E. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 787-803 Publication Date: Oct 2018 Publication Type(s): Review Abstract:Background: Significant pain can be experienced after laparoscopic cholecystectomy. This systematic review aims to formulate PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations to reduce postoperative pain after laparoscopic cholecystectomy. Methods: Randomised controlled trials published in the English language from January 2006 (date of last PROSPECT review) to December 2017, assessing analgesic, anaesthetic, or operative interventions for laparoscopic cholecystectomy in adults, and reporting pain scores, were retrieved from MEDLINE and Cochrane databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) search protocols. PROSPECT methodology was used, and recommendations were formulated after review and discussion by the PROSPECT group (an international group of leading pain specialists and surgeons). Results: Of 1988 randomised controlled trials identified, 258 met the inclusion criteria and were included in this review. The studies were of mixed methodological quality, and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported. Conclusions: We recommend basic analgesic techniques: paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration. Paracetamol and NSAID should be started before or during operation with dexamethasone (GRADE A). Opioid should be reserved for rescue analgesia only (GRADE B). Gabapentanoids, intraperitoneal local anaesthetic, and transversus abdominis plane blocks are not recommended (GRADE D) unless basic analgesia is not possible. Surgically, we recommend low- pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum (GRADE A). Single-port incision techniques are not recommended to reduce pain (GRADE A).Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

174. Comparison between neurally-assisted, controlled, and physiologically variable ventilation in healthy rabbits Author(s): Walesa M.; Bayat S.; Albu G.; Baudat A.; Habre W.; Petak F. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 918-927 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Various ventilation strategies have been proposed to reduce ventilation- induced lung injury that occurs even in individuals with healthy lungs. We compared new modalities based on an individualised physiological variable ventilation model to a conventional pressure- controlled mode. Methods: Rabbits were anaesthetised and ventilated for up to 7 h using pressure- controlled ventilation with (Group PCS, n=10), and without (Group PC, n=10) regular sighs. Variable ventilation in the other two groups was achieved via a pre-recorded spontaneous breathing pattern [Group physiologically variable ventilation (PVV), n=10] or triggered by the electrical activity of the diaphragm [Group neurally adjusted ventilation assist (NAVA), n=9]. Respiratory elastance, haemodynamic profile, and gas exchange were assessed throughout the ventilation period. Cellular profile, cytokine content of bronchoalveolar lavage fluid, and wet-to-dry lung weight ratio (W/D) were determined after protocol completion. Lung injury scores were obtained from histological analysis. Results: Marked deteriorations in elastance were observed (median and 95% confidence interval) in Group PC [48.6 (22)% increase from baseline], while no changes were detected in Groups PCS [3.6 (8.1)%], PVV [18.7 (13.2)%], and NAVA [-1.4 (12.2)%]. In comparison with Group PC, Group PVV had a lower lung injury score [0.29 (0.02) compared with 0.36 (0.05), P<0.05] and W/D ratio [5.6 (0.1) compared with 6.2 (0.3), P<0.05]. There was no difference in blood gas, haemodynamic, or inflammatory parameters between the groups. Conclusions: Individualised PVV based on a pre- recorded spontaneous breathing pattern provides adequate gas exchange and promotes a level of lung protection. This ventilation modality could be of benefit during prolonged anaesthesia, in which assisted ventilation is not possible because of the absence of a respiratory drive.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

175. Factor IX from prothrombin complex concentrate augments low dose tissue factor-triggered thrombin generation in vitro Author(s): Hasan S.; Williams B.; Henderson R.; Mazzeffi M.A.; Tanaka K.A.; Abuelkasem E. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 936-943 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Prothrombin complex concentrate (PCC) is increasingly used to correct acquired coagulopathy in trauma and surgery. Dosing of PCC is guided by the prothrombin time, which only reflects the onset of thrombin generation, but does not account for variations in intrinsic pathway coagulation factors, including factor IX (FIX). We hypothesised that FIX contained in PCC could strongly influence thrombin generation patterns. Methods: Pooled normal, FIX-deficient, and warfarinised plasma were used to analyse the effects of FIX contained in PCC. PCC was evaluated at final concentrations of 0.2 and 0.4 IU ml-1 in FIX-deficient and normal plasma, and at 0.6 IU ml-1 in warfarinised plasma with elevated FVIII (1.5 IU ml-1), 40% dilution with saline, or both. The effects on thrombin generation were assessed by measuring both procoagulant and inhibitory segments. Results: FIX-deficient plasma had lower peak thrombin generation [30.6 (20.5-35.8) nM vs 130.2 (107-168) nM] and endogenous thrombin potential [472 (391-532) nM vs 1096 (958-1190) nM] than normal plasma. PCC addition resulted in significant increases of peak thrombin generation [81.8 (37.3-98.3) nM] and endogenous thrombin potential [808 (472-842) nM] in FIX-deficient plasma. The combination of FVIII and PCC resulted in greater increases relative to each agent alone, restoring normal thrombin generation. After 40% dilution, adding PCC, FVIII, or both, to FIX-deficient plasma increased peak thrombin generation, and prolonged the inhibitory phase of the endogenous thrombin potential. Conclusions: FIX derived from PCC strongly enhances tissue factor-triggered thrombin generation in the presence of elevated FVIII activity. Haemodilution further enhances procoagulant effects of FIX and FVIII by slowing down inhibition of procoagulant enzymes. Dosing of PCC per prothrombin time may underestimate PCC's procoagulant potential because it does not account for intrinsic tenase or antithrombin activity.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

176. Blood flow index as an indicator of successful sciatic nerve block: a prospective observational study using laser speckle contrast imaging Author(s): Wu X.; Li J.; Joypaul K.; Bao W.W.; Wang D.; Huang Y.J.; Mei W.; Li P.C. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 859-866 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Laser speckle contrast imaging allows real-time, non-invasive, quantitative measurements of regional blood flow. The objectives of this prospective observational study were to use laser speckle contrast imaging to evaluate blood flow changes after sciatic nerve block, and to determine whether this novel optical technique can evaluate block success. Methods: This observational study included 63 adult patients undergoing elective lower limb surgery with sciatic nerve block. Blood flow images and blood flow index (BFI) values of toes were recorded using laser speckle contrast imaging 5 min before nerve block and at 5 min intervals until 30 min after sciatic block. The sensitivity, specificity, and cut-off value of laser speckle contrast imaging for predicting successful sciatic block were determined by receiver operator characteristic (ROC) curve analysis. Results: The BFI values of toes were significantly increased at each time point after successful sciatic block, compared with the baseline value obtained 5 min before nerve block; in failed sciatic block, there were no significant differences. For successful sciatic block, the highest increase of BFI value was at the big toe. BFI increase of the big toe at 10 min after sciatic block has great potential as an indicator of block success. The area under the ROC curve was 0.954 at a cut-off value of 8.48 perfusion units (PU) with a sensitivity of 89% and a specificity of 100%. Conclusions: Laser speckle contrast imaging might be an early, objective, quantitative, and reliable indicator of successful sciatic block. BFI increase of the big toe not reaching 8.48 PU within 10 min after sciatic block indicates block failure. Clinical trial registration: NCT03169517.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

177. Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model Author(s): Eugene N.; Oliver C.M.; Bassett M.G.; Poulton T.E.; Kuryba A.; Johnston C.; Anderson I.D.; Moonesinghe S.R.; Grocott M.P.; Murray D.M.; Cromwell D.A.; Walker K.; Cripps M.; Cripps P.; Davies E.; Drake S.; Galsworthy M.; Goodwin J.; Salih T.; Lourtie J.; Papadimitriou D.; Peden C. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 739-748 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Among patients undergoing emergency laparotomy, 30-day postoperative mortality is around 10-15%. The risk of death among these patients, however, varies greatly because of their clinical characteristics. We developed a risk prediction model for 30-day postoperative mortality to enable better comparison of outcomes between hospitals. Methods: We analysed data from the National Emergency Laparotomy Audit (NELA) on patients having an emergency laparotomy between December 2013 and November 2015. A prediction model was developed using multivariable logistic regression, with potential risk factors identified from existing prediction models, national guidelines, and clinical experts. Continuous risk factors were transformed if necessary to reflect their non-linear relationship with 30-day mortality. The performance of the model was assessed in terms of its calibration and discrimination. Interval validation was conducted using bootstrap resampling. Results: There were 4458 (11.5%) deaths within 30-days among the 38 830 patients undergoing emergency laparotomy. Variables associated with death included (among others): age, blood pressure, heart rate, physiological variables, malignancy, and ASA physical status classification. The predicted risk of death among patients ranged from 1% to 50%. The model demonstrated excellent calibration and discrimination, with a C-statistic of 0.863 (95% confidence interval, 0.858-0.867). The model retained its high discrimination during internal validation, with a bootstrap derived C-statistic of 0.861. Conclusions: The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

178. Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation Author(s): Feigl G.; Aichner E.; Mattersberger C.; Zahn P.K.; Avila Gonzalez C.; Litz R. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 883-889 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: The posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site. Methods: After a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection. Results: Muscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases. Conclusions: We describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

179. Femoral nerve catheter vs local infiltration for analgesia in fast track total knee arthroplasty: short-term and long-term outcomes Author(s): Fenten M.G.E.; Bakker S.M.K.; Stienstra R.; Wymenga A.B.; Heesterbeek P.J.C.; Scheffer G.J. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 850-858 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: The aim was to compare the effects on short-term and long-term pain and functional outcome of periarticular local anaesthetic infiltration (LIA) with LIA of the posterior knee capsule in combination with a femoral nerve block (FNB) catheter in patients undergoing total knee arthroplasty. Methods: Eighty patients were randomised to one of two groups: Subjects in group LIA received periarticular LIA with ropivacaine 0.2% for postoperative analgesia; subjects in group FNB received LIA of the posterior capsule and a FNB catheter. The primary outcome parameter was functional capacity of the knee 12 months after surgery. Secondary parameters included mobility as determined by accelerometer data, pain, satisfaction with the analgesic regimen, hospital length of stay, and use of pain medication 3 and 12 months after surgery. Results: There were no differences between groups in long-term functional capacity, patient satisfaction and hospital length of stay. In the first 2 days, subjects in group FNB had slightly lower pain scores and used less opioids, and subjects in group LIA had a higher level of accelerometer activity. Three and 12 months after surgery, subjects in group FNB had lower maximum pain scores and were less likely to use any pain medication 12 months after surgery. Conclusions: Both techniques were similar regarding long-term functional outcome. Subjects in group FNB had slightly lower pain scores and lower opioid consumption after operation, lower maximum pain scores at 3 and 12 months, and were less likely to use any pain medication at 12 months. Clinical trial registration: NCT01966263.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

180. Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome Author(s): Piraccini E.; Calli M.; Bellantonio D.; Maitan S.; Biondi G.; Byrne H.; Musetti G. Source: European Journal of Pain (United Kingdom); Oct 2018; vol. 22 (no. 9); p. 1673-1677 Publication Date: Oct 2018 Publication Type(s): Article Available at European journal of pain (London, England) - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region. Methods: We describe a 60- year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine. Results: Pain disappeared and the result was maintained 3 months later. Discussion: This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region. Significance: The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

181. European Pain Federation (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management Author(s): Hauser W.; Finn D.P.; Kalso E.; Krcevski-Skvarc N.; Kress H.-G.; Morlion B.; Perrot S.; Schafer M.; Wells C.; Brill S. Source: European Journal of Pain (United Kingdom); Oct 2018; vol. 22 (no. 9); p. 1547-1564 Publication Date: Oct 2018 Publication Type(s): Review Available at European journal of pain (London, England) - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Cannabis-based medicines are being approved for pain management in an increasing number of European countries. There are uncertainties and controversies on the role and appropriate use of cannabis-based medicines for the management of chronic pain. EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper to empower and inform specialist and nonspecialist prescribers on appropriate use of cannabis-based medicines for chronic pain. The expert panel reviewed the available literature and harnessed the clinical experience to produce these series of recommendations. Therapy with cannabis-based medicines should only be considered by experienced clinicians as part of a multidisciplinary treatment and preferably as adjunctive medication if guideline-recommended first- and second-line therapies have not provided sufficient efficacy or tolerability. The quantity and quality of evidence are such that cannabis-based medicines may be reasonably considered for chronic neuropathic pain. For all other chronic pain conditions (cancer, non-neuropathic noncancer pain), the use of cannabis-based medicines should be regarded as an individual therapeutic trial. Realistic goals of therapy have to be defined. All patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to reach the predefined goals and/or the patient is additionally burdened by an unacceptable level of adverse effects and/or there are signs of abuse and misuse of the drug by the patient, therapy with cannabis-based medicines should be terminated. Significance: This position paper provides expert recommendations for nonspecialist and specialist healthcare professionals in Europe, on the importance and the appropriate use of cannabis-based medicines as part of a multidisciplinary approach to pain management, in properly selected and supervised patients.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

182. Fascial layers influence the spread of injectate during ultrasound-guided infraclavicular brachial plexus block: a cadaver study Author(s): Brenner D.; Mahon P.; Iohom G.; Shorten G.; Cronin M.; O'Flynn C. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 876-882 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Fascial layers of the neurovascular sheath containing the brachial plexus influence distribution of local anaesthetic, hence increasing the risk of block failure when performing infraclavicular brachial plexus block (ICB). Methods: Ultrasound-guided infraclavicular brachial plexus block was performed on cadavers using a single injection technique with dye (20-30 ml). After injection, we carried out consecutive dissection of the neurovascular bundle to study dye injectate spread and identify the presence of fascial layers. Ultrasound video images (scout scan and injection) and recordings of dissections were evaluated by independent experts (regional anaesthetists and anatomists). Results: Well defined fascial layers were identified at dissection in seven out of 12 infraclavicular spaces studied. These fascial layers impeded the spread of dye injectate substantially in six cases and partially in one case. No fascial layers were identified at dissection in five cases, in each of which the spread of injectate was complete throughout the neurovascular bundle. The sensitivity and specificity of ultrasonography and haptic sensation for detection of fascial layers were poor. Conclusions: When fascial layers are present in the neurovascular sheath, they impede the spread of injectate during infraclavicular brachial plexus block. Ultrasound detection of these fascial layers is unreliable in cadavers. These findings support the use of greater volumes of injectate or a multiple injection technique when performing this block.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

183. Controversies in office-based anesthesia: Obstructive sleep apnea considerations Author(s): Gupta R.; Pyati S. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1102-1107 Publication Date: Sep 2018 Publication Type(s): Review Abstract:As the number of procedures being performed in the office-based anesthesia (OBA) setting are increasing, so are the number of patients presenting for surgery with obstructive sleep apnea (OSA). There continues to be controversy regarding whether these patients can be safely cared for in the OBA setting. To date, no national guideline has clearly addressed this issue and while some have extrapolated lessons from what has been published for OSA in the ambulatory surgery center (ASC) setting, some argue that there is a significant difference in the availability of resources in the ASC versus the OBA setting. Those opposing OSA patients for OBA setting point to the prevalence of "practice drift," and no federal oversight as overarching reasons why the OBA is not an appropriate setting. Proponents of the OBA setting argue that a well-equipped OBA can have similar resources, and therefore similar outcomes, as an OR in the ASC setting. In this paper we explore the divergent views on this topic and present some recommendations based on best evidence.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

184. Non-ventilatory therapies for acute respiratory distress syndrome Author(s): Bourenne J.; Hraiech S.; Rambaud R.; Forel J.-M.; Guervilly C.; Papazian L.; Persico N. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1093-1101 Publication Date: Sep 2018 Publication Type(s): Review Abstract:Acute respiratory distress syndrome (ARDS) commonly affects intensive care unit patients and is associated with high mortality. In addition to etiologic treatment and protective ventilation, non-ventilatory therapies represent a significant part of ARDS care. Pharmacological treatments, extra corporeal devices and prone positioning are commonly grouped under this term. Studies have evaluated the individual effects of some of these non-ventilatory therapies in large randomized controlled trials. Recent advances concerning the beneficial use of neuromuscular blocking agents and prone positioning deserve attention. Conversely, the use of inhaled nitric oxide and almitrine remains to be specified. The debate concerning the role of corticosteroids could be renewed considering the emergence of new biomarkers. Finally, the use of extracorporeal membrane oxygenation and extra-corporeal CO2 removal remain under question. The aim of this review is to summarize the latest data concerning the mainly used non-ventilatory therapies and to integrate them into a global strategy of ARDS patient care.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

185. Chronic non-cancer pain in children: We have a problem, but also solutions Author(s): Vega E.; Beaulieu Y.; Gauvin R.; Ferland C.; Stabile S.; Pitt R.; Gonzalez Cardenas V.H.; Ingelmo P.M. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1081-1092 Publication Date: Sep 2018 Publication Type(s): Review Abstract:Chronic non-cancer pain in children and adolescents has been described as "a modern public health disaster" that has generated significant medical and economic burdens within society. Seen as a disease in its own right, chronic pain has short and long-term consequences that impact not only the patient's health but also that of friends and families, due to significant parenting stress and disruptions in family life and structure. The evidence supporting pharmacological treatments and interventional procedures is limited, and no single strategy has been shown to be completely effective in children with chronic non-cancer pain. Therefore, considering the multifactorial nature of chronic pain, these patients should be treated with a multidisciplinary, balanced approach that seeks a primary outcome of improved functioning rather than of pain reduction. Using a bio-psycho- social approach, a multidisciplinary team, including a physiotherapist, nurse, social worker, psychologist, and physician, has been effective in achieving this outcome of improved functioning in children and adolescents with chronic pain. In this review, we discuss the impact, associated conditions, and evolution of chronic pain, along with the crucial role of every member of a multidisciplinary chronic pain clinic involved in the care of the children and adolescents with chronic non-cancer pain.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

186. Monitoring the Oxygen Reserve Index can contribute to the early detection of deterioration in blood oxygenation during one-lung ventilation Author(s): Koishi W.; Kumagai M.; Ogawa S.; Hongo S.; Suzuki K. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1063-1069 Publication Date: Sep 2018 Publication Type(s): Article Abstract:BACKGROUND: Hypoxemia can occur during one-lung ventilation (OLV), but monitoring blood oxygenation using percutaneous oxygen saturation (SpO2) can be limited by detection latency, and SpO2 sometimes does not change during OLV. The Oxygen Reserve Index (ORiTM) is a novel index reported to detect impending desaturation before this is observed with SpO2 monitoring. This study assessed whether the ORi decreased earlier than SpO2 during OLV and evaluated its correlation with the partial pressure of arterial oxygen (PaO2) during OLV. METHODS: The study enrolled 15 patients undergoing elective thoracic surgery. The patient's trachea was intubated with a left-sided double-lumen endotracheal tube and the lungs were mechanically ventilated in pressure- control mode for 10 min, with the fraction of inspired oxygen set at 0.6. Right OLV was then initiated for 15 min or until SpO2 declined to 91%, while continuously recording the ORi and SpO2. PaO2 was measured 5 min before and every 3 min during OLV. Mean (SD) times from the start of OLV to the start of the decreases in ORi and SpO2 were calculated. RESULTS: ORi started decreasing significantly before SpO2 (ORi vs. SpO2: 171 [102] vs. 372 [231] s; P<0.01). ORi showed a significant, strong correlation with PaO2 (r2=0.671, P<0.01). CONCLUSIONS: ORi decreased earlier than SpO2 during OLV. This index could contribute to the early detection of deterioration in blood oxygenation during OLV.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

187. Mortality and long-term quality of life after percutaneous tracheotomy in Intensive Care Unit: A prospective observational study Author(s): Vargas M.; Brunetti I.; Micalizzi C.; Insorsi A.; Ball L.; Folentino M.; Sileo R.; Delucia A.; Cerana M.; Accattatis A.; Delisi D.; Pelosi P.; Servillo G.; Sutherasan Y.; Gratarola A.; Mora F.; Peretti G. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1024-1031 Publication Date: Sep 2018 Publication Type(s): Article Abstract:BACKGROUND: Quality of life and mortality after percutaneous dilatational tracheotomy (PDT) has been poorly investigated. The aims of this study were to evaluate the independent risk factors for Intensive Care Unit (ICU) mortality and investigate quality of life over the first year after PDT in critically ill patients. METHODS: This was a prospective, single-center, cohort study performed in a tertiary care University Hospital, enrolling consecutive ICU patients requiring elective PDT, collecting data during the tracheotomy procedure and the ICU stay. Follow-up was performed at three, six and twelve months after PDT. The medical interview included the Euro Quality of Life questionnaire comprising five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression). RESULTS: Atotal of 137 patients were included in the study. In the multivariate analysis, ICU mortality was independently associated with age (OR1.089; P=0.003) and SAPSII(OR1.047; P=0.003), and inversely with neurologic disease (OR0.162; P=0.004). Mortality increased over time (ICU mortality 26.7%; in-hospital mortality 43.1%; 3-months mortality 47.4%; 6- months mortality 61.3%; and 1-year mortality 70.8%; P=0.0001). Tracheostomized patients due to respiratory disease had a higher ICU mortality (50%) compared to those with neurological disease (13.6%). quality of life (QoL) of tracheostomized patients was severely compromised at 3-months (QoL: 17, 15-19), 6-months (QoL: 17; 16-19), while moderately compromised at 1-year (QoL: 13; 9- 16). Asubgroup analysis showed better QoLat 3-months, 6-months and 1-year in respiratory compared to neurological tracheostomized patients (P=0.01). CONCLUSIONS: Patients baseline characteristics and indication for PDTprocedure are important determinants of in- ICU mortality and QoLin tracheostomized patients.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

188. The effectiveness of generic self-management interventions for patients with chronic musculoskeletal pain on physical function, self-efficacy, pain intensity and physical activity: A systematic review and meta-analysis Author(s): Elbers S.; Wittink H.; Pool J.J.M.; Smeets R.J.E.M. Source: European Journal of Pain (United Kingdom); Oct 2018; vol. 22 (no. 9); p. 1577-1596 Publication Date: Oct 2018 Publication Type(s): Review Available at European journal of pain (London, England) - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Generic self-management programs aim to facilitate behavioural adjustment and therefore have considerable potential for patients with chronic musculoskeletal pain. Our main objective was to collect and synthesize all data on the effectiveness of generic self-management interventions for patients with chronic musculoskeletal pain in terms of physical function, self-efficacy, pain intensity and physical activity. Our secondary objective was to describe the content of these interventions, by means of classification according to the Behaviour Change Technique Taxonomy. We searched PubMed, CENTRAL, Embase and Psycinfo for eligible studies. Study selection, data extraction and risk of bias were assessed by two researchers independently. Meta-analyses were only performed if the studies were sufficiently homogeneous and GRADE was used to determine the quality of evidence. We identified 20 randomized controlled trials that compared a self-management intervention to any type of control group. For post-intervention results, there was moderate quality evidence of a statistically significant but clinically unimportant effect for physical function and pain intensity, both favouring the self-management group. At follow-up, there was moderate quality evidence of a small clinically insignificant effect for self-efficacy, favouring the self-management group. All other comparisons did not indicate an effect. Classification of the behaviour change techniques showed large heterogeneity across studies. These results indicate that generic self-management interventions have a marginal benefit for patients with chronic musculoskeletal pain in the short- term for physical function and pain intensity and for self-efficacy in the long-term, and vary considerably with respect to intervention content. Significance: This study contributes to a growing body of evidence that generic self-management interventions have limited effectiveness for patients with chronic musculoskeletal pain. Furthermore, this study has identified substantial differences in both content and delivery mode across self-management interventions.Copyright © 2018 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC Database: EMBASE

189. Comorbid fibromyalgia: A qualitative review of prevalence and importance Author(s): Fitzcharles M.-A.; Perrot S.; Hauser W. Source: European Journal of Pain (United Kingdom); Oct 2018; vol. 22 (no. 9); p. 1565-1576 Publication Date: Oct 2018 Publication Type(s): Review Available at European journal of pain (London, England) - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However, there is increasing report of FM associated with other diseases that are not defined by chronic pain. This qualitative review examines the evidence for comorbid FM in illness, and where available the effect of FM on the primary disease. Other than for musculoskeletal disorders, the published literature reporting an association of FM with illness is limited with scanty reports for some neurological, gastrointestinal, mental health and other overlapping pain conditions. Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases. When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed. Significance: Comorbid fibromyalgia (FM) in other medical conditions is largely unrecognized. When reported as accompanying rheumatic diseases, FM adversely affects global health status. With limited reports of comorbid FM with other conditions, neglect to diagnose comorbid FM may misdirect treatments.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

190. Quality of life after spinal cord injury: The impact of pain Author(s): Burke D.; Lennon O.; Fullen B.M. Source: European Journal of Pain (United Kingdom); Oct 2018; vol. 22 (no. 9); p. 1662-1672 Publication Date: Oct 2018 Publication Type(s): Article Available at European journal of pain (London, England) - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Pain is a common complication after spinal cord injury (SCI). A mixture of nociceptive and neuropathic pain (NP) can present. Limited studies have investigated the impact of different pain phenotypes on quality of life (QoL) post-SCI. Methods: Members registered to a national support group for those with SCIs were surveyed (n = 1574). The survey comprised questions relating to demographics and SCI characteristics, The Douleur Neuropathique 4 (DN4) (interview), the International SCI Pain Basic Data Set recording the worst pain and the World Health Organisation Quality of Life BREF (WHOQOL-BREF). An ANCOVA model with post hoc analysis explored between group factors of pain type and intensity of pain categories on QoL, controlling for additional confounding variables. Significance was set p < 0.05. A linear regression explored whether pain intensity, type or interference best predicted QoL. Results: The response rate was 41% (n = 643), 70% (n = 447) were male. The mean age of respondents was 52 years (SD 14.2) and mean time from SCI was 17 years (SD 12.4). In the previous week, 71% (n = 458) experienced pain, 37% (n = 236) of which had NP as defined in the study. Respondents experiencing NP demonstrated significantly poorer QoL than those without pain (p < 0.001) or nociceptive pain (p < 0.05). Those reporting high pain intensity had significantly lower QoL than those with moderate or no pain (p < 0.001). Pain interference consistently and best-predicted domains of QoL (p < 0.001). Conclusion: High-intensity pain and NP negatively impacts QoL post-SCI. However pain interference more than intensity or type best explains the variance in QoL reported. Significance: Neuropathic pain type and severe pain intensities negatively impact QoL after SCI. Pain interference items better predict reported QoL than either pain type or intensity, suggesting better pain management strategies are warranted.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

191. Ultrasound-guided adductor canal block: a cadaver study investigating the effect of a thigh tourniquet Author(s): Nair A.; Kellett C.F.; Dolan J.; Tanner K.E.; Kerr C.M.; Jones B.; Pollock P.J. Source: British Journal of Anaesthesia; Oct 2018; vol. 121 (no. 4); p. 890-898 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Placement of local anaesthetic within the adductor canal using ultrasonography is an alternative to femoral nerve blocks for postoperative pain relief after knee joint replacement surgery. However, the effect of an inflated thigh tourniquet on the distribution of local anaesthetic within the adductor canal is unknown. The aim of this cadaveric study was to compare the distribution of radio-opaque dye within the adductor canal in the presence or absence of an inflated thigh tourniquet. Methods: Bilateral ultrasound-guided adductor canal blocks were performed on the thawed lower limbs of five fresh frozen human cadavers. The left and right lower cadaver limbs were randomised to receive or not receive a thigh tourniquet inflated to 300 mm Hg for 1 h. X-rays with iohexol radio-opaque dye were obtained in four views, and fiducial markers inserted as reference points. Virtual editing technology was used to recreate outlines representing the distribution of the radio-opaque dye and superimpose these on anatomical images. Results: Radio-opaque dye was distributed on the medial aspect of the thighs with entire and well circumscribed margins. The majority of the radio-opaque dye was confined within the adductor canal. Superior-inferior dye distribution was 315 mm [95% confidence intervals (CI) 289-342] and 264 mm (95% CI 239-289) in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -80.46 to -22.22, P=0.0081). Image analysis using the recreated radio-opaque outlines suggested that the most proximal point of the radio-opaque dye was 100 mm (95% CI 82-117) or 117 mm (95% CI 62-171) below the inguinal ligament in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -38 to 72, P=0.456). Conclusions: Application and inflation of thigh tourniquets significantly increased the combined superior-inferior dye distribution within the adductor canal of cadaveric limbs. There was insufficient evidence to suggest significant proximal spread of 25 ml of local anaesthetic to involve the motor branches of the femoral nerve. In some patients, the local anaesthetic may reach the popliteal fossa in close approximation to the sciatic nerve.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

192. The Use of Regional or Local Anesthesia for Carotid Endarterectomies May Reduce Blood Loss and Pulmonary Complications Author(s): Malik O.S.; Brovman E.Y.; Urman R.D. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: Over 150,000 carotid endarterectomy (CEA) procedures are performed each year. Perioperative anesthetic management may be complex due to multiple patient and procedure- related risk factors. The authorsaimed to determine whether the use of general anesthesia (GA), when compared with regional anesthesia (RA), would be associated with reduced perioperative morbidity and mortality in patients undergoing a CEA. Design: Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Setting: The authors evaluated patients undergoing a CEA at multiple university- and community- based settings. Participants: A total of 43,463 patients were identified; 22,845 patients were propensity matched after excluding for missing data. Interventions: The study population was divided into 2 groups: patients undergoing RA or GA. The RA group included regional anesthesia performed by the anesthesiologist or surgeon, monitored anesthesia care, and local infiltration. Methods: The primary endpoint was 30-day mortality. Secondary endpoints included surgical site infection, pulmonary complications, return to the operating room, acute kidney injury, cardiac arrest, urinary tract infection, myocardial infarction, thromboembolism, perioperative transfusion, sepsis, and days to discharge. Measurements and Main Results: Younger age, Hispanic ethnicity, body mass index <18.5, dyspnea, chronic obstructive pulmonary disease, and smoking history were associated with receiving GA. Patients with low hematocrit and low platelets were more likely to get RA. There was no mortality difference. GA was associated with a significantly higher rate of perioperative transfusions (p = 0.037) and perioperative pneumonia (p = 0.027). Conclusion: The use of RA over GA in CEA is associated with decreased risk of postoperative pneumonia and a reduced need for perioperative blood transfusions.Copyright © 2018 Elsevier Inc. Database: EMBASE

193. Renal Angina Is a Sensitive, but Nonspecific Identifier of Postcardiac Surgery Acute Kidney Injury Author(s): Fierro M.A.; Stafford-Smith M.; Swaminathan M.; Ehieli E.I.; Cooter M.; Traylor A. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Acute kidney injury (AKI) is a common complication of cardiac surgery, and early detection is difficult. This study was performed to determine the sensitivity, specificity, positive predictive value, negative predictive value, and statistical performance of renal angina (RA) as an early predictor of AKI in an adult cardiac surgical patient population. Design: Retrospective, nonrandomized, observational study. Setting: A single, university-affiliated, quaternary medical center. Participants: The study comprised 324 consecutive patients undergoing coronary artery bypass grafting or cardiac valvular surgery from February 1 through July 30, 2014. Interventions: None. Measurements and Main Results: One hundred-seven patients at moderate or high risk of developing postoperative renal injury were identified, 82 of whom met criteria for RA. The occurrence of RA was found to have an 80.9% sensitivity and 30.8% specificity for the prediction of AKI using Acute Kidney Injury Network criteria and 89.3% sensitivity and 27.8% specificity when paired with the Risk, Injury, Failure, Loss, End Stage Renal Disease criteria. A receiver operating characteristic area under the curve analysis revealed a nonsignificant predictive ability of 55.8% (95% confidence interval 0.47-0.65) when RA was paired with Acute Kidney Injury Network criteria; however, the receiver operating characteristic area under the curve was significant when paired with Risk, Injury, Failure, Loss, End Stage Renal Disease criteria, with a predictive ability of 0.586 (0.509-0.662). Conclusions: RA is a sensitive, but nonspecific, predictor of postcardiac surgery AKI, with clinical utility most suited as a screening tool.Copyright © 2018 Elsevier Inc. Database: EMBASE

194. Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study Author(s): Drew T.; McCaul C.L. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Evaluation of the anterior neck anatomy is used to identify the cricothyroid membrane (CTM) before front of neck airway access. This has been traditionally performed using palpation which results in misidentification of the CTM in a high proportion of subjects. The 'laryngeal handshake' is currently advocated by the Difficult Airway Society as the method to identify the CTM. We sought to investigate the accuracy of this technique in females. Methods: Five clinicians were asked to identify the CTM using the 'laryngeal handshake' technique in a total of 45 anaesthetised females (Group L) and by conventional palpation in 45 controls (Group P). We measured and analysed the distance to actual CTM using ultrasound, the time to identification, and perceived difficulty using a visual analogue scale. Results: Successful identification of the CTM occurred in 28/45 (62%) patients in Group L vs 15/45 (33%) in Group P [P=0.006; mean difference, 29%; 95% confidence interval (CI), 21-39%]. Distance to the CTM (P=0.012) and visual analogue scale (P=0.012) were significantly reduced in Group L. Mean time to CTM identification was greater in Group L at 31 (5.6) s, compared with Group P, which took 18 (5.5) s (P<0.001). The midline was accurately identified more frequently in Group L than in Group P (39/45 vs 28/45, P=0.008). Conclusions: The 'laryngeal handshake' method of palpation is more accurate but takes longer than conventional palpation technique in locating the CTM and the midline. This is of particular relevance if a vertical incision is required to perform front of neck access when anatomy is indistinct.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

195. Predicting pain recovery in patients with acute low back pain: Updating and validation of a clinical prediction model Author(s): da Silva T.; Mills K.; Hancock M.J.; Macaskill P.; Kongsted A.; Maher C.G. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: The prognosis of acute low back pain (LBP) is typically good; however, there is substantial variation in individual patient's outcomes. We recently developed a prediction model that was able to predict the likelihood of pain recovery in patients with acute LBP who continue to have pain approximately 1 week after initially seeking care. The aims of the current study were to (a) re-categorize the variables in the developmental dataset to be able to validate the model in the validation dataset; (b) refit the existing model in the developmental dataset; and (c) validate the model in the validation dataset. Methods: The validation study sample comprised 737 patients with acute LBP, with a pain score of >=2/10, 1 week after initially seeking care and with duration of current episode of <=4 weeks. The primary outcome measure was days to pain recovery. Some of the variables from the development dataset were re-categorized prior to refitting the existing model in the developmental dataset using Cox regression. The performance (calibration and discrimination) of the prediction model was then tested in the validation dataset. Results: Three variables of the development dataset were re-categorized. The performance of the prediction model with re- categorized variables in the development dataset was good (C-statistic = 0.76, 95% CI 0.70-0.82). The discrimination of the model using the validation dataset resulted in a C-statistic of 0.71 (95% CI 0.63- 0.78). The calibration for the validation sample was acceptable at 1 month. However, at 1 week the predicted proportions within quintiles tended to overestimate the observed recovery proportions, and at 3 months, the predicted proportions tended to underestimate the observed recovery proportions. Conclusions: The updated prediction model demonstrated reasonably good external validity and may be useful in practice, but further validation and impact studies in relevant populations should be conducted. Significance: A clinical prediction model based on five easily collected variables demonstrated reasonable external validity. The prediction model has the potential to inform patients and clinicians of the likely prognosis of individuals with acute LBP but requires impact studies to assess its clinical usefulness.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

196. Misaligned feeding may aggravate pain by disruption of sleep-awake rhythm Author(s): Xu F.; Zhao X.; Liu H.; Shao X.; Chu S.; Gong X.; Ma Z.; Gu X. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 255-260 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Increasing evidence suggests that patients with eating disorders are more likely to develop chronic pain. A misaligned diet has been reported to disrupt the sleep-awake rhythms. Combined with our previous investigation on circadian pain, we aimed to investigate the role of misaligned diet in the pain sensitivity and the underlying mechanisms. METHODS: Two- month-old C57BL/6J male mice were administered chronic constriction injury (CCI) surgery to establish neuropathic pain models. CCI mice were randomized to scheduled food access throughout the whole day (CCI-free), during the daytime (CCI-misaligned), and at night (CCI-aligned), respectively. The paw withdrawal mechanical threshold, indicating pain behavior, was measured by Von Frey. The gross motor activity pattern indicating the sleep-awake rhythm was monitored by Mini-Mitter. Melatonin (Mel) was administered to ameliorate the sleep-awake rhythm (CCI-free + Mel and CCI-misaligned + Mel). The expressions of circadian pain-related proteins were detected by quantitative polymerase chain reaction and western blot. The primary outcome is the pain threshold and the secondary outcome is the sleep-awake rhythm. RESULTS: Misaligned diet during the peri-CCI surgery period significantly decreased the paw withdrawal mechanical threshold compared with the CCI-free mice (day 14: 0.40 +/- 0.09 vs 0.64 +/- 0.15; P = .03;) and altered the sleep-awake rhythm. Mel pretreatment alleviated the increased pain (day 14, CCI-misaligned + Mel versus CCI-misaligned: day 14: 0.60 +/- 0.13 vs 0.35 +/- 0.12; P = .022) and the disrupted sleep-awake rhythm caused by misaligned feeding. The mRNA levels of N-methyl-d-aspartate receptor subtype 2B (NR2B), Ca2+/calmodulin-dependent protein kinase II (CaMKII), and cyclic adenosine monophosphate- response element binding protein (CREB) in the spinal dorsal horn increased in CCI-misaligned mice compared with the CCI-free mice. The phosphor-NR2B, phosphor-CaMKII, and phosphor-CREB also increased in CCI-misaligned mice compared with the CCI-free mice. However, the expressions of NR2B, CaMKII, and CREB were decreased in CCI-misaligned + Mel mice compared to CCI-misaligned mice at both transcriptional and translational levels. CONCLUSIONS: Misaligned diet might aggravate pain sensitivity through the disruption of the sleep-awake cycle, which could be recovered by Mel. NR2B-CaMKII-CREB may participate in the disruption of sleep-awake rhythm-mediated pain aggravation.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

197. Proximal versus distal continuous adductor canal blocks: Does varying perineural catheter location influence analgesia? A randomized, subject-masked, controlled clinical trial Author(s): Sztain J.F.; Khatibi B.; Said E.T.; Abramson W.B.; Gabriel R.A.; Finneran J.J.; Bellars R.H.; Nguyen P.L.; Ilfeld B.M.; Monahan A.M.; Ball S.T.; Gonzales F.B.; Ahmed S.S.; Donohue M.C.; Padwal J.A. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 240-246 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: A continuous adductor canal block provides analgesia after surgical procedures of the knee. Recent neuroanatomic descriptions of the thigh and knee led us to speculate that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal catheter location. We therefore tested the hypothesis that during a continuous adductor canal nerve block, postoperative analgesia would be improved by placing the perineural catheter tip 2-3 cm cephalad to where the femoral artery descends posteriorly to the adductor hiatus (distal location) compared to a more proximal location at the midpoint between the anterior superior iliac spine and the superior border of the patella (proximal location). METHODS: Preoperatively, subjects undergoing total knee arthroplasty received an ultrasound-guided perineural catheter inserted either in the proximal or distal location within the adductor canal in a randomized, subject-masked fashion. Subjects received a single injection of lidocaine 2% via the catheter preoperatively, followed by an infusion of ropivacaine 0.2% (8 mL/h basal, 4 mL bolus, 30 minutes lockout) for the study duration. After joint closure, the surgeon infiltrated the entire joint using 30 mL of ropivacaine (0.5%), ketorolac (30 mg), epinephrine (5 micro g/mL), and tranexamic acid (2 g). The primary end point was the median level of pain as measured on a numeric rating scale (NRS) during the time period of 8:00 am to 12:00 Pm the day after surgery. RESULTS: For the primary end point, the NRS of subjects with a catheter inserted at the proximal location (n = 24) was a median (10th, 25th-75th, 90th quartiles) of 0.5 (0.0, 0.0-3.2, 5.0) vs 3.0 (0.0, 2.0-5.4, 7.8) for subjects with a catheter inserted in the distal location (n = 26; P = .011). Median and maximum NRSs were lower in the proximal group at all other time points, but these differences did not reach statistical significance. There were no clinically relevant or statistically significant differences between the treatment groups for any other secondary end point, including opioid consumption and ambulation distance. CONCLUSIONS: For continuous adductor canal blocks accompanied by intraoperative periarticular local anesthetic infiltration, analgesia the day after knee arthroplasty is improved with a catheter inserted at the level of the midpoint between the anterior superior iliac spine and the superior border of the patella compared with a more distal insertion closer to the adductor hiatus.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

198. Benefit and harm of adding epinephrine to a local anesthetic for neuraxial and locoregional anesthesia: A meta-analysis of randomized controlled trials with trial sequential analyses Author(s): Tramer M.R.; Schneider A.; Zaarour M.; Elia N.; Tschopp C. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 228-239 Publication Date: Jul 2018 Publication Type(s): Review Abstract:BACKGROUND: This systematic review examines the benefit and harm of adding epinephrine to local anesthetics for epidural, intrathecal, or locoregional anesthesia. METHODS: We searched electronic databases to October 2017 for randomized trials comparing any local anesthetic regimen combined with epinephrine, with the same local anesthetic regimen without epinephrine, reporting on duration of analgesia, time to 2 segments regression, or any adverse effects. Trial quality was assessed using the Cochrane risk of bias tool and a random-effects model was used. Trial sequential analyses (TSA) were applied to identify the information size (IS; number of patients needed to reach a definite conclusion) and were set to detect an increase or decrease of effect of 30%-50%, depending on the end point considered. Alpha levels were adjusted (1%) for multiple outcome testing. RESULTS: We identified 70 trials (3644 patients, 17 countries, from 1970 to 2017). Median number of patients per trial was 44 (range, 9-174). Thirty-seven trials (1781 patients) tested epinephrine for epidural, 27 (1660) for intrathecal, and 6 (203) for locoregional anesthesia (sciatic, femoral, popliteal, axillary blocks). TSA enabled us to conclude that adding epinephrine to epidural local anesthetics could not decrease postoperative pain intensity by 30%, and did not impact the risk of intraoperative arterial hypotension. IS was insufficient to conclude on the impact of epinephrine on the risk of motor block (IS, 4%), arterial hypotension (20%), urinary retention (23%), or pain intensity at rest (27%) during labor. TSA confirmed that adding epinephrine to intrathecal local anesthetics increased the duration of motor block (weighted mean difference [WMD] 64 minutes; 99% CI, 37-91), analgesia (WMD 34 minutes; 99% CI, 6-62), and the time to 2 segments regression (WMD 20 minutes; 99% CI, 11-28). IS was insufficient to conclude on its impact on arterial hypotension (IS, 15%), or when administrated in a combined spinal-epidural, on motor block (IS, 11%) or arterial hypotension (IS, 11%). Adding epinephrine to local anesthetics for a locoregional block increased the duration of analgesia (WMD 66 minutes; 98% CI, 32-100]). CONCLUSIONS: Adding epinephrine to intrathecal or locoregional local anesthetics prolongs analgesia and motor block by no more than 60 minutes. The impact of adding epinephrine to epidural local anesthetics or to a combined spinal-epidural remains uncertain.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

199. Newborn resuscitation skills in health care providers at a zambian tertiary center, and comparison to world health organization standards Author(s): Mistry S.C.; Lin R.; Kettley L.C.; Pearson J.A.; Akrimi S.; Mumphansha H.; Mayne D.J.; Hangoma W.; Dylan Bould M. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 217-223 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Birth asphyxia is a leading cause of early neonatal death. In 2013, 32% of neonatal deaths in Zambia were attributable to birth asphyxia and trauma. Basic, timely interventions are key to improving outcomes. However, data from the World Health Organization suggest that resuscitation is often not initiated, or is conducted suboptimally. Currently, there are little data on the quality of newborn resuscitation in the context of a tertiary center in a lower- middle income country. We aimed to measure the competencies of clinical practitioners responsible for newborn resuscitation. METHODS: This observational study was conducted over 5 months in Zambia. Health care professionals were recruited from anesthesia, pediatrics, and midwifery. Newborn skills and knowledge were examined using the following: (1) multiple-choice questions; (2) a ventilation skills test; and (3) 2 low-medium fidelity simulation scenarios. Participant demographics including previous resuscitation training and a self-efficacy rating score were noted. The primary outcome examined performance scores in a simulated scenario, which assessed the care of a newborn that failed to respond to basic interventions. Secondary outcome measures included apnea times after delivery and performance in the other assessments. RESULTS: Seventy-eight participants were enrolled into the study (13 physician anesthesiology residents, 13 pediatric residents, and 52 midwives). A significant difference in interprofessional performance was observed when examining checklist scores for the unresponsive newborn simulated scenario (P = .006). The median (quartiles) checklist score (out of 18) was 14.0 (13.0-14.75) for the anesthesiologists, 11.0 (8.5-12.3) for the pediatricians, and 10.8 (8.3-13.9) for the midwives. A score of 14 or more was required to pass the scenario. There was no significant difference in performance between participants with and without previous newborn resuscitation training (P = .246). The median (quartiles) apnea time after delivery was significantly different between all groups (P = .01) with anesthetic and pediatric residents performing similarly, 61 (37-97) and 63 (42.5-97.5) seconds, respectively. The midwifery participants displayed a significantly longer apnea time, 93.5 (66.3-129) seconds. Self-efficacy rating scores displayed no correlation between confidence level and the primary outcome, Spearman coefficient 0.06 (P = .55). CONCLUSIONS: Newborn resuscitation skills among health care professionals are varied. Midwives lead the majority of deliveries with anesthesiologists and pediatricians only being present at operative or high-risk births. It is therefore common that midwifery practitioners will initiate resuscitation. Despite this, midwives perform poorly when compared to anesthesia and pediatric residents. To address this discrepancy, a multidisciplinary, simulation-based newborn resuscitation program should be considered with continual clinical reenforcement of best practice.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

200. Rates of perioperative respiratory adverse events among caucasian and African American children undergoing general anesthesia Author(s): Syed M.; Martin T.; Zhang X.; Schmitz M.; Tariq S. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 181-187 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Perioperative respiratory adverse events (PRAEs) account for the major cause of morbidity and mortality in children undergoing general anesthesia. In our institutional clinical practice, we suspected that African American children experienced untoward respiratory events more frequently than other racial groups. Identification of high-risk groups can guide decision making in the perioperative period, and aggressive optimization of specific care can enhance safety and improve outcomes. METHODS: Data came from a retrospective chart review for records from August 2013 to December 2013. The primary aim was to compare the incidence of PRAEs among racial groups of young children at a single institution. We also analyzed factors that are potentially associated with a higher risk of PRAEs. There were 1148 records that met the inclusion criteria. Racial identities, PRAEs, and risk factors were identified. Logistic regression analysis was performed to evaluate differences in PRAEs among racial groups controlling for confounding variables. RESULTS: Of all 1148 patients, 62 (5.4%) had a PRAE. African American children had significantly higher incidences of PRAE (26/231, 11.4%) compared to Caucasian (27/777, 3.5%; P < .001). Although the most common PRAE was laryngospasm, bronchospasm was the most common PRAE for African American children. Otolaryngology procedures were most commonly associated with PRAEs, followed by orthodontic procedures. CONCLUSIONS: In a multivariable logistic analysis, African American pediatric patients were shown to have significantly higher odds of PRAEs when compared with the Caucasian group.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

201. Clonidine effect on pain after cesarean delivery: A randomized controlled trial of different routes of administration Author(s): Bliacheriene F.; Vago T.M.; Corregliano G.T.; Torres M.L.; Francisco R.P.; Ashmawi H.A.; Fernandes H.S. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 165-170 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Intrathecal clonidine prolongs spinal anesthesia. We evaluated the effects of the addition of intrathecal or intravenous clonidine (75 micro g) to standard cesarean delivery spinal anesthesia on postoperative pain and neonatal outcomes. METHODS: In a randomized, placebo-controlled, double-blind trial, 64 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated and compared among 3 groups: intrathecal clonidine 75 micro g, intravenous clonidine 75 micro g, and placebo. The primary outcome was acute postoperative pain. A sample size of 26 individuals per group (N = 78) was planned. RESULTS: From April 2015 to April 2016, 64 women were analyzed (14 excluded). No differences in postoperative pain scores were found (Numerical Verbal Scale for pain at movement at 24 hours of postcesarean delivery: 4.53 +/- 3.0 vs 4.45 +/- 2.73 vs 3.93 +/- 3.07 for control, intrathecal, and intravenous, respectively, P = .771). Intrathecal and intravenous clonidine led to more sedation, in comparison to the control group, during the intraoperative period (Richmond Agitation and Sedation Scale: -0.3 +/- 0.47 vs -1 +/- 0.53 vs -0.73 +/- 0.45 for control, intrathecal, and intravenous, respectively, overall P < .001; Dunn correction: P < .001 for intrathecal versus control; P = .021 for intravenous versus control; and P = .208 for intrathecal versus intravenous). CONCLUSIONS: Intrathecal or intravenous clonidine had no effect on postoperative pain after cesarean delivery. Both intrathecal and intravenous clonidine caused more sedation.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

202. Safety and effectiveness of a novel facemask for positive pressure ventilation Author(s): Brown T.A.; Bridges K.H.; Sabbagh M.J.; Hand W.R.; Warters R.D.; Wolf B.J.; Szabo T.A. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 151-156 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Manual positive pressure ventilation is an essential skill in a variety of clinical situations. The C&E technique is commonly used with standard facemasks to provide effective ventilation. The Tao mask is a novel design that allows a more ergonomic grip. A seal between the mask and face is made with downward pressure of the palm, centered on the mask, and jaw lift is achieved with 4 fingers centered under the mandible. The purpose of this study was to evaluate the safety and effectiveness of the Tao mask compared to a standard mask before and after the administration of neuromuscular blockade (NMB) using 2 previously established ventilation scales. METHODS: One hundred fifty-two patients >18 years of age who were scheduled for general anesthesia were recruited. All care team members were shown a brief instructional video on the use of the Tao mask. After induction of general anesthesia with a standardized protocol, each patient was ventilated with both the standard (Vital Signs #082510) and Tao masks and effectiveness was measured using the Han and Warters scales. This process was repeated after NMB. The sequence of masks was determined with a random-number generator. RESULTS: Tao mask ventilation scores were significantly better than standard mask scores on both the Han scale and the Warters scale before the administration of NMB (P < .001 for both). Tao mask scores were also significantly better than standard mask scores on the Warters scale after the administration of NMB (P < .001). However, there was no significant difference on the Han scale between the 2 mask types after NMB (P = .180). On the Warters scale, there were significantly fewer patients who were difficult to ventilate with the Tao mask than the standard mask before NMB (18 vs 40; P < .001) and after NMB (8 vs 17; P = .005). No adverse events were reported with either mask. CONCLUSIONS: Our results indicate that the Tao mask demonstrated equivalent safety and superior effectiveness compared to a standard mask. The study design favored the standard mask because all participating practitioners had multiple years of experience with the standard mask and no prior experience with the Tao mask. Since the incidence of inadequate mask ventilation goes up significantly with inexperienced operators, the improved effectiveness of the Tao mask could be even more profound with novice operators.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

203. Perioperative peripheral nerve injury after general anesthesia: A qualitative systematic review Author(s): Murkin J.M.; Posner K.L.; Domino K.B.; Chui J. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 134-143 Publication Date: Jul 2018 Publication Type(s): Article Abstract:Perioperative peripheral nerve injury (PNI) is a well-recognized complication of general anesthesia that continues to result in patient disability and malpractice claims. However, the multifactorial etiology of PNI is often not appreciated in malpractice claims given that most PNI is alleged to be due to errors in patient positioning. New advances in monitoring may aid anesthesiologists in the early detection of PNI. This article reviews recent studies of perioperative PNI after general anesthesia and discusses the epidemiology and potential mechanisms of injury and preventive measures. We performed a systematic literature search, reviewed the available evidence, and identified areas for further investigation. We also reviewed perioperative PNI in the Anesthesia Closed Claims Project database for adverse events from 1990 to 2013. The incidence of perioperative PNI after general anesthesia varies considerably depending on the type of surgical procedure, the age and risk factors of the patient population, and whether the detection was made retrospectively or prospectively. Taken together, studies suggest that the incidence in a general population of surgical patients undergoing all types of procedures is <1%, with higher incidence in cardiac, neurosurgery, and some orthopedic procedures. PNI represent 12% of general anesthesia malpractice claims since 1990, with injuries to the brachial plexus and ulnar nerves representing two-thirds of PNI claims. The causes of perioperative PNI after general anesthesia are likely multifactorial, resulting in a "difficult to predict and prevent" phenomenon. Nearly half of the PNI closed claims did not have an obvious etiology, and most (91%) were associated with appropriate anesthetic care. Future studies should focus on the interaction between different mechanisms of insult, severity and duration of injury, and underlying neuronal reserves. Recent automated detection technology in neuromonitoring with somatosensory evoked potentials may increase the ability to identify at-risk patients and individualize patient management.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

204. Consensus statement on perioperative use of neuromuscular monitoring Author(s): Brull S.J.; Johnson K.B.; Kopman A.F.; Hunter J.M.; Fulesdi B.; Arkes H.R.; Elstein A.; Todd M.M.; Naguib M. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 71-80 Publication Date: Jul 2018 Publication Type(s): Article Abstract:A panel of clinician scientists with expertise in neuromuscular blockade (NMB) monitoring was convened with a charge to prepare a consensus statement on indications for and proper use of such monitors. The aims of this article are to: (a) provide the rationale and scientific basis for the use of quantitative NMB monitoring; (b) offer a set of recommendations for quantitative NMB monitoring standards; (c) specify educational goals; and (d) propose training recommendations to ensure proper neuromuscular monitoring and management. The panel believes that whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation. Ideally, this should be done at the hand muscles (not the facial muscles) with a quantitative (objective) monitor. Objective monitoring (documentation of train-of-four ratio =0.90) is the only method of assuring that satisfactory recovery of neuromuscular function has taken place. The panel also recommends that subjective evaluation of the responses to train-of-four stimulation (when using a peripheral nerve stimulator) or clinical tests of recovery from NMB (such as the 5-second head lift) should be abandoned in favor of objective monitoring. During an interim period for establishing these recommendations, if only a peripheral nerve stimulator is available, its use should be mandatory in any patient receiving a neuromuscular blocking drug. The panel acknowledges that publishing this statement per se will not result in its spontaneous acceptance, adherence to its recommendations, or change in routine practice. Implementation of objective monitoring will likely require professional societies and anesthesia department leadership to champion its use to change anesthesia practitioner behavior.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

205. Complications associated with mortality in the national surgical quality improvement program database Author(s): Maile M.D.; Jewell E.S.; Kheterpal S.; Engoren M.; Sferra J.J.; Freundlich R.E. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 55-62 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Attributing causes of postoperative mortality is challenging, as death may be multifactorial. A better understanding of complications that occur in patients who die is important, as it allows clinicians to focus on the most impactful complications. We sought to determine the postoperative complications with the strongest independent association with 30-day mortality. METHODS: Data were obtained from the 2012-2013 National Surgical Quality Improvement Program Participant Use Data Files. All inpatient or admit day of surgery cases were eligible for inclusion in this study. A multivariable least absolute shrinkage and selection operator regression analysis was used to adjust for patient pre- and intraoperative risk factors for mortality. Attributable mortality was calculated using the population attributable fraction method: the ratio between the odds ratio for mortality and a given complication in the population. Patients were separated into 10 age groups to facilitate analysis of age-related differences in mortality. RESULTS: A total of 1,195,825 patients were analyzed, and 9255 deceased within 30 days (0.77%). A complication independently associated with attributable mortality was found in 1887 cases (20%). The most common causes of attributable mortality (attributable deaths per million patients) were bleeding (n = 368), respiratory failure (n = 358), septic shock (n = 170), and renal failure (n = 88). Some complications, such as urinary tract infection and pneumonia, were associated with attributable mortality only in older patients. DISCUSSION: Additional resources should be focused on complications associated with the largest attributable mortality, such as respiratory failure and infections. This is particularly important for complications disproportionately impacting younger patients, given their longer life expectancy.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

206. Anesthesia for percutaneous pulmonary valve implantation: A case series Author(s): Salazar R.A.; Heggie J.; Wolski P.; Horlick E.; Osten M.; Meineri M. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 39-45 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: Twenty percent of patients born with congenital heart disease present with right ventricular outflow tract abnormalities. These patients require multiple surgical procedures in their lifetime. Transcatheter pulmonary valve replacement (TPVR) has become a viable alternative to conventional pulmonary valve and right ventricular outflow tract surgery in pediatric and adult populations. In this retrospective review, we analyze the perioperative management of adult patients who underwent TPVR in our center. METHODS: The study consisted of a chart review of patients who underwent TPVR at Toronto General Hospital between 2006 and 2015. Information about preoperative assessment, intraoperative anesthetic management, and intra- and postprocedural complications was collected. Two types of percutaneous valves have been used for a conduit or valve size between 16 and 28 mm. These procedures are done via the femoral, jugular, or subclavian vein under general anesthesia. RESULTS: Seventy-nine adults (17-68 years of age) who underwent elective TPVR procedures were included. General anesthesia was used in all cases. Defibrillation was necessary in 1 case, and bradycardia was spontaneously resolved in another 1. Eighty-five percent were successfully extubated at the end of the procedure. Five patients required intraoperative inotropic support. Three patients presented self-resolved hemoptysis. Mechanical ventilation for >24 hours was necessary in 3 cases, 2 of which also required concomitant inotropic support. Four failed deployments and 1 case of persistent conduit stenosis were reported. Three patients required reintubation. All patients were discharged home. CONCLUSIONS: Patients undergoing TPVR represent a complex and heterogeneous population. General anesthesia with endotracheal intubation is preferred. Setup for urgent lung isolation and cardiac defibrillation should be considered. Postoperative monitoring and intensive care setting are required. Anesthesiologists with cardiac anesthesia training are probably better suited to manage these patients.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

207. Anesthesiology and palliative care: Past, present, and future Author(s): Fine P.G.; Davis M.S.; Muir J.C.; Byas-Smith M. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 12-14 Publication Date: Jul 2018 Publication Type(s): Review Database: EMBASE

208. Safety and efficacy of addition of hyaluronidase to a mixture of lidocaine and bupivacaine in scalp nerves block in elective craniotomy operations; Comparative study Author(s): Mohamed A.A.; Radwan T.A.; Mohamed M.M.; Mohamed H.A.; Mohamed Elemady M.F.; Osman S.H.; Safan T.F.; Khair T.M.; Ali N.A.; Fahmy R.S.; Belita M.I.; Abdalla S.R.; Atta E.M.; Zaid O.I.; Seleem A.A.; Ragab A.S.; Salem A.E.; Alkholy B.M. Source: BMC Anesthesiology; Sep 2018; vol. 18 (no. 1) Publication Date: Sep 2018 Publication Type(s): Article Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Available at BMC anesthesiology - from springer.com Abstract:Background: Patients undergoing craniotomy operations are prone to various noxious stimuli, many strategies are commenced to provide state of analgesia, for better control of the stress response and to overcome its undesired effects on the haemodynamics and post-operative pain. Scalp nerves block are considered one of these strategies. This study was conceived to evaluate the effect of addition of hyaluronidase to the local anaesthetic mixture used in the scalp nerves block in patients undergoing elective craniotomy operations. Methods: 64 patients undergoing elective craniotomy operations were enrolled in this prospective randomized, double-blind comparative study. Patients were randomly assigned to two groups. Group LA, patients subjected to scalp nerves block with 15 ml bupivacaine 0.5%, 15 ml lidocaine 2%, in 1:400000 epinephrine. Group H as Group LA with15 IU /ml Hyaluronidase. Results: Patients in the H group showed lower VAS values for 8 h postoperative, compared to the LA group. The haemodynamic response showed lower values in the H group, compared to the LA group. Those effects were shown in the intraoperative period and for 6 h post-operative. No difference was detected regarding the incidence of complications nor the safety profile. Conclusion: Our data supports the idea that addition of hyaluronidase to the local anesthetic mixture improves the success rates of the scalp nerves block and its efficacy especially during stressful intraoperative periods and in the early postoperative period. No evident undesirable effects in relation to the addition of hyaluronidase. Trial registration: Clinical Trial registry on ClinicalTrials.gov, NCT 03411330, 25-1-2018.Copyright © 2018 The Author(s). Database: EMBASE

209. Craniotomie sur patient eveille utilisant la dexmedetomidine et des blocs des nerfs du scalp: une etude de cohorte retrospectiveAwake craniotomy using dexmedetomidine and scalp blocks: a retrospective cohort study Author(s): McAuliffe N.; Nicholson S.; Rigamonti A.; Hare G.M.T.; Garavaglia M.; Cusimano M.; Pshonyak I.; Das S. Source: Canadian Journal of Anesthesia; Oct 2018; vol. 65 (no. 10); p. 1129-1137 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Purpose: Anesthetic and surgical considerations for awake craniotomy (AC) include airway patency, patient comfort, and optimization of real-time brain mapping. The purpose of this study is to report our experience of using dexmedetomidine and scalp blocks, without airway intervention, as a means to facilitate and optimize intraoperative brain mapping and brain tumour resection during AC. Methods: We conducted a retrospective cohort study of 55 patients who underwent AC from March 2012 to September 2016. The incidence of critical airway outcomes, perioperative complications, and successful intraoperative mapping was determined. The primary outcome was the incidence of a failed AC anesthetic technique as defined by the need to convert to general anesthesia with a secured airway prior to (or during) brain mapping and brain tumour resection. Secondary outcomes were the intraoperative incidence of: 1) altered surgical management due to information acquired through real-time brain mapping, 2) interventions to restore airway patency or rescue the airway, 3) hemodynamic instability (> 20% from baseline), 4) nausea and vomiting, 5) new onset neurologic deficits, and 6) seizure activity. Results: There were no anesthesia-related critical events and no patients required airway manipulation or conversion to a general anesthetic. Multimodal language, motor, and sensory assessment with direct cortical electrical stimulation was successfully performed in 100% of cases. In 24% (13/55) of patients, data acquired during intraoperative brain mapping influenced surgical decision-making regarding the extent of tumour resection. Nine (16%) patients had intraoperative seizures. Conclusions: Dexmedetomidine-based anesthesia and scalp block facilitated AC surgery without any requirement for urgent airway intervention or unplanned conversion to a full general anesthetic. This approach can enable physiologic testing before and during tumour resection facilitating real-time surgical decision-making based on intraoperative brain mapping with patients awake thereby minimizing the risk of neurologic deficit and increasing the opportunity for optimal surgical resection.Copyright © 2018, Canadian Anesthesiologists' Society. Database: EMBASE

210. Epidemiology of acute kidney injury and the role of urinary [TIMP-2].[IGFBP7]: a prospective cohort study in critically ill obstetric patients Author(s): Tyagi A.; Luthra A.; Kumar M.; Das S. Source: International Journal of Obstetric Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: There are few data regarding acute kidney injury in critically-ill obstetric patients. A combination of urinary cell cycle arrest markers, tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein7 (IGFBP7), is validated for the early prediction of acute kidney injury in non-obstetric patients. Methods: We evaluated the epidemiology of acute kidney injury in critically-ill obstetric patients and the role of the biomarker combination in predicting acute kidney injury and mortality. Acute kidney injury, its severity and risk factors, were assessed using Kidney Disease: Improving Global Outcomes (KDIGO) guidelines during the intensive care unit stay. An ELISA technique measured TIMP-2 and IGFBP7 in urine samples collected at the time of admission there. Results: Results for 66 patients showed an overall incidence of acute kidney injury of 40/66 (61%), with 50%, 10% and 40% being in stage 1, 2 and 3 respectively. Patients with acute kidney injury showed significantly greater sepsis and shock; longer stay and higher mortality during intensive care (33% vs 0%) and in hospital (38% vs 0%) compared to those without (P <0.05). The area-under-the receiver operating characteristics curve was <0.5 for urinary [TIMP-2].[IGFBP7] as a predictor of kidney injury and mortality (P >0.05). Conclusions: Acute kidney injury is common in critically-ill obstetric patients, increasing mortality and duration of hospitalization. It was significantly more common in patients with septic shock. Previously validated results of urinary [TIMP- 2].[IGFBP7] that successfully predict early acute kidney injury or mortality are not applicable to obstetric patients.Copyright © 2018 Elsevier Ltd Database: EMBASE

211. Multimodal general anesthesia approach for Ex Utero Intrapartum Therapy (EXIT) procedures: two case reports Author(s): Dinges E.; Heier J.; Delgado C.; Bollag L. Source: International Journal of Obstetric Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:High-dose volatile anesthesia is the most common method of achieving uterine relaxation for Ex Utero Intrapartum Therapy (EXIT) procedures. Other methods employ nitroglycerin for additional uterine relaxation with or without remifentanil for additional fetal analgesia. We report a combination approach including one minimum alveolar concentration of volatile anesthetic plus nitroglycerin and remifentanil infusions, to provide timely uterine relaxation under general anesthesia for both mother and fetus, during two EXIT procedures.Copyright © 2018 Elsevier Ltd Database: EMBASE

212. Familial factors predicting recovery and maintenance of physical activity in people with low back pain: Insights from a population-based twin study Author(s): Zadro J.R.; Shirley D.; Ferreira P.H.; Duncan G.E. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: It is unknown how familial factors influence the recovery from low back pain (LBP) and the maintenance activity behaviours. We aimed to investigate whether individual and within-family physical activity (PA) and sedentary behaviour influenced recovery from LBP, and maintenance of PA and sedentary behaviour in people with and without LBP. Methods: Longitudinal logistic regression analyses were performed on adult twins from the Washington State Twin Registry. First, individual and within-family (based on co-twin data) sufficient PA (at least 75 min of vigorous-intensity PA, or 150 min of moderate-intensity PA per week) and high leisure sitting time (>=3 hr/day) were our exposure variables (baseline). LBP within the past 3 months at follow-up defined non-recovery (outcome). Second, within-family sufficient PA and high leisure sitting time were our exposure variables(baseline) and our outcomes were individual PA and sitting time at follow-up. All analyses were adjusted for follow-up length (range: 1-7 years) and confounding variables. Results: Individual and within-family PA and sitting time were not associated with recovery. Within-family PA and sitting time predicted individual maintenance of PA (OR = 1.47, 95% CI: 1.17-1.84, n = 1,388 twins) and sitting time (OR = 1.41, 95% CI: 1.10-1.82, n = 1,534). Within- family PA and sitting time had the strongest effects on those without (OR = 1.79, 95% CI: 1.33-2.41, n = 788) and with LBP (OR = 1.90, 95% CI: 1.32-2.76, n = 698), respectively. Conclusion: Having active family members increased the likelihood of continuing to be active (particularly for those without LBP), while having sedentary family members increased the likelihood of maintaining sedentary behaviours (particularly for those with LBP). Significance: This study was the first to investigate how familial activity behaviours influence recovery from LBP and ongoing activity behaviours. People with LBP living within a sedentary family likely require specific interventions to reduce their sedentary behaviours.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

213. Current Aura Without Headache Author(s): Shah D.R.; Friedman D.I.; Dilwali S. Source: Current Pain and Headache Reports; Nov 2018; vol. 22 (no. 11) Publication Date: Nov 2018 Publication Type(s): Review Abstract:Purpose of Review: This review evaluates and explains our current understanding of a rare subtype of migraine, typical aura without headache, also known as migraine aura without headache or acephalgic migraine. Recent Findings: Typical aura without headache is a known entity within the spectrum of migraine. Its pathophysiology is suggested to be similar to classic migraines, with cortical spreading depression leading to aura formation but without an associated headache. No clinical trials have been performed to evaluate treatment options, but case reports suggest that most patients will respond to the traditional treatments for migraine with aura. Bilateral greater occipital nerve blocks may be helpful in aborting migraine with prolonged aura. Transcranial magnetic stimulation has shown efficacy in aborting attacks of migraine with aura but has not been specifically tested in isolated aura. Summary: Typical aura without headache occurs exclusively in 4% patients with migraine, and may take place at some point in 38% of patients with migraine with aura. Typical aura without headache commonly presents with visual aura without headache, brainstem aura without headache, and can also develop later in life, known as late-onset migraine accompaniment.Copyright © 2018, Springer Science+Business Media, LLC, part of Springer Nature. Database: EMBASE

214. Delai de recuperation apres une anesthesie generale dans les hopitaux disposant d'une unite de soins postanesthesiques de phase I par rapport a des hopitaux n'en disposant pas : une etude de cohorte historiqueTime to recovery after general anesthesia at hospitals with and without a phase I post-anesthesia care unit: a historical cohort study Author(s): Thenuwara K.N.; Yoshimura T.; Nakata Y.; Dexter F. Source: Canadian Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: There is little knowledge about how hospitals can best handle disruptions that reduce post-anesthesia care unit (PACU) capacity. Few hospitals in Japan have any PACU beds and instead have the anesthesiologists recover their patients in the operating room. We compared postoperative recovery times between a hospital with (University of Iowa) and without (Shin- yurigaoka General Hospital) a PACU. Methods: This historical cohort study included 16 successive patients undergoing laparoscopic gynecologic surgery with endotracheal intubation for general anesthesia, at each of the hospitals, and with the hours from OR entrance until the last surgical dressing applied >= two hours. Postoperative recovery times, defined as the end of surgery until leaving for the surgical ward, were compared between the hospitals. Results: The median [interquartile range] of recovery times was 112 [94-140] min at the University of Iowa and 22 [18-29] min at the Shin-yurigaoka General Hospital. Every studied patient at the University of Iowa had a longer recovery time than every such patient at Shin-yurigaoka General Hospital (Wilcoxon-Mann- Whitney, P < 0.001). The ratio of the mean recovery times was 4.90 (95% confidence interval [CI], 4.05 to 5.91; P < 0.001) and remained comparable after controlling for surgical duration (5.33; 95% CI, 3.66 to 7.76; P < 0.001). The anesthetics used in the Iowa hospital were a volatile agent, hydromorphone, ketorolac, and neostigmine compared with the Japanese hospital where bispectral index monitoring and target-controlled infusions of propofol, remifentanil, acetaminophen, and sugammadex were used. Conclusions: This knowledge can be generally applied in situations at hospitals with regular PACU use when there are such large disruptions to PACU capacity that it is known before a case begins that the anesthesiologist likely will need to recover the patient (i.e., when there will not be an available PACU bed and/or nurse). The Japanese anesthesiologists have no PACU labour costs but likely greater anesthesia drug/monitor costs.Copyright © 2018, Canadian Anesthesiologists' Society. Database: EMBASE

215. The effects of general anaesthesia on oxygen consumption: A meta-analysis guiding future studies on perioperative oxygen transport Author(s): Jakobsson J.; Vadman S.; Kalman S.; Bartha E.; Hagel E. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Increased oxygen extraction, the ratio of consumption to delivery, has been associated with poor outcome after surgery. Oxygen consumption (VO2) can change in several ways in the perioperative period, but is seldom monitored directly in routine care. This study investigates the effects of general anaesthesia on VO2. Methods: We searched PubMed, EMBASE, and Cochrane Library 1946-2018 for studies including VO2 measurements before and after anaesthesia induction. Quality was assessed by Cochrane risk of bias tool and NIH Quality Assessment tool for before-and- after studies. Changes in VO2 after anaesthesia induction were pooled in a random effects model meta-analysis with standardized mean differences transformed to absolute changes of VO2. Changes in VO2 after surgical incision and after recovery from anaesthesia were analysed as secondary outcomes in the included studies. Results: Twenty-four studies including 453 patients were analysed for VO2 changes induced by anaesthesia. Studies were published during 1969-2000 and mean age of patients ranged 28-70 years. VO2 decreased after anaesthesia induction by -65 (-75; -55, 95% CI) mL min-1 and indexed VO2 (VO2I) by -33 (-38; -28, 95% CI) mL min-1 m-2. After surgical incision and in the post-operative period VO2 increased again. Heterogeneity was considerable among the studies and the overall quality of evidence was very low. Conclusions: General anaesthesia probably reduces oxygen consumption but the effect estimate is uncertain. Given the limited generalizability and low quality of the available evidence, new studies in modern perioperative settings and in today's older high-risk surgical patient populations are needed.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

216. Beyond Hypnograms: Assessing Sleep Stability Using Acoustic and Electrical Stimulation Author(s): Venugopal R.; Kumar G.; Nair A.K.; Kutty B.M.; Sasidharan A.; Marigowda V.; Sharma S.; Mukundan C.S. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objective: Conventional polysomnographic recordings reflect brain dynamics associated with sleep architecture. We hypothesized that noninvasive tools like transcranial alternating current stimulation (tACS) and acoustic stimulation (for generating event related potentials [ERPs]) would help to predict sleep stability and provide a window to actively assess brain activity during sleep. Materials and Methods: Twelve healthy male volunteers participated in the multiple whole-night polysomnography (PSG) recording protocol. Acoustic tones (100 msec duration) were presented throughout night to evaluate ERP during sleep. Furthermore, 30 sec tACS were presented during nonrapid eye movement (NREM) and rapid eye movement (REM) sleep on subsequent two nights without disturbing the subject's sleep. For ERP analysis, event-locked artifact-free epochs from each sleep stage were averaged separately. For tACS analysis, 30 sec prestimulus and poststimulus artifact-free EEG epochs were subjected to bootstrapping-based comparison of power spectral values. Results: Acoustic stimulation generated sleep stage-dependent ERP components (N350, N550, and P900) in all participants. The tACS stimulation during NREM sleep (0.75 Hz) increased parietal delta power but decreased frontocentral theta and increased frontal gamma power when delivered during REM sleep (40Hz). These interventions provide details on sleep stability as larger N550-P900 ERP-complex correlated with lower NREM disruptions (Spearman's rho = -0.553; p = 0.049; n = 10) and tACS-related theta power perturbation with higher REM disruptions (Spearman's rho = 0.734; p = 0.030; n = 7). Conclusions: Noninvasive brain stimulation approaches such as sleep ERP and sleep tACS are reliable tools to evaluate sleep stability during NREM and REM sleep, respectively, but more large-sample studies are warranted.Copyright © 2018 International Neuromodulation Society Database: EMBASE

217. Required cefazolin concentration to maximize diagnostic accuracy of the basophil activation test for cefazolin-induced anaphylaxis Author(s): Horiuchi T.; Orihara M.; Sakamoto S.; Saito S.; Takazawa T.; Yokohama A.; Takahashi J.; Tomioka A.; Yoshida N.; Hagiwara K. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: Identifying the causative agent of perioperative anaphylaxis is key to preventing its recurrence. Besides skin testing, the basophil activation test (BAT) is increasingly being accepted as an additional and reliable method. Cefazolin seems to be a major cause of perioperative anaphylaxis. However, few studies have described use of the BAT for cefazolin-induced anaphylaxis. In this study, we aimed to determine the optimum cefazolin concentration required in the BAT for an accurate diagnosis. Methods: Seven patients who presented with immediate hypersensitivity to cefazolin and 21 control subjects were studied. We conducted skin tests and performed BATs using both CD203c and CD63 as markers of activated basophils. We measured the ratio of activated basophils after stimulation with serial dilutions of cefazolin and investigated the cefazolin concentration that resulted in better sensitivity and specificity. Results: All patients demonstrated positive reactions to cefazolin, while all control subjects showed negative reactions on skin tests. The net percentage of both CD203c- and CD63-labeled activated basophils was greater when higher concentrations of cefazolin than previously reported were used. In control subjects, however, the number of activated basophils by cefazolin stimulation was negligible regardless of its concentration. In the case of CD203c, the sensitivity was 86% with a cefazolin concentration of 3 mg/ml, while in the case of CD63, the sensitivity was 100% with a cefazolin concentration of 10 mg/ml. Conclusion: Using a higher concentration of cefazolin than previously reported for the BAT might increase the accuracy of diagnosis of cefazolin-induced anaphylaxis.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

218. L'analyse de classe latente stratifie le risque de mortalite chez les patients developpant une insuffisance renale aigue apres une chirurgie generale intra-abdominale a risque eleve : une etude de cohorte historiqueLatent class analysis stratifies mortality risk in patients developing acute kidney injury after high-risk intraabdominal general surgery: a historical cohort study Author(s): Kim M.; Li G.; Wall M.M.; Kiran R.P. Source: Canadian Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: Risk stratification for postoperative acute kidney injury (AKI) evaluates a patient's risk for developing this complication using preoperative characteristics. Nevertheless, it is unclear if these characteristics are also associated with mortality in patients who actually develop this complication, so we aimed to determine these associations. Methods: The 2011-15 American College of Surgeons National Surgical Quality Improvement Program was used to obtain a historical, observational cohort of high-risk intraabdominal general surgery patients with AKI, which was defined as an increase in serum creatinine > 177 micro mol.L-1 (2 mg.dL-1) above the preoperative value and/or the need for dialysis. Latent class analysis, a model-based clustering technique, classified patients based on preoperative comorbidities and risk factors. The associations between the latent classes and the time course of AKI development and mortality after AKI were assessed with the Kruskall-Wallis test and Cox models. Results: A seven-class model was fit on 3,939 observations (derivation cohort). Two patterns for the time course of AKI diagnosis emerged: an "early" group (median [interquartile range] day of diagnosis 3 [1-10]) and a "late" group (day 9 [3- 16]). Three patterns of survival after AKI diagnosis were identified (groups A-C). Compared with the group with the lowest mortality risk (group A), the hazard ratios (95% confidence intervals) for 30- day mortality were 1.79 [1.55 to 2.08] for group B and 3.55 [3.06 to 4.13] for group C. These differences in relative hazard were similar after adjusting for the postoperative day of AKI diagnosis and surgical procedure category. Conclusions: Among patients with AKI after high-risk general surgery, the preoperative comorbid state is associated with the time course of and survival after AKI. This knowledge can stratify mortality risk in patients who develop postoperative AKI.Copyright © 2018, Canadian Anesthesiologists' Society. Database: EMBASE

219. Precision des technologies de surveillance continue de la frequence respiratoire a distance destinees aux unites cliniques de basse intensite : etude observationnelle prospectiveAccuracy of remote continuous respiratory rate monitoring technologies intended for low care clinical settings: a prospective observational study Author(s): van Loon K.; Peelen L.M.; van de Vlasakker E.C.; Kalkman C.J.; van Wolfswinkel L.; van Zaane B. Source: Canadian Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: Altered respiratory rate (RR) has been identified as an important predictor of serious adverse events during hospitalization. Introduction of a well-tolerated continuous RR monitor could potentially reduce serious adverse events such as opioid-induced respiratory depression. The purpose of this study was to investigate the ability of different monitor devices to detect RR in low care clinical settings. Methods: This was a prospective method-comparison study with a cross-sectional design. Thoracic impedance pneumography (IPG), frequency modulated continuous wave radar, and an acoustic breath sounds monitor were compared with the gold standard of capnography for their ability to detect RR in breaths per minute (breaths.min-1) in awake postoperative patients in the postanesthesia care unit. The Bland and Altman method for repeated measurements and mixed effect modelling was used to obtain bias and limits of agreement (LoA). Furthermore, the ability of the three devices to assist with correct treatment decisions was evaluated in Clarke Error Grids. Results: Twenty patients were monitored for 1,203 min, with a median [interquartile range] of 61 [60-63] min per patient. The bias (98.9% LoA) were 0.1 (-7.9 to 7.9) breaths.min-1 for the acoustic monitor, -1.6 (-10.8 to 7.6) for the radar, and -1.9 (-13.1 to 9.2) for the IPG. The extent to which the monitors guided adequate or led to inadequate treatment decisions (determined by Clarke Error Grid analysis) differed significantly between the monitors (P = 0.011). Decisions were correct 96% of the time for acoustic, 95% of the time for radar, and 94% of the time for IPG monitoring devices. Conclusions: None of the studied devices (acoustic, IPG, and radar monitor) had LoA that were within our predefined (based on clinical judgement) limits of +/- 2 breaths.min-1. The acoustic breath sound monitor predicted the correct treatment more often than the IPG and the radar device.Copyright © 2018, The Author(s). Database: EMBASE

220. Blood monoamines as potential biomarkers for conditioned pain modulation efficacy: An exploratory study in paediatrics Author(s): Ferland C.E.; Teles A.R.; Saran N.; Ouellet J.A.; Ingelmo P.; Marchand S. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Monoaminergic pathways are involved in the process of pain inhibition and facilitation. The objective of this study was to investigate the role of blood monoamines as biomarkers of conditioned pain modulation (CPM) efficacy. Methods: One hundred and five paediatric patients with chronic back pain were enrolled in this observational study. The protocol involved dosage of plasma monoamines (dopamine, DOPA; serotonin, 5-HT; epinephrine, Epi; norepinephrine, NE; metanephrine, ME; and normetanephrine, NME) and clinical assessment (CPM, functional disability, pain, sleep quality, anxiety and depression). Results: 5-HT and DOPA were positively correlated among each other and were both negatively correlated with Epi, ME, NE and NME. CPM presented a positive correlation with DOPA and 5-HT. On the other hand, Epi, ME, NE and NME correlated negatively with CPM. Different correlation coefficients were observed between genders, with stronger coefficients being observed in the male subpopulation. Stepwise regression controlling for age and gender indicated that ME (B = -0.987, SE(B) = 0.299, p = 0.002) was the only significant predictor for CPM efficacy. Higher blood ME was associated with poorer CPM efficacy. ME explained 53% of variation of CPM in males (R2 = 0.536, p < 0.0001) and 7% in females (R2 = 0.074, p = 0.014). In males, blood ME >15 pg/ml predicted inefficient CPM with 88.9% sensitivity and 83.3% specificity. Conclusions: Our findings suggest that ME can be a potential biomarker for CPM efficacy in paediatrics. Future studies are needed to assess the efficacy of tailored treatments for pain according to blood ME. Significance: We were able to demonstrate an association between CPM and circulating monoamines. In the clinical setting, sampling ME could provide the clinician an idea of the individual's pain modulation potential. This may be particularly important for children with cognitive impairment, for whose CPM paradigm cannot be used.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

221. Diagnostic point-of-care ultrasound: applications in obstetric anaesthetic management Author(s): Zieleskiewicz L.; Bouvet L.; Einav S.; Duclos G.; Leone M. Source: Anaesthesia; Oct 2018; vol. 73 (no. 10); p. 1265-1279 Publication Date: Oct 2018 Publication Type(s): Review Available at Anaesthesia - from Wiley Abstract:Complications during pregnancy are not frequent, but may occur abruptly. Point-of-care ultrasound is a non-invasive, non-ionising diagnostic tool that is available at the bed-side when complications occur. This review covers the use of ultrasound in various clinical situations. Gastric ultrasound can identify stomach contents that put the woman at risk for pulmonary aspiration. In the future, this tool will probably be used routinely before induction of anaesthesia to determine the presence of stomach contents above a particular risk threshold. Difficult tracheal intubation, and the potential for 'can't intubate, can't oxygenate', is more frequent in pregnant women. Point-of-care ultrasound of the airway allows accurate identification of the cricothyroid membrane, permitting rapid and safer establishment of front-of-neck airway access. Combined cardiac and lung ultrasound can determine the potential risk:benefit of fluid administration in the pregnant patient. Such prediction is of critical importance, given the tendency of pregnant women to develop pulmonary oedema. Combined echocardiography and lung ultrasound can be combined with ultrasound of the leg veins to differentiate between the various causes of acute respiratory failure, and guide treatment in this situation. Finally, as shown in the general population, multi-organ point-of-care ultrasound allows early diagnosis of the main causes of circulatory failure and cardiac arrest at the bed-side. As the importance of point-of-care ultrasound in critical patients is increasingly recognised, it is emerging as an important tool in the therapeutic armoury of obstetric anaesthetists.Copyright © 2018 Association of Anaesthetists Database: EMBASE

222. The impact of preinduction fentanyl dosing strategy on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy Author(s): Dutta A.; Sethi N.; Choudhary P.; Sood J.; Panday B.C.; Chugh P.T. Source: Journal of Opioid Management; 2018; vol. 14 (no. 4); p. 283-293 Publication Date: 2018 Publication Type(s): Article Abstract:Objective: Postoperative nausea and vomiting (PONV) is commonly attributed to opioid analgesics; consequently, perioperative opioid dosage reduction is a common practice. However, inadequate fentanyl analgesia may have adverse implications (sympathetic activation, pain). We conducted this randomized clinical study to analyze whether preinduction fentanyl 3 micro g kg-1 administered by different techniques increases incidence of PONV. Design: Randomized-control, prospective, investigator and observer blinded, two-arm, single-center comparison. Setting: Operating room, postoperative ward. Patients: Two hundred seventy patients, aged 20-60 years of either sex and belonging to ASA physical status I/II, scheduled to undergo laparoscopic cholecystectomy under general anesthesia. Interventions: The patients were randomly allocated to receive preinduction fentanyl 3 micro g kg-1 administered by "single-bolus," three equally divided "intermittent boluses" or a "short-infusion" technique. Main outcome measures: The patients were evaluated for PONV profile (primary outcome); and postoperative parameters (pain, sedation, respiratory depression) (secondary outcome). Results: Two hundred fifty-seven patients completed the study and 29.1 percent (n = 75) experienced PONV. The study groups were comparable for PONV incidence ("single-bolus": n = 23, 25.8 percent; "intermittent-boluses": n = 27, 32.5 percent; "short- infusion": n = 25, 29.4 percent), total frequency of PONV ("single-bolus": n = 28, 31.5 percent; "intermittent-boluses": n = 39, 47.0 percent; "short-infusion": n = 36, 42.4 percent), and frequency of rescue antiemetic usage ("single-bolus": n = 24, 30.7 percent; "intermittent-boluses": n = 28, 35.8 percent; "short-infusion": n = 26, 33.3 percent). Patients who received preinduction fentanyl as "intermittent-boluses" were less sedated in the postoperative period (p < 0.001). Conclusions: Controlled administration of preinduction fentanyl 3 micro g kg-1 by commonly employed administration methods does not seem to impact PONV profile. Further studies are needed to establish a temporal link between preinduction fentanyl and PONV.Copyright © 2018 Journal of Opioid Management, All Rights Reserved. Database: EMBASE

223. Meta-analysis and trial sequential analysis of local vs. general anaesthesia for carotid endarterectomy Author(s): Hajibandeh S.; Antoniou S.A.; Torella F.; Antoniou G.A. Source: Anaesthesia; Oct 2018; vol. 73 (no. 10); p. 1280-1289 Publication Date: Oct 2018 Publication Type(s): Review Available at Anaesthesia - from Wiley Abstract:Controversy exists regarding the best choice of anaesthesia for carotid endarterectomy. We aimed to evaluate the peri-operative outcomes of local vs. general anaesthesia for carotid endarterectomy. We conducted a systematic search of electronic information sources and applied a combination of free text and controlled vocabulary searches adapted to thesaurus headings, search operators and limits in each of the electronic databases. We defined peri-operative stroke, transient ischaemic attack, mortality and myocardial infarction as the primary outcome measures. We identified 12 randomised controlled trials and 21 observational studies reporting a total of 58,212 patients undergoing carotid endarterectomy under local or general anaesthesia. Analysis of observational studies demonstrated that local anaesthesia was associated with a significantly lower incidence of stroke (odds ratio (OR (95% CI) 0.66 (0.55-0.80), p < 0.0001), transient ischaemic attack (0.52 (0.38-0.70), p < 0.0001), myocardial infarction (0.55 (0.41-0.75), p = 0.0002) and mortality (0.72 (0.56-0.94), p = 0.01) compared with general anaesthesia. Analysis of randomised controlled trials did not find a significant difference in the risk of stroke (0.92 (0.67-1.28), p = 0.63), transient ischaemic attack (2.20 (0.48-10.03), p = 0.31), myocardial infarction (1.25 (0.57-2.72), p = 0.58) or mortality (0.61 (0.35-1.05), p = 0.07) between local and general anaesthesia. On trial sequential analysis of the randomised trials, the Z-curve did not cross the alpha-spending boundaries or futility boundaries for stroke, mortality and transient ischaemic attack, suggesting that more trials are needed to reach conclusive results. Our meta-analysis of observational studies suggests that local anaesthesia for carotid endarterectomy may be associated with lower peri-operative morbidity and mortality compared with general anaesthesia. Although randomised studies have not confirmed any advantage for local anaesthesia, this may be due to a lack of pooled statistical power in these trials.Copyright © 2018 Association of Anaesthetists Database: EMBASE

224. A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery Author(s): Park M.H.; Ahn H.J.; Yang M.K.; Seong B.G.; Kim J.A.; Son H.J. Source: Anaesthesia; Oct 2018; vol. 73 (no. 10); p. 1260-1264 Publication Date: Oct 2018 Publication Type(s): Article Available at Anaesthesia - from Wiley Abstract:We evaluated the effect of pre-operative serratus anterior plane block on postoperative pain and opioid consumption after thoracoscopic surgery. We randomly allocated 89 participants to block with 30 ml ropivacaine 0.375% (n = 44), or no block without placebo or sham procedure (n = 45). We analysed results from 42 participants in each group. Serratus anterior plane block reduced mean (SD) remifentanil dose during surgery, 0.12 (0.06) mg.h-1 vs. 0.16 (0.06) mg.h-1, p = 0.016, and reduced mean (SD) fentanyl consumption in the first 24 postoperative hours, 3.8 (1.9) mug.kg-1 vs. 5.7 (1.6) mug.kg-1, p = 0.000004. Block also reduced the worst median (IQR [range]) pain scores reported in the first 24 postoperative hours: 6 (5-7 [3-10]) vs. 7 (6-7 [3-10]), p = 0.027. Block decreased dissatisfaction with pain management, categorised as 'highly unsatisfactory', 'unsatisfactory', 'neutral', 'satisfactory' or 'highly satisfactory': 1/2/21/18/0 vs. 1/14/15/11/1, p = 0.0038. There were no differences in the rates of nausea, vomiting, dizziness or length of hospital stay. Serratus anterior plane block may be used to reduce pain and opioid use after thoracoscopic lung surgery.Copyright © 2018 Association of Anaesthetists Database: EMBASE

225. Enquete multicentrique sur l'education des residents en soins intensifs sur les dons d'organes et de tissusA multicentre investigation of organ and tissue donation education for critical care residents Author(s): Sarti A.J.; Sutherland S.; Hartwick M.; Cardinal M.-P.; Cardinal P.; Healey A.; Dhanani S.; Oczkowski S.; Ball I.; Messenger D.; Soliman K.; Mema B.; Valiani S. Source: Canadian Journal of Anesthesia; Oct 2018; vol. 65 (no. 10); p. 1120-1128 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Purpose: To describe critical care medicine residents' training, expertise, and skills regarding organ and tissue donation processes and procedures. Methods: We undertook a qualitative multicentre study and employed a purposive sample of program directors, physicians, nurses, residents, and organ donation leaders from all nine academic intensive care unit (ICU) training centres (five adult, four pediatric) in Ontario (n = 71). Interviews, conducted by telephone between December 2015 and March 2016, were audio-recorded and transcribed verbatim. Data collection and analysis were performed using an iterative process and continued until saturation was achieved. Results: Five main themes were identified: 1) gaps in residents' knowledge for both neurologic determination of death (NDD) and circulatory determination of death (DCD) cases; 2) commitment to the provision of organ and tissue donation training; 3) limited experiential learning (NDD and DCD); 4) challenges related to the provision of training on organ donation and need for a standardized curriculum; and 5) communication with family members. Overall, this study showed system-level gaps in training resulting from the lack of a standardized provincial curriculum on organ donation. Conclusions: Qualitative data corroborated that residents need more exposure to clinical cases, especially regarding DCD donors. A standardized education curriculum would be beneficial for all residents within the ICU. Developing a better shared understanding of the donation process will improve team communication and performance, translate into a better end-of-life experience for families, and potentially result in increased donation rates.Copyright © 2018, Canadian Anesthesiologists' Society. Database: EMBASE

226. Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005- 2015: a national observational study Author(s): Strom C.; Afshari A.; Lundstrom L.H.; Lohse N. Source: Anaesthesia; Oct 2018; vol. 73 (no. 10); p. 1195-1206 Publication Date: Oct 2018 Publication Type(s): Article Available at Anaesthesia - from Wiley Abstract:There are few data available that describe the current anaesthetic management of children. We have analysed anaesthetic practice and peri-operative complications for children in Denmark aged less than two years. We conducted a population-based observational cohort study using the Danish Anaesthesia Database to identify children who received anaesthesia in hospital from 1 January 2005 until 31 December 2015. Data were combined with that from the Danish National Patient Registry and the Danish Civil Registration System. Age, sex, height, weight, ASA physical status, days in hospital before anaesthesia, number of anaesthetics per child, indications for anaesthesia, methods of anaesthesia, airway management and complications were all recorded. A total of 17,436 children (64% of whom were male) received 27,653 anaesthetics during the study period. In 58% of cases, the child had an ASA physical status score of 1. Thirty-seven percent had a previous anaesthetic episode. Seventy-nine percent were anaesthetised at a university hospital. The indications for anaesthesia were surgery (70%), diagnostic radiology (16%), non-surgical care (11%) and other indications (3%). General anaesthesia combining intravenous and inhalational agents was the most common approach for surgery (68%) and diagnostic radiology (47%). For non-surgical care, general anaesthesia using inhalational agents was the most common method (42%). Neuraxial blocks were used infrequently. The most common regional anaesthetic nerve block was an infraclavicular brachial plexus block (11%). Peri-operative complications occurred in 1.71% of cases. A large proportion of anaesthetics were conducted in children with comorbidities. Non-surgical indications for anaesthesia were frequent and peri-operative complications were rare.Copyright © 2018 Association of Anaesthetists Database: EMBASE

227. Factors influencing consent to organ donation after brain death certification: A survey of 29 Intensive Care Units Author(s): Piemonte G.; Rasero L.; Migliaccio M.L.; Bagatti S.; Lopane P.; Nativi A.; Peris A.; Bambi S.; Tadini-Buoninsegni L.; Guetti C.; Bonizzoli M.; Bombardi M.; D'Antonio L.; Guazzini A.; Di Pasquale C. Source: Minerva Anestesiologica; Sep 2018; vol. 84 (no. 9); p. 1044-1052 Publication Date: Sep 2018 Publication Type(s): Conference Paper Abstract:BACKGROUND: Family refusal (FR) to heart beating donation (HBD) in Intensive Care Unit (ICU) is increasing in recent years with a significant impact on the number of transplantable organs. Fostering setting humanization, quality of relationships, respect for will and family reliance towards ICU could be relevant in containing FR to organ donation (OD) in ICU. Our aims were to highlight the effects of structural features of ICUs and humanization determinants on FR in HBD process, and to describe visiting policies, structure and modalities of support in ICUs. METHODS: A survey was conducted among all the ICUs of the Tuscany Region included in the National Transplant System of the Ministry of Health in Italy. Data on ICUs' general and architectural characteristics, visiting policies and support for families were collected. Baseline characteristics of brain dead certified patients (BDCPs) were retrieved from the Registry of the Regional Transplant Centre. RESULTS: Twenty-nine (93.5%) ICUs out of 31 completed the survey. 330 BDCPs were managed during 2016 in the ICUs studied, with an opposition rate of 33.3%. The following independent factors for opposition emerged: BDCPs' age (OR=1.025; 95% CI: 1.007-1.042; P=0.005), ICU length of stay (LOS) (OR=1.065; 95% CI: 1.005-1.128; P=0.034) and the availability of an ICU team trained in procurement (OR=0.472; 95% CI: 0.275-0.811; P=0.007). CONCLUSIONS: Older age of BDCPs and a prolonged ICU LOS resulted in FR. ICU team specific education emerged as the only modifiable protective factor for oppositions, thus continuous and in-depth training programs for physicians and nurses could be of importance in preventing FR.Copyright © 2018 Edizioni Minerva Medica. Database: EMBASE

228. Analysis of inpatient falls after total knee arthroplasty in patients with continuous femoral nerve block Author(s): Turbitt L.R.; McHardy P.G.; Casanova M.; Shapiro J.; Li L.; Choi S. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 224-227 Publication Date: Jul 2018 Publication Type(s): Article Abstract:Continuous femoral nerve block (cFNB) is thought to increase the risk of falls after total knee arthroplasty (TKA). Previous studies have failed to consider the timing of cFNB removal in relation to inpatient falls. We investigated all inpatient falls after TKA over a 3-year period using our institutional safety report database. Ninety-five falls were reported from a total of 3745 patients. The frequency of falls after TKA persisted at a similar rate despite removal of cFNB and likely regression of femoral nerve block. Other modifiable risk factors may play a more prominent role in falls risk after TKA.Copyright © 2017 International Anesthesia Research Society. Database: EMBASE

229. A survey of current anesthesia trends for electrophysiology procedures Author(s): Woltz E.M.; Wolf B.J.; Gold M.R.; Nelson E.W. Source: Anesthesia and Analgesia; Jul 2018; vol. 127 (no. 1); p. 46-53 Publication Date: Jul 2018 Publication Type(s): Article Abstract:BACKGROUND: There has been a dramatic shift in recent years in anesthesia coverage for electrophysiology (EP) procedures. An anesthesiologist and electrophysiologist at our institution jointly developed a survey, which was distributed to the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society. Its goal was to document current practice patterns and examine perceived variability in coverage. METHODS: On approval of the leadership from the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society, an online survey was administered to the membership. The survey included demographic data, anesthetic type, and perceptions of the respondents. RESULTS: Four hundred seventy-nine surveys were completed. Thirty-eight percent were completed by electrophysiologists and 63% by anesthesiologists, giving a response rate of 8.24% for anesthesiologists and 13.6% for electrophysiologists. Of these, 57% of respondents worked in an academic setting. Over the past 2 years, 66.5% of respondents reported anesthesia involvement in EP cases increasing. These cases are reportedly covered by all anesthesiologists in a group 55% of the time, cardiac anesthesia 32.5%, and a designated team at the remainder of the institutions. Seventy-six percent of respondents reported having designated EP block time in the schedule. Ninety-two percent of respondents reported that patient satisfaction has increased with the involvement of anesthesia services. CONCLUSIONS: Anesthesia coverage for EP procedures has continued to increase with an increase in patient satisfaction. Anesthesiologists have had to adapt and provide designated block time to accommodate this increase and also, in some instances, form teams that go beyond simply cardiac anesthesiologists to care for these patients during their procedures.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

230. The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications Author(s): Rakotoarison S.; Abadagan H.; Abbas N.; Abdelatif A.I.; Abdoulaye T.; Abd-rouf A.; Abduljalil A.; Abdulrahman A.; Abdurazig S.; Abokris A.; Abozaid W.; Abugassa S.O.A.; Abuhdema F.; Abujanah S.A.; Abusamra R.; Abushnaf A.; Abusnina S.A.; Abuzalout T.S.; Ackermann H.M.; Adamu Y.B.; Addanfour A.; Adeleke D.M.; Adigun T.A.; Adisa A.O.; Adjignon S.V.; Adu-Aryee N.A.; Afolabi B.B.; Agaba A.F.X.; Agaba P.K.A.; Aghadi K.; Agilla H.; Ahmed B.; Ahmed E.-Z.; Ahmed A.-J.; Ahmed M.; Ahossi R.; Aji S.A.; Akanyun S.; Akhideno I.; Akhter M.; Akinyemi O.A.; Akkari M.; Akodjenou J.; AL Samateh A.L.; al Shams E.S.; Alagbe-Briggs O.T.; Alakkari E.A.; Alalem R.B.; Alashhab M.; Alatise O.I.; Alatresh A.; Alayeb Alayeb M.S.I.; Albakosh B.A.; Albert F.; Alberts A.N.J.D.; Aldarrat A.D.; Alfari A.; Alfetore A.; Algbali M.; Algddar A.; Algedar H.A.; Alghafoud I.A.; Alghazali A.; Alhajj M.; Alhendery Alhendery A.; Alhoty F.F.H.; Ali A.; Ali Y.A.; Alioune B.S.; Alkassem M.A.; Alkchr M.A.; Alkesa T.S.; Alkilani A.; Alkobty Alkobty F.; Allaye T.; Alleesaib S.B.M.; Alli A.; Allopi K.; Allorto N.L.; Almajbery A.; Almesmary R.; Almisslati S.H.A.; Almoraid F.; Alobeidi H.; Alomami M.A.; Alphonsus C.S.; Alqawi O.A.; Alraheem A.A.; Alsabri S.A.; Alsayed A.; Alsellabi B.; Al-Serksi M.; Alshareef M.S.A.; Altagazi A.A.; Aluvale J.S.; Alwahedi H.W.; Alzahra E.A.; Alzarouk M.A.; Al-Zubaidy K.; Amadou M.; Amanor-Boadu S.D.; Amer A.-A.; Amisi B.T.; Amuthenu M.A.; Anabah T.W.A.; Anani F.; Anderson P.G.R.; Andriamampionona A.G.B.; Andrianina L.; Anele A.; Angelin R.; Anjar N.; Antunez O.; Antwi-Kusi A.; Anyanwu L.J.C.; Aribi A.A.; Arowolo O.A.; Arrey O.; Ashebir D.Z.; Assefa S.B.; Assoum G.; Athanse V.; Athombo J.S.; Atiku M.; Atito-Narh E.; Atomabe A.; Attia A.; Aungraheeta M.; Aurelia D.M.A.; Ayandipo O.O.; Ayebale A.E.T.; Azzaidey H.M.Z.; Babajee N.B.; Badi H.B.; Badianga E.K.; Baghni R.B.; Bahta M.T.; Bai M.; Baitchu Y.; Baloyi A.M.; Bamuza K.A.; Bamuza M.I.; Bangure L.; Bankole O.B.; Barongo M.L.; Barow M.M.; Basenero A.; Bashiya L.; Basson C.H.; Bechan S.; Belhaj S.; Ben Mansour M.M.; Benali D.; Benamour A.S.B.; Berhe A.; Bertie J.D.; Bester J.J.A.; Bester M.; Bezuidenhout J.D.; Bhagwan K.; Bhagwandass D.R.; Bhat K.A.P.; Bhuiyan M.M.Z.U.; Biccard B.M.; Bigirimana F.; Bikuelo C.J.; Bilby B.E.; Bingidimi S.S.; Bischof K.E.; Bishop D.G.; Bitta C.; Bittaye M.; Biyase T.; Blake C.A.; Blignaut E.; Blignaut F.; BN Tanjong B.N.; Bogoslovskiy A.; Boloko P.M.; Boodhun S.K.B.; Bori I.; Boufas F.; Brand M.; Brouckaert N.T.; Bruwer J.D.; Buccimazza I.; Bula Bula I.M.; Bulamba F.; Businge B.C.; Bwambale Y.B.; Cacala S.R.C.; Cadersa M.A.; Cairns C.; Carlos F.; Casey M.E.; Castro A.C.; Chabayanzara N.D.; Chaibou M.S.; Chaibva T.N.O.; Chakafa N.K.; Chalo C.; Changfoot C.; Chari M.C.; Chelbi L.; Chibanda J.T.; Chifamba H.N.; Chikh N.; Chikumba E.; Chimberengwa P.; Chirengwa J.; Chitungo F.M.; Chiwanga M.C.; Chokoe M.M.; Chokwe T.M.; Chrirangi B.; Christian M.; Church B.; Cisekedi J.C.; Clegg-Lamptey J.N.; Cloete E.; Coltman M.; Conradie W.; Constance N.; Coulibaly Y.; Cronje L.; Da Silva M.A.; Daddy H.; Dahim L.; Daliri D.; Dambaki M.S.; Dasrath A.; Davids J.G.; Davies G.L.; De Lange J.T.; de Wet J.B.; Dedekind B.; Degaulle M.A.; Dehal V.; Deka P.D.; Delinikaytis S.; Desalu I.S.; Dewanou H.; Deye M.B.M.; Dhege C.; Diale B.S.G.; Dibwe D.F.; Diedericks B.J.S.; Dippenaar J.M.; Dippenaar L.; Diyoyo M.P.; Djessouho E.; Dlamini S.N.; Dodiyi-Manuel A.; Dokolwana B.A.; Domoyyeri D.P.; Drummond L.W.; du Plessis D.E.; du Plessis W.M.; du Preez L.J.; Dube K.; Dube N.Z.; Dullab K.D.; Duvenhage R.; Echem R.C.; Edaigbini S.A.; Egote A.K.; Ehouni A.; Ekwen G.; Ekwunife N.C.; El Hensheri M.; Elfaghi I.E.; Elfagieh M.A.; Elfallah S.; Elfiky M.; Elgelany S.; Elghallal A.M.; Elghandouri M.G.; Elghazal Z.S.; Elghobashy A.M.; Elharati F.T.; Elkhogia A.M.; Elkhwildi R.M.; Ellis S.; Elmadani L.; Elmadany H.B.; Elmehdawi H.; Elmgadmi A.; Eloi H.; Elrafifi D.; Elsaadi G.; Elsaity R.B.; Elshikhy A.; Eltaguri M.; Elwerfelli A.; Elyasir I.E.; Elzoway A.Z.; Elzufri A.M.; Enendu E.O.; Enicker B.C.; Enwerem E.O.; Esayas R.; Eshtiwi M.; Eshwehdi A.A.; Esterhuizen J.L.; Esterhuizen T.M.; Etuk E.B.; Eurayet O.; Eyelade O.R.; Fanjandrainy R.F.; Fanou L.; Farina Z.; Fawzy M.; Feituri A.; Fernandes N.L.; Ford L.M.; Forget P.; Francois T.; Freeman T.; Freeman Y.B.M.; Gacii V.M.; Gadi B.; Gagara M.; Gakenia A.; Gallou P.D.; Gama G.G.N.; Gamal M.G.; Gandy Y.G.; Ganesh A.; Gangaly D.; Garcia M.; Gatheru A.P.; Gaya S.S.D.; Gbehade O.; Gerbel G.; Ghnain A.; Gigabhoy R.; Giles D.G.; Girmaye G.T.; Gitau S.; Githae B.; Gitta S.; Gobin V.; Goga R.; Gomati A.A.G.; Gonzalez M.E.; Gopall J.; Gordon C.S.; Gorelyk O.; Gova M.; Govender K.; Govender P.; Govender S.; Govindasamy V.; Green-Harris J.T.K.; Greenwood M.B.; Grey-Johnson S.V.; Grobbelaar M.; Groenewald M.A.; Grunewald K.K.; Guegni A.; Guenane M.; Gueye S.; Guezo M.; Gunguwo T.; Gweder M.G.; Gwila M.; Habimana L.; Hadecon R.; Hadia E.; Hamadi L.; Hammouda M.; Hampton M.I.; Hanta R.; Hardcastle T.C.; Hariniaina J.A.; Hariparsad S.; Harissou A.H.; Harrichandparsad R.; Hasan S.H.A.; Hashmi H.B.; Hayes M.P.; Hdud A.; Hebli S.H.; Heerah H.M.S.N.; Hersi S.; Hery A.H.; Hewitt-Smith A.; Hlako T.C.; Hodges S.C.H.; Hodgson R.E.; Hokoma M.; Holder H.; Holford E.B.; Horugavye E.; Houston C.; Hove M.; Hugo D.; Human C.M.; Hurri H.; Huwidi O.; Ibrahim A.I.; Ibrahim T.; Idowu O.K.; Igaga I.E.; Igenge J.; Ihezie O.; Ikandi K.; Ike I.A.R.; Ikuku J.J.N.; Ilbarasi M.N.; Ilunga I.B.B.; Ilunga J.P.M.; Imbangu N.A.V.; Imessaoudene Z.; Imposo D.H.; Iraya A.M.; Isaacs M.; Isiguzo M.; Issoufou A.; Izquirdo P.; Jaber A.; Jaganath U.V.; Jallow C.S.; Jamabo S.; Jamal Z.S.; Janneh L.; Jannetjies M.J.; Jasim I.; Jaworska M.A.J.; Jay Narain S.; Jermi K.; Jimoh R.; Jithoo S.; Johnson M.; Joomye S.; Judicael R.M.; Judicael M.; Juwid A.; Jwambi L.P.; Kabango R.; Kabangu J.K.; Kabatoro D.K.; Kabongo A.N.; Kabongo K.; Kabongo L.T.; Kabongo M.D.; Kady N.; Kafu S.; Kaggya M.; Kaholongo B.N.K.; Kairuki P.C.K.; Kakololo S.I.; Kakudji K.; Kalisa A.; Kalisa R.; Kalufwelu M.R.; Kalume S.; Kamanda R.J.; Kangili M.K.; Kanoun H.; Kapesa; Kapp P.; Karanja J.K.; Karar M.; Kariuki K.; Kaseke K.; Kashuupulwa P.N.K.; Kasongo K.J.P.; Kassa S.K.; Kateregga G.K.; Kathrada M.I.S.; Katompwa P.M.; Katsukunya L.; Kavuma K.A.M.; Khalfallah; Khamajeet A.; Khetrish S.B.; Kibandwa; Kibochi W.; Kilembe A.M.; Kintu A.K.; Kipng'etich B.; Kiprop B.; Kissoon V.M.K.; Kisten T.K.; Kiwanuka J.K.; Kluyts H.-L.; Knox M.E.K.; Koledale A.K.; Koller V.L.; Kolotsi M.A.; Kongolo M.; Konwuoh N.D.; Koperski W.V.J.; Koraz M.Y.K.; Kornilov A.A.; Koto M.Z.; Kransingh S.; Krick D.; Kruger S.; Kruse C.; Kuhn W.; Kuhn W.P.; Kukembila A.M.; Kule K.L.; Kumar M.; Kusel B.S.; Kusweje V.K.; Kuteesa K.J.; Kutor Y.Y.; Labib M.A.; Laksari M.; Lanos F.; Lawal T.A.; Le Manach Y.; Lee C.; Lekoloane R.M.; Lelo S.N.; Lerutla B.; Lerutla M.T.; Levin A.I.; Likongo T.B.; Limbajee M.L.; Linyama D.M.; Lionnet C.; Liwani M.M.; Loots E.; Lopez A.G.; Lubamba C.L.C.; Lumbala K.F.; Lumbamba A.J.M.; Lumona J.; Lushima R.F.; Luthuli L.; Luweesi H.L.; Lyimo T.S.K.; Maakamedi H.M.; Mabaso B.M.; Mabina M.; Maboya M.E.; Macharia I.; Macheka A.M.; Machowski A.Z.; Madiba T.E.; Madsen A.S.M.; Madzimbamuto F.; Madzivhe L.J.; Mafafo S.C.; Maghrabi M.; Mahamane D.D.; Maharaj A.; Maharaj A.D.; Mahmud M.R.; Mahoko M.; Mahomedy N.A.; Mahomva O.; Mahureva T.M.; Maila R.K.; Maimane D.M.; Maimbo M.; Maina S.N.; Maiwald D.A.; Maiyalagan M.D.; Majola N.; Makgofa N.; Makhanya V.; Makhaye W.P.; Makhlouf N.M.; Makhoba S.; Makopa E.K.; Makori O.; Makupe A.M.; Makwela M.A.; Malefo M.E.; Malongwe S.M.; Maluleke D.M.; Maluleke M.R.; Mamadou K.T.; Mamaleka M.P.; Mampangula Y.; Mamy R.M.; Mananjara M.N.R.; Mandarry M.T.M.; Mangoo D.M.; Manirimbere C.; Manneh A.; Mansour A.; Mansour I.; Manvinder M.; Manyere D.V.; Manzini V.T.; Manzombi J.K.; Mapanda P.M.; Marais L.C.; Maranga O.; Maritz J.P.B.; Mariwa F.K.; Masela R.S.; Mashamba M.M.; Mashava D.M.; Mashile M.V.; Mashoko E.; Masia O.R.; Masipa J.N.; Masiyambiri A.T.M.; Matenchi M.W.; Mathangani W.; Mathe R.C.; Matola C.Y.; Matondo P.M.; Matos-Puig R.; Matoug F.F.H.; Matubatuba J.T.; Mavesere H.P.; Mavhungu R.; Maweni S.; Mawire C.J.M.; Mawisa T.; Mayeza S.; Mbadi R.; Mbayabu M.; Mbewe N.; Mbombo W.D.; Mbuyi T.; Mbuyi W.M.S.; Mbuyisa M.W.; Mbwele B.; Mehyaoui R.M.; Menkiti I.D.; Mesarieki L.V.M.; Metali A.; Mewanou S.; Mgonja L.; Mgoqo N.; Mhatu S.; Mhlari T.M.; Miima S.; Milod I.M.; Minani P.; Mitema F.; Mlotshwa A.; Mmasi J.E.; Mniki T.; Mofikoya B.O.; Mogale J.O.; Mohamed A.; Mohamed S.; Mohamed T.S.; Mohamed A.M.; Mohamed P.; Mohammed I.; Mohammed F.A.M.; Mohammed M.; Mohammed N.M.; Mohlala M.P.; Mokretar R.; Molokoane F.M.; Mongwe K.N.; Montenegro L.; Montwedi O.D.; Moodie Q.K.; Moopanar M.; Morapedi M.; Morulana T.G.; Moses V.L.; Mossy P.; Mostafa H.; Motilall S.R.; Motloutsi S.P.; Moussa K.; Moutari M.; Moyo O.M.; Mphephu P.E.; Mrara B.; Msadabwe C.; Mtongwe V.M.; Mubeya F.K.; Muchiri K.; Mugambi J.; Muguti G.I.M.; Muhammad A.B.; Mukama I.F.; Mukenga M.M.; Mukinda F.K.; Mukuna P.M.; Mungherera A.R.W.; Munlemvo D.M.; Munyaradzi T.W.; Munyika A.A.; Muriithi J.M.; Muroonga M.P.; Murray R.; Mushangwe V.K.; Mushaninga M.; Musiba V.E.M.; Musowoya J.M.; Mutahi S.; Mutasiigwa M.G.H.; Mutizira G.; Muturi A.; Muzenda T.; Mvwala K.R.; Mvwama N.M.; Mwale A.; Mwaluka C.N.; Mwamba J.D.; Mwanga H.A.M.; Mwangi C.M.; Mwansa S.; Mwenda V.; Mwepu I.M.; Mwiti T.M.; Mzezewa S.Z.; Nabela L.; Nabukenya M.T.N.; Nabulindo S.M.; Naicker K.; Naidoo D.; Naidoo L.; Naidoo L.C.; Naidoo N.; Naidoo R.; Naidoo R.D.; Naidoo S.; Naidoo T.D.; Naidu T.K.; Najat N.Z.; Najm Y.; Nakandungile F.; Nakangombe P.; Namata C.N.; Namegabe E.S.; Nansook A.; Nansubuga N.P.; Nantulu C.; Nascimento R.; Naude G.T.; Nchimunya H.; Ndaie M.A.; Ndarukwa P.N.; Ndasi H.; Ndayisaba G.; Ndegwa D.; Ndikumana R.; Ndonga A.K.N.; Ndung'u C.; Neil M.C.; Nel M.S.; Neluheni E.V.; Nesengani D.S.; Nesengani N.T.; Netshimboni L.E.; Ngalala A.M.; Ngari B.M.; Ngari N.B.M.; Ngatia E.; Ngcobo G.K.; Ngcobo T.S.; Ngorora D.; Ngouane D.; Ngugi K.; Ngumi Z.W.W.; Nibe Z.; Ninise E.; Niyondiko J.C.; Njenga P.W.; Njenga M.N.; Njoroge M.; Njoroge S.; Njuguna W.; Njuki P.N.; Nkesha T.; Nkuebe T.N.; Nkuliyingoma N.P.; Nkunjana M.; Nkwabi E.; Nkwine R.N.; Nnaji C.; Notoane I.; Nsalamba S.; Ntlhe L.M.; Ntoto C.; Ntueba B.; Nyassi M.T.; Nyatela-Akinrinmade Z.; Nyawanda H.O.; Nyokabi N.N.; Nziene V.N.; Obadiah S.; Ochieng O.J.P.; Odia P.K.; Oduor O.E.O.; Ogboli-Nwasor E.O.; Ogendo S.W.O.; Ogunbode O.; Ogundiran T.O.; Ogutu O.; Ojewola R.W.; Ojujo M.; Ojuka D.O.; Okelo O.S.; Okiya S.; Okonu N.; Olang P.R.; Omigbodun A.O.; Omoding S.; Omoshoro-Jones J.; Onyango R.; Onyegbule A.; Orjiako O.; Osazuwa M.O.; Oscar K.; Osinaike B.B.; Osinowo A.O.; Othin O.M.; Otman F.F.H.; Otokwala J.; Ouanes F.; Oumar O.; Ousseini A.O.; Padayachee S.; Pahlana S.M.; Pansegrouw J.; Paruk F.P.; Patel M.B.; Patel U.; Patience A.P.; Pearse R.M.; Pembe J.D.; Pengemale G.N.; Perez N.; Aguilera Perez M.F.; Peter A.M.; Phaff M.; Pheeha R.M.; Pienaar B.H.; Pillay V.; Pilusa K.A.; Pochana M.P.; Polishchuk O.; Porrill O.S.; Post E.F.; Prosper A.; Pupyshev M.; Rabemazava A.; Rabiou M.S.; Rademan L.; Rademeyer M.; Raherison R.A.R.; Rajah F.R.; Rajcoomar M.S.R.; Rakhda Z.; Rakotoarijaona A.H.R.; Rakotoarisoa A.H.N.; Rakotoarison S.R.; Rakotoarison R.R.; Ramadan L.; Ramananasoa M.L.R.; Rambau M.; Ramchurn T.P.R.; Ramilson H.E.; Ramjee R.J.; Ramnarain H.; Ramos R.; Rampai T.J.; Ramphal S.R.; Ramsamy T.; Ramuntshi R.; Randolph R.; Randriambololona D.M.A.; Ras W.A.P.; Rasolondraibe R.A.F.; Rasolonjatovo J.D.L.C.; Rautenbach R.M.; Ray S.; Rayne S.R.; Razanakoto F.A.R.; Reddy S.R.; Reed A.R.; Rian J.R.; Rija F.R.; Rink B.; Robelie A.T.; Roberts C.A.; Rocher A.G.L.; Rocher S.; Rodseth R.N.; Rois I.; Rois W.; Rokhsi S.; Roos J.; Rorke N.F.; Roura H.; Rousseau F.J.; Rousseau N.; Royas L.; Roytowski D.; Rungan D.; Rwehumbiza S.S.R.; Ryabchiy B.B.; Ryndine V.; Saaiman C.R.; Sabwa H.K.; Sadat S.; Saed S.S.; Salaheddin E.; Salaou H.; Saleh M.; Salisu-Kabara H.M.; Doles Sama H.; Samateh A.L.; Sam-Awortwi W.; Samuel N.; Sanduku D.K.; Sani C.M.; Sanyang L.N.; Sarah H.N.; Sarkin-Pawa A.; Sathiram R.; Saurombe T.; Schutte H.; Sebei M.P.; Sedekounou M.D.; Segooa M.P.; Semenya E.M.; Semo B.O.; Sendagire C.S.; Senoga S.A.; Senusi F.S.; Serdyn T.; Seshibe M.D.; Shah G.B.; Shamamba R.; Shambare C.S.; Shangase T.N.; Shanin S.H.; Shefren I.E.; Sheshe A.A.; Shittu O.B.; Shkirban A.S.; Sholadoye T.; Shubba A.; Sigcu N.; Sihope S.E.; Sikazwe D.S.; Sikombe B.S.; Simaga Abdoul K.; Simo W.A.G.; Singata K.; Singh A.S.; Singh S.; Singh U.; Sinoamadi V.; Sipuka N.; Sithole N.L.M.; Sitima S.; Skinner D.L.; Skinner G.C.; Smith O.I.; Smits C.A.G.; Sofia M.S.I.; Sogoba G.; Sohoub A.; Sookun S.S.; Sosinska O.; Souhe R.; Souley G.; Souleymane T.; Spicer J.M.; Spijkerman S.; Steinhaus H.; Steyn A.; Steyn G.; Steyn H.C.; Stoltenkamp H.L.; Stroyer S.; Swaleh A.; Swayeb E.; Szpytko A.J.; Taiwo N.A.; Tarhuni A.; Tarloff D.; Tchaou B.; Tchegnonsi C.; Tchoupa M.; Teeka M.O.; Thakoor B.; Theunissen M.M.; Thomas B.P.; Thomas M.B.; Thotharam A.; Tobiko O.; Torborg A.M.; Tshisekedi S.M.; Tshisola S.K.; Tshitangano R.; Tshivhula F.; Tshuma H.T.; Tumukunde J.; Tun M.; Udo I.A.; Uhuebor D.I.; Umeh K.U.; Usenbo A.O.; Uwiteyimbabazi J.D.; Van der Merwe D.J.; van der Merwe F.H.; van der Walt J.E.; van Dyk D.; Van Dyk J.G.; van Niekerk J.J.S.; van Wyk S.; van Zyl H.A.; Veerasamy B.; Venter P.J.; Vermeulen A.J.; Villarreal R.; Visser J.; Visser L.; Voigt M.; von Rahden R.P.; Wafa A.; Wafula A.; Wambugu P.K.; Waryoba P.; Waweru E.N.; Weideman M.; Wise R.D.; Wynne E.E.; Yahya A.I.; Yahya A.A.; Yahya R.; Yakubu Y.; Yanga J.J.; Yangazov Y.M.; Yousef O.; Yousef G.; Youssouf C.; Yunus A.A.; Yusuf A.S.; Zeiton A.Z.; Zentuti H.Z.; Zepharine H.; Zerihun A.B.; Zhou S.; Zidan A.; Zimogo Zie S.; Zinyemba C.Z.; Zo A.; Zomahoun L.; Zoobei N.Z.; Zoumenou E.; Zubia N.Z. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

231. Effect of remifentanil on postoperative nausea and vomiting: a randomized pilot study Author(s): Watanabe T.; Moriya K.; Tsubokawa N.; Baba H. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Opioid-related postoperative nausea and vomiting should not occur following remifentanil administration because of its relatively short time to elimination. However, studies have indicated that the incidence of postoperative nausea and vomiting associated with remifentanil is similar to that with other opioids. Hence, we aimed to determine whether intraoperative remifentanil itself is associated with postoperative nausea and vomiting when postoperative pain is managed without opioid use. In this prospective pilot study, 150 patients who underwent unilateral upper limb surgery under general anesthesia with brachial plexus block were included. Patients in the remifentanil and control groups received 0.5 micro g/kg/min remifentanil and saline, respectively. Postoperative pain was managed using a brachial plexus block, non-steroidal anti-inflammatory drugs, and acetaminophen. The presence of postoperative nausea and vomiting within the first 24 h after anesthesia was assessed by an evaluator blinded to patient allocation. Eight patients were excluded from the final analysis, resulting in 72 and 70 patients in the remifentanil and control groups, respectively. Postoperative nausea and vomiting within 24 h after surgery occurred in 11 and 9 patients in the remifentanil and control groups, respectively. These data suggest that remifentanil use only minimally affects the incidence of postoperative nausea and vomiting under sevoflurane anesthesia. UMIN Clinical Trials Registry identification number: UMIN000016110.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

232. The Adjective Rating Scale for Withdrawal: Validation of its ability to assess severity of prescription opioid misuse Author(s): Coloma-Carmona A.; Carballo J.L.; Rodriguez-Marin J.; van-der Hofstadt C.J. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Withdrawal symptoms have been widely shown to be a useful indicator of the severity of opioid dependence. One of the most used instruments to assess them is the Adjective Rating Scale for Withdrawal (ARSW). However, there is a lack of adaptations and validations for its use with prescription opioids, even less for chronic pain patients under treatment with these analgesics. Thus, the aims of this study were to analyse the psychometric properties and invariance across gender of the ARSW in a sample of chronic noncancer pain patients. Methods: Data were collected from 208 consumers of opioid medication, chronic noncancer pain patients. Participants completed sociodemographic, ARSW, prescription opioid dependence (DSM-IV-TR) and prescription opioid-use disorder (DSM-5) measurements. Gender invariance was assessed through multigroup confirmatory factor analysis (CFA). Results: The ARSW showed a unidimensional factor structure and high internal consistency (Cronbach's alpha = 0.85). Multigroup CFA showed configural, metric, scalar and strict invariances of ARSW across gender. Predictive validity analyses indicated that ARSW has good capacity for identifying the severity of prescription opioid-use disorder, using both DSM-IV- TR and DSM-5 criteria. Conclusions: These findings show that the ARSW is a valid and reliable tool for use in the assessment of the withdrawal of prescription opioids in chronic pain patients under treatment with these analgesics, regardless of their gender. Significance: Findings supported the reliability and validity of the ARSW to assess withdrawal of prescription opioids in individuals with chronic noncancer pain. The instrument can be applied indistinctly in men and women. An increase in the ARSW scores could be used as an indicator of potential risk of prescription opioid-use disorder during long-term treatments.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

233. Effect of a lateral infraclavicular brachial plexus block on the axillary and suprascapular nerves as determined by electromyography - a cohort study Author(s): Steen-Hansen C.; Rothe C.; Lange K.H.W.; Lundstrom L.H. Source: Anaesthesia; Oct 2018; vol. 73 (no. 10); p. 1251-1259 Publication Date: Oct 2018 Publication Type(s): Article Available at Anaesthesia - from Wiley Abstract:We aimed to examine to what extent a lateral infraclavicular brachial plexus block affected the axillary and the suprascapular nerve. We included patients undergoing hand surgery anaesthetised with a lateral infraclavicular brachial plexus block. Our primary outcome was the relative change in surface electromyography during maximum voluntary isometric contraction of the medial deltoid muscle (axillary nerve) and the infraspinatus muscle (suprascapular nerve) from baseline to 30 min after the block procedure. A reduction in electromyography of > 50% defined a successful block. The impact of the block on the shoulder nerves was compared with the surgical target nerves of the arm and hand (musculocutaneous, radial, median and ulnar nerves). Twenty patients were included. The medians of the relative changes in the surface electromyography were significantly reduced (both p < 0.001) with 92% for the deltoid muscle and 30% for the infraspinatus muscle, respectively. In total, 18 out of 20 patients had reductions > 50% for the deltoid muscle, which was significantly different from the infraspinatus muscle, where the proportion was 5 out of 20 (p < 0.001). The medians of the relative reductions in electromyography for the arm and hand muscles were 90-96%, similar to the effect on the deltoid muscle. Our results suggest that a lateral infraclavicular block provides block of the axillary nerve comparable to the block of the surgical target nerves. The suprascapular nerve is blocked to a lesser degree. Combining a lateral infraclavicular brachial plexus block with a selective suprascapular block for shoulder surgery warrants further studies.Copyright © 2018 Association of Anaesthetists Database: EMBASE

234. Left Ventricular Decompression Using a Percutaneous Transvalvular Microaxial Ventricular Assist Device in Patients Receiving VA ECMO Author(s): Allen C.T.; Litton E. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

235. To OTE or Not to OTE: That Is the Question-Current International Trends of on the Table Extubation After Pediatric Cardiac Surgery Author(s): Richards M.; Latham G.; Ross F.; Eisses M.; Geiduschek J.; Joffe D. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

236. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care Author(s): Krichevskiy L.A.; Kozlov I.A. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.Copyright © 2018 Elsevier Inc. Database: EMBASE

237. Extended-Release Morphine for Chronic Breathlessness in Pulmonary Arterial Hypertension-A Randomized, Double-Blind, Placebo-Controlled, Crossover Study Author(s): Ferreira D.H.; Currow D.C.; Ekstrom M.; Sajkov D.; Vandersman Z.; Eckert D.J. Source: Journal of Pain and Symptom Management; Oct 2018; vol. 56 (no. 4); p. 483-492 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Context: Pulmonary arterial hypertension (PAH) affects people of all ages and is associated with poor prognosis. Chronic breathlessness affects almost all people with PAH. Objectives: This randomized, placebo-controlled, double-blind, crossover study aimed to evaluate the effects of regular, low-dose, extended-release (ER) morphine for PAH-associated chronic breathlessness. Methods: Participants with PAH-associated chronic breathlessness were randomized to 1) seven days of ER morphine 20 mg, 2) seven-day washout, and 3) seven days of identically looking placebo, or vice versa. Primary end points were breathlessness "right now"-morning and evening-measured with a Visual Analogue Scale. Secondary end points included additional breathlessness measures, quality of life, function, harms, and blinded treatment preference (ACTRN12609000209291). Results: Within a period of seven years, 50 patients were assessed in detail and 23 (46%) were randomized (despite broad eligibility criteria). Four participants withdrew while taking morphine. Nineteen participants completed the study. Breathlessness "right now" was higher on morphine compared with placebo both for morning [mean (M) +/- SD 31.7 +/- 25 mm vs. 26.9 +/- 22 mm; effect size (80% CI) = -0.22 (-0.6 to 0.2)] and evening [(M +/- SD 33.5 +/- 28 mm vs. 25.6 +/- 21 mm; effect size (80% CI) = -0.33 (-0.8 to 0.1)]. All secondary measures of breathlessness were higher with morphine as were nausea and constipation. Conclusion: This study does not support a Phase III study of ER morphine for people with PAH-associated chronic breathlessness. Recruiting to the target sample size was difficult, the direction of effect in every measure of breathlessness favored placebo and morphine generated more harms.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

238. Ultrasound-guided phrenic nerve block for intraoperative persistent hiccups: A case report Author(s): Zhang Y.; Ma W.; Duan F. Source: BMC Anesthesiology; Sep 2018; vol. 18 (no. 1) Publication Date: Sep 2018 Publication Type(s): Article Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Available at BMC anesthesiology - from PubMed Central Abstract:Background: Continuous hiccups during surgery not only affect the surgical procedure, they can also cause adverse effects for the patient. Apart from active investigation of the cause of the hiccups, their timely termination is also necessary. Case presentation: We reported a case of a 70- year-old woman with continuous intraoperative hiccups that appeared during vaginal hysterectomy under low continuous epidural anesthesia. After the ineffectiveness CO2 repeated inhalation and intravenous administration of chlorpromazine and methoxychlorpromide, we performed unilateral phrenic nerve block under ultrasound guidance. Hiccups were terminated without any related complications. Conclusions: During intraoperative continuous hiccups, ultrasound guided phrenic nerve block may be a suitable treatment option when physical methods and drug therapy are not effective. However, given the absence of a vital risk related to hiccups, this block should imply the complete absence of any respiratory contraindication and a prolonged postoperative respiratory monitoring.Copyright © 2018 The Author(s). Database: EMBASE

239. Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project Author(s): Hwang F.; Hidalgo A.; Mosenthal A.C.; Lamba S.; Berlin A.; Boardingham C.; Walther S.; Jacob M.; Gandhi C.D. Source: Journal of Pain and Symptom Management; Oct 2018; vol. 56 (no. 4); p. 588-593 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Background: Few patients with dysphagia because of stroke receive early palliative care (PC) to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. Measures: To increase documented goals of care (GOC) discussions among acute stroke patients before feeding gastrostomy tube placement. Intervention: We undertook a rapid-cycle continuous quality improvement process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for PC referral prompted by the speech and language pathology evaluation. Outcomes: During a six-month period, 21 patients underwent gastrostomy tube placement; 52% had preprocedure GOC discussions postintervention, with the rate of compliance increasing steadily from 13% (11/87, preintervention) to 100% (2/2) in the final two months. Conclusions/Lessons Learned: We effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

240. Sacral neuromodulation for fecal incontinence (FI) Author(s): Eltermam D.; Shepherd S. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: This study assessed pre-post changes in patient important outcomes in patients who underwent Sacral Neuromodulation for fecal incontinence (FI). Methods: FI can dramatically reduce quality of life in patients who experience this condition. Sacral neuromodulation (SNM) is a standard therapeutic option for the management of FI syndromes. There is a gap in our knowledge on how SNM affects patient quality of life among patients who experience FI. An administrative database managed by the principle investigator identified patients who underwent SNM for FI. The primary outcome was change in the Cleveland Clinic Incontinence Score (CCIS), FI Severity Index (FISI), FI Quality of Life (FIQoL), Irritable Bowel Severity (IBS) Score, and Patient Assessment of Constipation-symptoms score (PACS-SYM) 3 months post-procedure. Mean values were assessed with 95% confidence intervals. Statistical analysis was conducted with a two-sided paired t-test with an alpha level of 0.05. Results: 62 patients (58 women and 4 men) received SNM for FI. The mean age is 57.9 (+/- 3.25) years. Mean difference values for outcomes were reported for the CCIS [-11(+/- 3)], FIQoL [-30(+/-10], FISI [-15 (+/-4), IBS Score [-11(+/-3)], PAC-SYM [-8(+/-3)]. A two-sided paired t test showed statistically significant p-values for CCIS (p = 0.00001), FISI (p = 0.00001), IBS (p = 0.00001), PAC-SYM (p = 0.00001). Conclusions: SNM is effective at improving patient quality of life by reducing symptom severity and frequency. Further research is needed to assess demographic characteristics associated with improved quality of life outcomes post-SNM among patients who experience FI. Database: EMBASE

241. Use of vancomycin impregnated beads to salvage intrathecal pump pocket dehiscence Author(s): Canuel J.F.; Simard A.; Padilla Del Rey M. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: When an intrathecal pump becomes exposed, implant salvage is attempted with systemic antibiotics, surgical debridement, liberal irrigation, and creation of a new subcutaneous pocket. Our goal is to demonstrate the successful use of antibiotic-impregnated calcium sulfate beads in a patient to prevent infection. Methods: A 71-year-old male was treated in our pain center for failed back surgery syndrome. Twenty-five years earlier, a medullar spinal cord stimulator was implanted and multilevel spinal fusions were performed. The patient underwent implantation of a Medtronic (Minneapolis, USA) intrathecal pump in 1999. In 2016, catheter replacement, pocket revision and pump replacement were performed due to opioid withdrawal and rotor malfunction. Four months later, the patient developed a 5-mm wound dehiscence with exposed hardware and purulent drainage. Wound cultures were positive for staphylococcus lugdensis. The patient was treated with IV ceftriaxone for 4 days. The subcutaneous pocket and pump were cleaned using surgical irrigation with saline solution. One gram of vancomycin was mixed with calcium sulfate Stimulan (Staffordshire, United Kingdom) and left in place before skin closure. Results: Postoperatively, the patient did not show any sign of infection and was discharged on postoperative day 3. Ten months after the procedure, no relapse of dehiscence nor infection has occurred. Conclusions: This case report highlights the successful use of calcium sulfate beads of vancomycin for the treatment of intrathecal pump pocket dehiscence. Case-series and prospective studies should be performed in carefully selected patients to demonstrate non-inferiority over the creation of a new subcutaneous pocket. Database: EMBASE

242. A systematic review of parasthesia-free spinal cord stimulation modes for complex regional pain syndrome Author(s): Costanzi M.; Mednikov; Bhatia A. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: Complex regional pain syndrome (CRPS) is often associated with severe pain. Tonic spinal cord stimulation (T-SCS) is often used for CRPS but it has a high failure rate and or it is associated with intolerable paresthesias and attenuation of analgesia over time. Paresthesia-free SCS (PF-SCS) modes including high frequency (HF), Burst, and high density (HD) stimulation have been introduced recently with success in treating failed back surgery and neuropathic pain syndromes. This systematic review was conducted to summarize the evidence on the role of PF-SCS for CRPS. Methods: A literature search of multiple databases was conducted. Outcomes including impact of PF-SCS on intensity of pain, features of CRPS, and associated domains (functional outcomes, quality of life, medication usage, and patient satisfaction) were assessed. Results: The literature search yielded 13 papers (7 case series, 5 conference abstracts, 1 randomized trial) involving 62 patients. PF-SCS modes reported were mostly HF (10 papers), Burst (2 papers), and HD (1 paper). Failure of T-SCS after a period of analgesic benefit was commonly reported with PF-SCS modes often providing "rescue" analgesia. Resolution of symptoms and signs of CRPS was reported in some papers and absence of paresthesias was often quoted as an important benefit. Outcomes were monitored from less than a day to 2 years following initiation of PF-SCS. No adverse effects related to PF-SCS were reported. Conclusions: Paresthesia-free SCS modes have the potential to increase analgesic success rates in CRPS and further research including RCTs are warranted. Database: EMBASE

243. Posterior lumbar/sacral nerve root stimulation for treatment of chronic foot and/or Ankle pain Author(s): Pyles S.T.; Lechleiter K.; Chen L.; Jain R. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: Chronic focal pain relief has been reported using Dorsal Root Ganglion (DRG) stimulation (1). However, there is reportedly a high incidence of adverse events associated with this technique (2, 3). Effective treatment of groin and pelvic pain using stimulation with leads over the L1 dorsal nerve root has recently been demonstrated (4). We evaluated outcomes of proximal dorsal somatic nerve root stimulation as an alternative method for chronic foot/ankle pain. Methods: Institutional Review Board (IRB) approved waivers of consent were obtained for this single-center, case-series evaluating patients with chronic foot/ankle pain diagnosed with Complex Regional Pain Syndrome or Diabetic/non-Diabetic peripheral neuropathy (N = 9). Patients were implanted with a neurostimulator capable of anatomically-guided (3D) neural targeting (3DNT, Precision Spectra, Boston Scientific). Using a previously described technique, leads were placed antegrade through the sacral hiatus within a range of L5-S1(5). Results: A 6.3 point reduction in NRS (p < 0.0001) was reported at mean last follow-up duration = 315.6 day. 55% (5/9) of patients reported 91-100% improvement in their pain and 44% (4/9) reported no pain (NRS = 0) at last follow up. Additionally, >75% (7/9) of patients reported NRS <= 1, 56% preferred standard rate and 44% preferred higher rate stimulation. Conclusions: DRG stimulation may be associated with additional risks in addition to a more complex procedure (2). This small case-series demonstrates that neurostimulation within the L5-S1 range using 3DNT is a viable option to treat focal foot/ankle pain. A statistically significant reduction in NRS (p < 0.0001) was observed at a mean follow-up duration of 315.6 days. Future studies are needed to confirm these initial findings. Database: EMBASE

244. Correlation of patient-reported and objectively monitored activity and sleep in patients undergoing neuromodulation trials for neuropathic pain syndromes Author(s): Bhatia A.; Singh M.; Kalia S.K.; Hodaie M.; Lim A.; Kara J.; Mazzella F.; Mednikov A.; Paul D. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: Spinal cord stimulation (SCS) is used to ameliorate chronic neuropathic pain (NP).1 Though chronic NP is often associated with impaired physical activity2 and a poor quality of sleep, pain score - a subjective measure - are the most frequent and often the only outcome monitored during SCS trials. Validated questionnaires can be used to track activity and sleep during SCS trials but recall bias limits their reliability.3 We hypothesize that objective tracking of these domains allows better-informed decisions based on comprehensive assessment of multidimensional impact of SCS. Methods: Pre- and post-SCS trial data was collected from patients undergoing percutaneous SCS trials (1-2 weeks duration) for persistent NP in the back and lower limbs. Validated questionnaires were used to collect data on intensity and character of pain, activity, and sleep. These include numerical rating scores for pain, DN4 questionnaire, Oswestry Disability Index (ODI), Pain Disability Index (PDI), and Pain and Sleep Questionnaire three-item index (PSQ-3). Patients were also provided with wrist-worn accelerometers (GENEActiv, Activeinsights) throughout the trial period that track physical activity and sleep metrics. Results: Data from validated questionnaires and accelerometers was examined for correlation and its association with SCS trial outcomes. We collected data on 10 patients who participated in SCS trials for NP syndrome since introduction of accelerometers in our clinical practice. Our preliminary analysis indicates the potential utility of correlating validated questionnaires with objective assessment. Conclusions: Using data obtained from accelerometer-based sensors during SCS trials can improve long-term outcomes of SCS through more appropriate patient selection. Database: EMBASE

245. Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: 12-month results of an international multicenter randomized trial (PROMISE Study) Author(s): Rigoard P.; North R.; Taylor R.S.; Annemans L.; Tan Y.; Johnson M.J.; Van Den Abeele C.; Desai M.J. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6) Publication Date: Aug 2018 Publication Type(s): Conference Abstract Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: PROMISE is a multicenter, prospective, randomized, open-label, parallel-group study that assessed the clinical effectiveness of spinal cord stimulation (SCS) with a multicolumn lead in FBSS patients with predominant low back pain (LBP). Methods: Eligible subjects were randomized 1:1 to optimal medical management (OMM) or SCS plus OMM. Primary endpoint data was collected at 6 months after which patients could change treatment groups. The primary outcome was the proportion of subjects with >=50% reduction in LBP (responder). Secondary outcomes included change in LBP intensity, leg pain intensity, functional disability (Oswestry Disability Index, ODI) and health-related quality of life (Short-Form Health Survey, Physical Component Summary, SF-36-PCS). Results: There were 218 patients randomized in 28 centers (110 to SCS and 108 to OMM). At 6 months, there were significantly more responders in the SCS group compared to the OMM group (13.6% versus 4.6%, p = 0.036) and all secondary outcomes improved significantly (p < 0.001) in the SCS group. The between group difference was significant (p < 0.001) in favor of the SCS group. Of the 68 SCS subjects receiving SCS therapy at 12 months (SCS maintenance group), 26.5% (18/68) were responders. Statistically significant improvements in all secondary outcomes were observed compared to baseline. Of the 54 OMM subjects who switched to SCS and provided 12-months data, 38.9% (21/54) were responders. Conclusions: In a traditionally difficult to treat patient population, the addition of SCS with a multicolumn lead to OMM provided significant, sustained improvements in pain relief, health-related quality of life and function. Database: EMBASE

246. In reply: Encouraging a bare minimum while striving for the gold standard: a response to the updated WHO-WFSA guidelines Author(s): Gelb A.W.; Morriss W.W.; Johnson W.; Merry A.F. Source: Canadian Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

247. Encouraging a bare minimum while striving for the gold standard: a response to the updated WHO-WFSA guidelines Author(s): Hendel S.; Banguti P.; Workneh R.S.; Pinto E.; Coonan T.; Neighbour R.; Perndt H.; Froese A.; McQueen K. Source: Canadian Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

248. Factors Associated with Sport-Related Post-concussion Headache and Opportunities for Treatment Author(s): Register-Mihalik J.K.; Vander Vegt C.B.; Cools M.; Carnerio K. Source: Current Pain and Headache Reports; Nov 2018; vol. 22 (no. 11) Publication Date: Nov 2018 Publication Type(s): Review Abstract:Purpose of Review: The purpose of this review is to (1) describe factors both pre- and post- injury that are associated with post-concussion headache, (2) describe the influence of post- concussion headache on recovery following concussion, and (3) provide potential post-concussion treatment options that may reduce the burden of headache, as well as other symptoms to facilitate recovery. Recent Findings: Various factors may be associated with post-concussion headache presentation. These may include pre-injury or historical factors such as sex, family and self-history of headache and migraine, concussion history, and mood disorders. In addition, post-injury presentation factors for consideration may include injury mechanism, symptom clusters, cervicogenic dysfunction, and post-concussion physiologic dysfunction. Despite this complex interplay of factors, many treatment options may improve headache symptoms and recovery post- concussion including rehabilitation programs focusing on deficits such as visual-vestibular dysfunction, sub-symptom threshold exercise, and potential pharmacological interventions. Summary: Concussion is a complex injury that results in a variety of sequelae with headache being one of the most common. Understanding factors related to post-concussion headache presentation and the available options for treatment may improve patient care and outcomes post- concussion.Copyright © 2018, Springer Science+Business Media, LLC, part of Springer Nature. Database: EMBASE

249. A Concurrent Cognitive Task Does Not Perturb Quiet Standing in Fibromyalgia and Chronic Fatigue Syndrome Author(s): Rasouli O.; Stensdotter A.-K.; Fors E.A.; Vasseljen O. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Available at Pain research & management - from Publishers' website (via doi.org) Abstract:Background and Objectives. Cognitive complaints are common in fibromyalgia (FM) and chronic fatigue syndrome (CFS). Fatigue as well as pain may require greater effort to perform cognitive tasks, thereby increasing the load on processing in the central nervous system and interfering with motor control. Methods. The effect of a concurrent arithmetic cognitive task on postural control during quiet standing was investigated in 75 women (aged 19-49 years) and compared between FM, CFS, and matched controls (n=25/group). Quiet standing on a force plate was performed for 60 s/condition, with and without a concurrent cognitive task. The center of pressure data was decomposed into a slow component and a fast component representing postural sway and adjusting ankle torque. Results. Compared to controls, CFS and FM displayed lower frequency in the slow component (p<0.001), and CFS displayed greater amplitude in the slow (p=0.038 and p=0.018) and fast (p=0.045) components. There were no interactions indicating different responses to the added cognitive task between any of the three groups. Conclusion. Patients displayed insufficient postural control across both conditions, while the concurrent cognitive task did not perturb quiet standing. Fatigue but not pain correlated with postural control variables.Copyright © 2018 Omid Rasouli et al. Database: EMBASE

250. Procalcitonin kinetics after burn injury and burn surgery in septic and non-septic patients - a retrospective observational study Author(s): Cabral L.; Meireles R.; Vaz M.; Afreixo V.; Marques M.; Tourais I.; Chaves C.; Almeida L.; Paiva J.A. Source: BMC Anesthesiology; Sep 2018; vol. 18 (no. 1) Publication Date: Sep 2018 Publication Type(s): Article Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Available at BMC anesthesiology - from PubMed Central Abstract:Background: Early sepsis diagnosis is crucial for the correct management of burn patients, and it clearly influences outcomes. The systemic inflammatory response triggered by burns mimics sepsis presentation and complicates early sepsis diagnosis. Biomarkers were advocated to aid the diagnosis of early sepsis. Serum procalcitonin (PCT) exhibits fair accuracy and good correlation with sepsis severity, being used in diverse clinical settings. However, few studies have evaluated perioperative changes in PCT levels in burn patients. The present study evaluated PCT kinetics during the first days after burn injury and subsequent surgical interventions to assess PCT utility in distinguishing septic from non-septic inflammatory responses. Methods: This study was a retrospective observational study of all burn patients admitted to the Coimbra Burns Unit (Portugal) between January 2011 and December 2014 who presented with a total burn surface area >= 15% and who underwent subsequent surgery. PCT kinetics were investigated a) during the first five days after burn injury and b) preoperatively during the five days after surgery in three subsets of patients, including those with no preoperative and no postoperative sepsis (NN), no preoperative but postoperative sepsis (NS), and preoperative and postoperative sepsis (SS). A total of 145 patients met the selection criteria and were included in the analysis. Results: PCT levels in the first five days after burn injury were significantly higher in patients who developed at least one sepsis episode (n = 85) compared with patients who did not develop sepsis (n = 60). PCT values > 1.00 ng/mL were clearly associated with sepsis. Study participants (n = 145) underwent a total of 283 surgical interventions. Their distribution by preoperative/postoperative sepsis status was 142 (50.2%) in NN; 62 (21.9%) in NS; and 79 (27.9%) in SS. PCT values exhibited a parallel course in the three groups that peaked on the second postoperative day and returned to preoperative levels on the third day or later. The lowest PCT values were found in NN, and the highest values were observed in SS; the NS values were intermediate. Conclusions: PCT kinetics coupled with a clinical examination may be helpful for sepsis diagnosis during the first days after burn injury and burn surgery.Copyright © 2018 The Author(s). Database: EMBASE

251. Expanding Goals of Care Conversations Across a Health System: The Mapping the Future Program Author(s): Childers J.W.; Arnold R.M. Source: Journal of Pain and Symptom Management; Oct 2018; vol. 56 (no. 4); p. 637-644 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Context: Clinician failure to discuss goals of care (GOC) with seriously ill patients remains prevalent. Small-scale educational interventions have demonstrated improvement in physician communication skills, but it is unknown if these results translate into practice changes. Objectives: To implement a large-scale educational intervention that would facilitate increased GOC discussions in at-risk patients, increase clinician confidence in having GOC discussions, and prove to be sustainable. Methods: The Mapping the Future courses were four-to-eight-hour trainings, with brief lectures and demonstrations followed by practice with simulated patient cases. Participants completed precourse and postcourse surveys, including demographic information, self-confidence in a variety of communication tasks, willingness to initiate GOC discussions, barriers to GOC discussions, and self-perceived skill at having GOC conversations. We compared the rate of documentation of GOC discussions with at-risk inpatients in three hospitals for physicians who had taken the course and those who had not. Results: Over a two-year period, we trained 512 clinicians in 42 sessions. After the course, participants felt that they had improved in all the skills that we taught and agreed that they would be more likely to initiate GOC conversations. Trained physicians were more likely than their nontrained colleagues to document a GOC discussion with at-risk patients (30.8% vs. 27.2%; P = 0.0001). Conclusion: A large-scale educational intervention involving simulated patient cases increased GOC documentation across a health system. Other programs might consider collaboration with quality improvement specialists to measure the impact of education and situate it within other system changes to support increased GOC discussions.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

252. Quality of Life Trends in People With and Without Cancer Referred to Volunteer-Provided Palliative Care Services (ELSA): A Longitudinal Study Author(s): Walshe C.; Preston N.; Payne S.; Dodd S.; Perez Algorta G. Source: Journal of Pain and Symptom Management; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Context: Trends in symptoms and functional ability are known toward the end of life, but less is understood about quality of life, particularly prospectively following service referral. Objectives: This study compares quality of life trajectories of people with and without cancer, referred to volunteer-provided palliative care services. Methods: A secondary analysis of the ELSA trial (n = 85 people with cancer and n = 72 without cancer) was performed. Quality of life data (WHOQOL-BREF) were collected at baseline (referral), four weeks, eight weeks, and 12 weeks. Sociodemographic data were collected at baseline. We specified a series of joint models to estimate differences on quality of life trajectories between groups adjusting for participants who die earlier in the study. Results: People with cancer had a significantly better quality of life at referral to the volunteer-provided palliative care services than those with nonmalignant disease despite similar demographic characteristics (Cohen d's = 0.37 to 0.45). More people with cancer died during the period of the study. We observed significant differences in quality of life physical and environmental domain trajectories between groups (b = -2.35, CI -4.49, -0.21, and b = -4.11, CI -6.45, -1.76). People with cancer experienced a greater decline in quality of life than those with nonmalignant disease. Conclusion: Referral triggers for those with and without cancer may be different. People with cancer can be expected to have a more rapid decline in quality of life from the point of service referral. This may indicate greater support needs, including from volunteer-provided palliative care services.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

253. Treat to target strategy in early rheumatoid arthritis versus routine care - A comparative clinical practice study Author(s): Brinkmann G.H.; Grovle L.; Haugen A.J.; Norvang V.; Norli E.S.; Kvien T.; Mjaavatten M.D.; Lie E.; Bjorneboe O.; Lexberg A.S.; Rodevand E.; Bakland G.; Nygaard H.; Kroll F.; Widding-Hansen I.J.; Thunem C. Source: Seminars in Arthritis and Rheumatism; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: To assess the 2-year effect on disease activity and health-related quality of life (HRQoL) of implementing a clinical practice treat-to-target (T2T) strategy in patients with rheumatoid arthritis (RA). Methods: Patients in the Norwegian Very Early Arthritis Cohort 2.0 (NOR- VEAC 2.0), included 2010-2015, were treated according to T2T principles with visits at baseline, 3, 6, 9, 12 months, then every 6 months plus monthly visits until DAS28 <2.6. These patients were compared to a pre-T2T cohort of patients included in the Norwegian Disease Modifying Anti- Rheumatic Drug (NOR-DMARD) register 2006-2009. Both groups had a clinical diagnosis of RA (<=1 year) and were DMARD naive. Disease activity and HRQoL outcomes were analysed, and the primary outcome was SDAI remission (<=3.3) at 2 years. Results: The T2T cohort included 293 patients (mean (SD) age 54 (13) years, 66% females, disease duration median (25,75 perc) 98 (57,164) days) and the routine care cohort 392 patients (age 54 (13) years, 68% females, 4 (0,30) days since diagnosis). At 2 years, the proportion of patients achieving SDAI remission was 46% in the T2T cohort compared to 31% in the routine care cohort. EQ-5D was similar at baseline, but differed significantly between groups at 2 years (median (25,75 perc) 0.77 (0.69, 0.85) vs 0.73 (0.59, 0.80), p < 0.001). Methotrexate monotherapy was the dominant DMARD regimen used to achieve SDAI remission in both cohorts. Conclusion: Higher remission rates and better HRQoL were achieved in patients following a T2T strategy in clinical practice compared to routine care.Copyright © 2018 Elsevier Ltd Database: EMBASE

254. Exploring the patient experience of digital ulcers in systemic sclerosis Author(s): Hughes M.; Pauling J.D. Source: Seminars in Arthritis and Rheumatism; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Digital ulcers are common in patients with systemic sclerosis, affecting over half of patients during the course of their disease. For some patients, digital ulcers occur as isolated phenomena; whereas, for others, digital ulceration is recurrent, and often refractory to intervention. Demonstrating treatment efficacy for digital ulcer disease has typically focussed on clinician opinion of ulcer healing and new ulcer occurrence. Advances in management have improved outcomes which may have had the unfortunate effect of rendering traditional trial endpoints less effective at demonstrating treatment efficacy. Despite recent improvements in management, our work is not complete and digital ulceration remains a major cause of morbidity for many patients with systemic sclerosis. This review shall examine the patient experience of digital ulcers in systemic sclerosis. We shall consider how a detailed understanding of the severity and burden of digital ulceration, aetiopathogenesis, and their impact on emotional health, function, work and social participation might inform the development of novel clinical trial outcomes that can support future advances in the assessment and management of digital ulceration in systemic sclerosis.Copyright © 2018 Elsevier Inc. Database: EMBASE

255. Diagnostic accuracy of a calibrated abdominal compression to predict fluid responsiveness in children Author(s): Jacquet-Lagreze M.; Tiberghien N.; Hanna N.; Chardonnal L.; Bompard D.; Koffel C.; Fellahi J.-L.; Evain J.-N.; Courtil-Teyssedre S.; Baudin F.; Javouhey E.; Lilot M.; Portefaix A. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Fluid administration to increase stroke volume index (SVi) is a cornerstone of haemodynamic resuscitation. We assessed the accuracy of SVi variation during a calibrated abdominal compression manoeuvre (DELTASVi-CAC) to predict fluid responsiveness in children. Methods: Patients younger than 8 yr with acute circulatory failure, regardless of their ventilation status, were selected. SVi, calculated as the average of five velocity-time integrals multiplied by the left ventricular outflow tract surface area, was recorded at four different steps: baseline, after an abdominal compression with a calibrated pressure of 25 mm Hg, after return to baseline, and then after a volume expansion (VE) of 10 ml kg-1 lactated Ringer solution over 10 min. Patients were classified as responders if SVi variation after volume expansion (DELTASVi-VE) increased by at least 15%. Results: The 39 children included had a median [inter-quartile range (IQR)] age of 9 [5-31] months. Twenty patients were fluid responders and 19 were non-responders. DELTASVi-CAC correlated with DELTASVi-VE (r=0.829; P<0.001). The area under the receiver operating characteristic curve (ROCAUC) was 0.94 [95% confidence interval (CI), 0.85-0.99]. The best threshold for DELTASVi-CAC was 11% with a specificity of 95% [95% CI, 84-100] and a sensitivity of 75% [95% CI, 55-95]. ROCAUC of respiratory variation of IVC diameter (DELTAIVC) was 0.53 [95% CI, 0.32-0.72]. Conclusion: DELTASVi-CAC during abdominal compression was a reliable method to predict fluid responsiveness in children with acute circulatory failure regardless of their ventilation status. Clinical trials registration: CPP Lyon sud est II: ndegree ANSM 2015-A00388-41 Clinicaltrial.gov: NCT02505646.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

256. Airway management in microgravity: A systematic review Author(s): Warnecke T.; Tochtermann F.; Kerkhoff S.; Hinkelbein J.; Neuhaus C.; Komorowski M. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: In the near future, space programs will shift their focus toward long-duration interplanetary missions, in particular to the Moon and Mars. These exploration missions will be associated with an increased risk of acute medical problems, which will need to be handled by an autonomous crew operating in extreme isolation. An important skill in emergencies is represented by airway management. Many airway devices are available and it is unclear which one would be the most suitable in the context of a space mission. The aim of this systematic review was to analyze the existing literature on airway management in the special situation of weightlessness during space missions. Material and methods: We performed a standardized review of published literature on airway management in spaceflight and analogue environments using the database PubMed. Results: We identified a total of 3111 publications of which 3039 were initially excluded after evaluation. The screening identified three randomized comparative manikin studies, two of them in parabolic flights, one in a submerged setup. Under free-floating conditions, the insertion success rate of supraglottic airway devices (SGA) was excellent (91%-97%). The administration of artificial ventilation could be successfully achieved in weightlessness with SGA. The success rate of conventional laryngoscopy under free-floating conditions fluctuated between 15% and 86%. Conclusion: It appears possible to safely manage the airway in weightlessness, provided that certain conditions are ensured, such as restraining the patient and operator for conventional orotracheal intubation. If airway protection is required with endotracheal intubation, both the operator and the patient should be restrained.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

257. Haemodynamic stability after paracervical block: A randomized, controlled, double-blind study comparing bupivacaine-adrenaline with bupivacaine Author(s): Sjoeen G.H.; Falk R.S.; Hauge T.H.; Langesaeter E. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Paracervical block is widely used in gynaecological interventions on cervix and uterus. Many surgeons add adrenaline 100 mug or pitressin 3-5 IU in a total volume of 10-20 mL to reduce total blood loss. We wanted to examine haemodynamic stability in healthy patients given bupivacaine with and without adrenaline. Methods: In this randomised, double-blinded, controlled study, 30 healthy women scheduled for cervical conisation got a paracervical block using bupivacaine 50 mg with adrenaline 100 mug (BA-group, n = 14) or without adrenaline (B-group, n = 16) after induction of general anaesthesia. LiDCOplus was used for minimally invasive haemodynamic monitoring. Changes in cardiac output (CO) and systolic blood pressure (SBP) were the primary outcome. Changes in heart rate (HR), stroke volume (SV), and systemic vascular resistance (SVR) were secondary outcome variables. Area under the curve (AUC) ratios and change from baseline to maximal values were used as effect measures comparing the two groups. Results: The AUC-ratio for CO and SBP was 2.50 (P < 0.001) and 1.70 (P = 0.03), respectively. For HR, SV, and SVR the AUC-ratio was 1.59 (P < 0.01), 1.52 (P < 0.001), and 0.90 (P = 0.14), respectively. CO increased 68% (standard deviation (SD) 42%, P < 0.001), HR increased 41% (SD 26%, P < 0.001), and SV increased 26% (SD 17%, P < 0.001) from baseline to maximal values after 70-90 seconds in the BA-group. Conclusion: Paracervical block with bupivacaine 50 mg and adrenaline 100 mug may give haemodynamic instability in healthy females and is not recommended if haemodynamic side effects are to be avoided.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

258. Bias and sample size in intensive care unit trials: Protocol for a meta-epidemiological study Author(s): Anthon C.T.; Granholm A.; Perner A.; Moller M.H.; Laake J.H. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Systematic errors (bias) and random errors result in inflated and imprecise intervention effect estimates in randomised clinical trials (RCT) and meta-analyses. We aim to assess time trends in the Cochrane risk of bias domains and sample size in RCTs of intensive care unit (ICU) interventions. Methods and design: We will conduct a meta-epidemiologic study of RCTs included in Cochrane systematic reviews assessing any intervention used in adult patients admitted to the ICU. We will search the Cochrane Database of Systematic Reviews and include reviews published from March 2011 corresponding to the latest update in the Cochrane risk of bias tool. We will extract data on risk of bias judgments in the seven Cochrane bias domains and trial sample sizes and evaluate time trends using run charts. The primary outcome will be time trends in the annual proportion of trials with overall low risk of bias (low risk of bias in all bias domains). The secondary outcomes include time trends in the annual median trial sample size, and the annual proportion of trials with low-, unclear- and high risk of bias in each of the seven Cochrane bias domains. Discussion: The outlined meta-epidemiologic study will assess time trends in risk of bias and sample sizes in RCTs assessing ICU interventions. This will inform researchers, healthcare personnel and policymakers on the general reliability of findings from RCTs of ICU interventions over time, and inform future RCT design and reporting.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

259. Intraoperative anesthetic management of an infant with a bridging bronchus: A case report Author(s): Shakuo T.; Oe K.; Shimura Y.; Awakura H.; Yamada A. Source: Paediatric Anaesthesia; Sep 2018; vol. 28 (no. 9); p. 815-816 Publication Date: Sep 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:A newborn infant was diagnosed with an imperforate anus, and colostomy was performed one day after birth. He exhibited repeated episodes of poor oxygenation during intubation, and a CT scan revealed a bridging bronchus. He was scheduled to undergo sacroperineal repair in the prone position 8 months later. A tracheal tube, with its tip modified to widen the opening, was inserted through the nose. This led to normal oxygenation, even while in the prone position. The surgery was completed without any complications.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

260. Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass Author(s): Kaiser A.; Guzzetta N.A.; Miller K.; Tian G.; Moore R.H. Source: Paediatric Anaesthesia; Sep 2018; vol. 28 (no. 9); p. 795-802 Publication Date: Sep 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass. Methods: After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10 kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared. Results: Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24 hours postoperatively. Discussion: The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

261. Assessment of skin temperature during regional anaesthesia-What the anaesthesiologist should know Author(s): Hermanns H.; Hollmann M.W.; Stevens M.F.; Werdehausen R. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1280-1289 Publication Date: Oct 2018 Publication Type(s): Review Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Body temperature homeostasis is accurately regulated by complex feedback-driven neuronal mechanisms, which involve a multitude of thermoregulatory pathways. Thus, core temperature is constantly maintained within a narrow range. As one of the most effective regulatory systems skin temperature is dependent on skin blood flow. Skin blood flow in turn is highly dependent on sympathetic activity. Regional anaesthesia leads to blockade not only of somatosensory and motor nerve fibres but also of sympathetic fibres. As a consequence, vasoconstrictor tonic activity is abrogated and a vasodilation leads to an increase in skin blood flow and temperature. The aim of this review was to summarize the general physiology of thermoregulation and skin temperature as well as the alterations during regional anaesthesia. The main focus was the usefulness of measuring skin temperature as an indicator of regional anaesthesia success. According to the available literature, assessment of skin temperature can indeed serve to predict success of regional anaesthesia. Hence, it is important to realize that relevant and reliable temperature increase is only seen in the most distal body parts, ie fingers and toes. More proximally, temperature changes are frequently small and inconsistent, which means that assessment of block levels is not possible by temperature measurement. Furthermore, relevant skin temperature increases will only be observed in patients, which are initially vasoconstricted. In conclusion, measurement of skin temperature represents a reliable and feasible diagnostic tool to assess and predict the success or failure of regional anaesthesia procedures, especially in patients in which sensory testing is impossible.Copyright © 2018 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation. Database: EMBASE

262. Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography-A randomised trial Author(s): Fredholm M.; Jorgensen K.; Houltz E.; Ricksten S.-E. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1246-1254 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: We compared the direct inotropic and lusitropic effects of two inodilators, milrinone and levosimendan in patients after aortic valve replacement for aortic stenosis. Methods: In this randomised, blinded study, 31 patients with normal LV function, were randomised to either levosimendan (0.1 and 0.2 mug/kg/min, n = 15) or milrinone (0.4 and 0.8 mug/kg/min, n = 16) after aortic valve replacement. The effects on LV performance, LV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were assessed by a pulmonary artery catheter and transoesophageal two- dimensional speckle tracking echocardiography of the LV inferior wall. To circumvent the inodilator- induced hemodynamic changes on LV systolic and diastolic deformation, central venous pressure (CVP), systolic artery pressure (SAP), and heart rate were maintained constant by colloid infusion, phenylephrine-induced vasoconstriction and atrial pacing, respectively, during drug infusion. Results: Both inotropic agents induced a dose-dependent increase in cardiac index and stroke volume index by approximately 20% at the highest infusion rates with no differences between groups (P =.139 and.249, respectively). CVP, pulmonary capillary wedge pressure, SAP and heart rate were maintained constant in both groups. LV strain and SR-S increased with both agents, dose- dependently, by 17%-18% and 25%-30%, respectively, at the highest infusion rates, with no difference between groups (P =.434 and.284, respectively). Both agents improved early LV relaxation with no differences between groups (P =.637). At the higher doses, both agents increased SR-E by 30%. Conclusions: At clinically relevant infusion rates and a certain increase in LV performance the direct inotropic and lusitropic of milrinone and levosimendan were comparable.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

263. Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis Author(s): Hovaguimian F.; Tschopp C.; Beck-Schimmer B.; Puhan M. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1182-1193 Publication Date: Oct 2018 Publication Type(s): Review Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD). Methods: Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses. Results: Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD). Conclusion: The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

264. Renal effects of norepinephrine-induced variations in mean arterial pressure after liver transplantation: A randomized cross-over trial Author(s): Skytte Larsson J.; Bragadottir G.; Redfors B.; Ricksten S.-E. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1229-1236 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Acute kidney injury is commonly seen after liver transplantation. The optimal perioperative target mean arterial pressure (MAP) for renal filtration, perfusion and oxygenation in liver recipients is not known. The effects of norepinephrine-induced changes in MAP on renal blood flow (RBF), oxygen delivery (RDO2), glomerular filtration rate (GFR) and renal oxygenation (=renal oxygen extraction, RO2Ex) were therefore studied early after liver transplantation. Methods: Ten patients with an intra- and post-operative vasopressor-dependent systemic vasodilation were studied early after liver transplantation during sedation and mechanical ventilation. To achieve target MAP levels of 60, 75 and 90 mm Hg, the norepinephrine infusion rate was randomly and sequentially titrated. At each target MAP, data on cardiac index (CI), RBF and GFR were obtained by transpulmonary thermodilution (PiCCO), the renal vein thermodilution technique and renal extraction of chromium ethylenediaminetetraaceticacid (51Cr-EDTA), respectively. Renal oxygen consumption (RVO2) and extraction (RO2Ex) were calculated according to standard formulas. Results: At a target MAP of 75 mm Hg, CI (13%), RBF (18%), RDO2 (24%), GFR (31%) and RVO2 (20%) were higher while RO2Ex was unchanged compared to a target MAP of 60 mm Hg. Increasing MAP from 75 up to 90 mm Hg increased RVR by 38% but had no further effects on CI, RBF, RDO2 or GFR. Conclusions: In patients undergoing liver transplantation, RBF and GFR are pressure-dependent at MAP levels below 75 mm Hg. Our results suggest that MAP should probably be targeted to approximately 75 mm Hg for optimal perioperative renal filtration, perfusion and oxygenation in patients undergoing liver transplantation.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

265. Artificial ventilation during transport: A randomized crossover study of manual resuscitators with comparison to mechanical ventilators in a simulation model Author(s): Lucy M.J.; Gamble J.J.; Peeling A.; Lam J.T.H.; Balbuena L. Source: Paediatric Anaesthesia; Sep 2018; vol. 28 (no. 9); p. 788-794 Publication Date: Sep 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Positive-pressure ventilation in critically ill patients is commonly administered via a manual resuscitation device or a mechanical ventilator during transport. Our group previously compared delivered ventilation parameters between a self-inflating resuscitator and a flow-inflating resuscitator during simulated in-hospital pediatric transport. However, unequal group access to inline pressure manometry may have biased our results. In this study, we examined the performance of the self-inflating resuscitator and the flow-inflating resuscitator, both equipped with inline manometry, and several mechanical ventilators to deliver prescribed ventilation parameters during simulated pediatric transport. Methods: Thirty anesthesia providers were randomized to initial resuscitator device used to hand ventilate a test lung. The resuscitators studied were a Jackson-Rees circuit (flow-inflating resuscitator) or a Laerdal pediatric silicone resuscitator (self-inflating resuscitator), both employing manometers. The scenario was repeated using several mechanical transport ventilators (Hamilton-T1, LTV 1000, and LTV 1200). The primary outcome was the proportion of total breaths delivered within the predefined target PIP/PEEP range (30 +/- 3, 10 +/- 3 cm H2O). Results: The Hamilton-T1 outperformed the other ventilators for breaths in the recommended range (chi2 = 2284, df = 2, P <.001) and with no breaths in the unacceptable range (chi2 = 2333, df = 2, P <.001). Hamilton-T1 also outperformed all human providers in proportion of delivered acceptable and unacceptable breaths (chi2 = 4540, df = 3, P <.001 and chi2 = 639, df = 3, P <.001, respectively). Compared with the flow-inflating resuscitator, the self-inflating resuscitator was associated with greater odds of breaths falling outside the recommended range (Odds ratio (95% CI): 1.81 (1.51-2.17)) or unacceptable (Odds ratio (95% CI): 1.63 (1.48-1.81)). Conclusion: This study demonstrates that a majority of breaths delivered by manual resuscitation device fall outside of target range regardless of provider experience or device type. The mechanical ventilator (Hamilton- T1) outperforms the other positive-pressure ventilation methods with respect to delivery of important ventilation parameters. In contrast, 100% of breaths delivered by the LTV 1200 were deemed unacceptable.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

266. Continuous vital sign monitoring after major abdominal surgery-Quantification of micro events Author(s): Duus C.L.; Meyhoff C.S.; Aasvang E.K.; Olsen R.M.; Sorensen H.B.D.; Jorgensen L.N.; Achiam M.P. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1200-1208 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Millions of patients undergo major abdominal surgery worldwide each year, and the post-operative phase carries a high risk of respiratory and circulatory complications. Standard ward observation of patients includes vital sign registration at regular intervals. Patients may deteriorate between measurements, and this may be detected by continuous monitoring. The aim of this study was to compare the number of micro events detected by continuous monitoring to those documented by the widely used standardized Early Warning Score (EWS). Methods: Fifty patients were continuously monitored with peripheral arterial oxygen saturation (SpO2), heart rate (HR), and respiratory rate (RR) the first 4 days after major abdominal cancer surgery. EWS was monitored as routine practice. Number and duration of events were analyzed using Fisher's exact test and Wilcoxon rank sum test. Results: Continuous monitoring detected a SpO2<92% in 98% of patients vs 16% of patients detected by EWS (P <.0001). Micro events of SpO2<92% lasting longer than 60 minutes were found in 58% of patients by continuous monitoring vs 16% by the EWS (P <.0001). Fifty-two percent of patients had micro events of SpO2<85% lasting longer than 10 minutes. Continuous monitoring found tachycardia in 60% of patients vs 6% by the EWS. Frequency of events for bradycardia, tachypnea, and bradypnea showed similar patterns. Conclusion: Very low SpO2 and tachycardia in post-operative patients are common and under-diagnosed by the EWS. Continuous monitoring can discover these micro events and potentially contribute to earlier detection and, potentially, result in prevention of clinical complications.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

267. Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit Author(s): Horst S.; Kawati R.; Lipcsey M.; Rasmusson J.; Pikwer A.; Castegren M. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1261-1266 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background : Iatrogenic fluid overload is associated with increased mortality in the intensive care unit (ICU). Decisions on fluid therapy may, at times, be based on other factors than physiological endpoints. We hypothesized that because of psychological factors volume of available fluid bags would affect the amount of resuscitation fluid administered to ICU patients. Methods: We performed a prospective intervention cross-over study at 3 Swedish ICUs by replacing the standard resuscitation fluid bag of Ringer's Acetate 1000 mL with 500 mL bags (intervention group) for 5 separate months and then compared it with the standard bag size for 5 months (control group). Primary endpoint was the amount of Ringer's Acetate per patient during ICU stay. Secondary endpoints were differences between the groups in cumulative fluid balance and change in body weight, hemoglobin and creatinine levels, urine output, acute kidney failure (measured as the need for renal replacement therapy, RRT) and 90-day mortality. Results: Six hundred and thirty-five ICU patients were included (291 in the intervention group, 344 in the control group). There was no difference in the amount of resuscitation fluid per patient during the ICU stay (2200 mL [1000-4500 median IQR] vs 2245 mL [1000-5630 median IQR]), RRT rate (11 vs 9%), 90-day mortality (11 vs 10%) or total fluid balance between the groups. The daily amount of Ringer's acetate administered per day was lower in the intervention group (1040 (280-2000) vs 1520 (460-3000) mL; P =.03). Conclusions: The amount of resuscitation fluid administered to ICU patients was not affected by the size of the available fluid bags. However, altering fluid bag size could have influenced fluid prescription behavior.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

268. Pre-operative haemodynamic monitoring and resuscitation in hip fracture patients: Protocol for a prospective observational study Author(s): Agerskov M.; Hojlund J.; Foss N.B.; Sorensen H.; Secher N.H. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1314-1320 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: In a frail patient group often suffering from dehydration, hip fracture is potentially fatal partly because of the blood loss and thus deteriorated circulation. An important goal for haemodynamic monitoring and resuscitation is early detection of insufficient tissue perfusion. "The peripheral perfusion index" reflects changes in peripheral perfusion and blood volume. We hypothesize that hip fracture patients are hypovolaemic with poor peripheral perfusion and accordingly respond to controlled fluid resuscitation. The peripheral perfusion index might reflect restricted tissue perfusion in spite of stable central haemodynamic variables. Methods: This prospective observational study assess to what extend hip fracture patients suffer from hypovolaemia and respond to a stroke volume-guided fluid challenge. The secondary objectives are to evaluate correlation between the non-invasive peripheral perfusion index and minimally invasive measures of stroke volume, changes in blood volume and near-infrared spectroscopy determined tissue- and cerebral oxygenation and to compare results to prevalence of post-operative complications including mortality. We will include 50 patients (>65 years) presenting a hip fracture and treated in a multimodal fast-track regimen when written informed consent is available. Discussion: This is likely the first study to address pre-operative haemodynamic monitoring and resuscitation in hip fracture patients where adequate resuscitation is easily missed. We aim to evaluate feasibility of pre-operative stroke volume-guided haemodynamic optimization in the context of minimally- and non-invasive monitoring of peripheral perfusion and measure of blood volume.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

269. Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial Author(s): Taketa Y.; Irisawa Y.; Fujitani T. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1274-1279 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Although several approaches for ultrasound-guided thoracic paravertebral block have been introduced, little is known regarding the differences in analgesic efficacy. We conducted this prospective randomised trial to examine whether the type of approach for ultrasound-guided thoracic paravertebral block could affect analgesic quality in thoracotomy. Methods: Patients scheduled for video-assisted thoracotomy were randomly allocated into two groups by block technique: the intercostal approach (group IC) or the paralaminar approach (group PL). At the start and end of surgery, 20 mL of 0.5% ropivacaine was injected, followed by a continuous infusion of 0.2% ropivacaine at 5 mL h-1. We also started intravenous fentanyl patient- controlled analgesia at 0.5 mug kg-1 h-1 and bolus dose of 15 mug. The main outcome was the number of rescue fentanyl use. We also evaluated postoperative pain scores and number of blocked dermatomes showing a reduced sensation. Results: Enrolment was ceased because of implementation of a minimally invasive surgical method. Overall, 42 subjects completed the trial for analysis. The number of rescue fentanyl use in group PL was significantly less than that in group IC at 3, 6, 12 and 24 hour postoperatively. The numerical rating scale (NRS) at rest in group PL was significantly lower at 1, 3, 6, and 12 hour postoperatively. Patients in Group PL developed significantly wider sensory block level (median (IQR [range]); 4 (4-5 [2-7])) than those in Group IC (3 (3-3 [2-9])). Conclusions: We suggested that paralaminar approach provided superior analgesia for thoracotomy rather than the intercostal approach.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

270. Characteristics of jugular bulb oxygen saturation in patients after cardiac arrest: A prospective study Author(s): Wallin E.; Larsson I.-M.; Nordmark-Grass J.; Rosenqvist I.; Rubertsson S.; Kristofferzon M.- L. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1237-1245 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Using cerebral oxygen venous saturation post-cardiac arrest (CA) is limited because of a small sample size and prior to establishment of target temperature management (TTM). We aimed to describe variations in jugular bulb oxygen saturation during intensive care in relation to neurological outcome at 6 months post- CA in cases where TTM 33degreeC was applied. Method: Prospective observational study in patients over 18 years, comatose immediately after resuscitation from CA. Patients were treated with TTM 33degreeC M and received a jugular bulb catheter within the first 26 hours post-CA. Neurological outcome was assessed at 6 months using the Cerebral Performance Categories (CPC) and dichotomized into good (CPC 1-2) and poor outcome (CPC 3-5). Results: Seventy-five patients were included and 37 (49%) patients survived with a good outcome at 6 months post-CA. No differences were found between patients with good outcome and poor outcome in jugular bulb oxygen saturation. Higher values were seen in differences in oxygen content between central venous oxygen saturation and jugular bulb oxygen saturation in patients with good outcome compared to patients with poor outcome at 6 hours (12 [8-21] vs 5 [-0.3 to 11]% P =.001) post-CA. Oxygen extraction fraction from the brain illustrated lower values in patients with poor outcome compared to patients with good outcome at 96 hours (14 [9-23] vs 31 [25-34]% P =.008). Conclusions: Oxygen delivery and extraction differed in patients with a good outcome compared to those with a poor outcome at single time points. Based on the present findings, the usefulness of jugular bulb oxygen saturation for prognostic purposes is uncertain in patients treated with TTM 33degreeC post-CA.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

271. The association between pre-operative sepsis and 30-day mortality in hip fracture patients-A cohort study Author(s): Morch S.S.; Tantholdt-Hansen S.; Pedersen N.E.; Duus C.L.; Meyhoff C.S.; Petersen J.A.; Andersen C.O.; Jarlov J.O. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1209-1214 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Post-operative sepsis considerably increases mortality, but the extent of preoperative sepsis in hip fracture patients and its consequences are sparsely elucidated. The aim of this study was to assess the association between pre-operative sepsis and 30-day mortality after hip fracture surgery. Methods: We conducted a retrospective analysis of data collected among 1894 patients who underwent hip fracture surgery in the Capital Region of Denmark in 2014 (NCT03201679). Data on vital signs, cultures and laboratory data were obtained. Sepsis was defined as a positive culture of any kind and presence of systemic inflammatory response syndrome within 24 hours and was assessed within 72 hours before surgery and 30 days post-operatively. Primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay and admission to intensive care unit. Results: A total of 144 (7.6%) of the hip fracture patients met the criteria for pre-operative sepsis. The 30-day mortality was 13.9% in patients with pre-operative sepsis as compared to 9.0% in those without (OR 1.69, 95% CI [1.00; 2.85], P =.08). Patients with preoperative sepsis had longer hospital stays (median 10 days vs 9 days, mean difference 2.1 [SD 9.4] days, P =.03), and higher frequency of ICU admission (11.1% vs 2.7%, OR 4.15, 95% CI [2.19; 7.87], P <.0001). Conclusion: Pre-operative sepsis in hip fracture patients was associated with an increased length of hospital stay and tended to increase mortality. Pre-operative sepsis in hip fracture patients merits more intensive surveillance and increased attention to timely treatment.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

272. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of- hospital cardiac arrests Author(s): Setala P.; Kamarainen A.; Hoppu S.; Hellevuo H.; Tirkkonen J.; Huhtala H. Source: Acta Anaesthesiologica Scandinavica; Oct 2018; vol. 62 (no. 9); p. 1290-1296 Publication Date: Oct 2018 Publication Type(s): Article Available at Acta anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: We aimed to determine the incidence of and associated risk factors for cardiopulmonary resuscitation (CPR)-related injuries in non-survivors of out-of-hospital cardiac arrests (OHCAs) in an emergency medical service (EMS) system in which all CPR procedures are performed on scene and patients are not routinely transported to the hospital with ongoing CPR. Material and methods: We conducted this prospective observational study between 1 June 2013, and 31 May 2014. Data were collected from EMS datasheets and forensic autopsy records. The exclusion criteria were OHCAs due to trauma in the thoracic or abdominal area. EMS adhered to the European Resuscitation Council Resuscitation Guidelines (2010) during the resuscitation attempts. Results: Emergency medical service provided CPR in 280 attended OHCAs with 207 cases terminated on scene. A total of 149 patients underwent a forensic autopsy and 47% had a CPR-related injury. The most common injuries were multiple rib fractures (43%), with 22% of patients having more than eight fractured ribs. Abdominal visceral injuries or injuries related to airway management were rare. The injuries were associated with older age, male gender, initial shockable rhythm and public location of the cardiac arrest (P <.05 respectively). In the multivariable regression analysis, older age, male gender, and public location were independent predictors for injuries. There were no differences in the durations of the CPR attempt between the injured and non-injured groups. Conclusion: Older age, male gender, and public location were independently associated with CPR- related injuries. The duration of the resuscitation attempts did not affect the incident of injuries.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

273. Validation of the pictorial Baxter Retching Faces scale for the measurement of the severity of postoperative nausea in Spanish-speaking children Author(s): Watcha M.F.; Felberg M.A.; Bidani S.A.; Medellin E.; Lee A.D. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: As the intensity of nausea, a subjective symptom, is difficult to estimate in children, vomiting is used as the objective clinical endpoint in managing paediatric postoperative nausea and vomiting. The pictorial Baxter Retching Faces (BARF) scale is a validated quantitative measure of paediatric nausea, but versions in languages other than English have not been validated. Methods: Healthy Spanish-speaking children aged 7-18 yr (n=184) undergoing elective ambulatory surgery rated perioperative pain and nausea using visual analogue (VAS) and pictorial Faces Pain Scale - Revised and BARF scales, along with a Likert scale measurement of symptom changes. Parents kept a post-discharge diary. Results: Postoperative BARF scores were significantly higher in patients receiving anti-emetics {mean [standard deviation (SD)]: 4.6 (3.4) vs 0.9 (1.6); P<0.001}. Nausea scores obtained prior to rescue anti-emetics were higher than preoperative values [mean (SD) increase: 4.0 (3.6); P<0.001], and decreased after therapy [decrease: 2 (2.4); P=0.03]. The Spearman correlation [95% confidence interval (CI)] between the BARF and VAS nausea scores was 0.72 (0.64-0.78), and significantly stronger than BARF and pain score correlation [0.3 (0.1-0.4)]. The minimum (SD) clinically relevant difference was 1.2 (1.7) for both BARF and VAS nausea scales. The intra-class coefficient (95% CI) of BARF scores was 0.88 (0.76-0.94). The BARF scale had excellent performance in predicting patient-perceived need for anti-emetics (area under the curve-receiver operating characteristic: 0.899; 95% CI: 0.82-0.98). Conclusions: The BARF scale has construct, convergent, discriminant, and test-retest validity in measuring nausea severity in Spanish-speaking children, and may be a useful instrument in the management of paediatric postoperative nausea and vomiting. Clinical trial registration: NCT02007109.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

274. Sevoflurane based anaesthesia does not affect already impaired cerebral autoregulation in patients with type 2 diabetes mellitus Author(s): Sperna Weiland N.H.; Hermanides J.; Hollmann M.W.; Preckel B.; Immink R.V.; van der Ster B.J.P.; Stok W.J.; van Lieshout J.J. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: The baroreflex regulates arterial blood pressure (BP). During periods when blood pressure changes, cerebral blood flow (CBF) is kept constant by cerebral autoregulation (CA). In patients with diabetes mellitus (DM), low baroreflex sensitivity (BRS) is associated with impaired CA. As sevoflurane-based anaesthesia obliterates BRS, we hypothesised that this could aggravate the already impaired CA in patients with DM resulting in a 'double-hit' on cerebral perfusion leading to increased fluctuations in blood pressure and cerebral perfusion. Methods: On the day before surgery, we measured CBF velocity (CBFV), heart rate, and BP to determine BRS and CA efficacy (CBFVmean-to-BPmean-phase lead) in 25 patients with DM and in 14 controls. During the operation, BRS and CA efficacy were determined during sevoflurane-based anaesthesia. Patients with DM were divided into a group with high BRS (DMBRS) and a group with low BRS (DMBRS). Values presented are median (inter-quartile range). Results: Preoperative vs intraoperative BRS was 6.2 (4.5-8.5) vs 1.9 (1.1-2.5, P<0.001) ms mm Hg-1 for controls, 5.8 (4.9-7.6) vs 2.7 (1.5-3.9, P<0.001) ms mm Hg-1 for patients with DMBRS, and 1.9 (1.5-2.8) vs 1.1 (0.6-2.5, P=0.31) ms mm Hg-1 for patients with DMBRS. Preoperative vs intraoperative CA efficacy was 43degree (38-46) vs 43degree (38-51, P=0.30), 44degree (36-49) vs 41degree (32-49, P=0.52), and 34degree (28-40) vs 30degree (27-38, P=0.64) for controls, DMBRS, and DMBRS patients, respectively. Conclusions: In diabetic patients with low preoperative BRS, preoperative CA efficacy was also impaired. In controls and diabetic patients, CA was unaffected by sevoflurane-based anaesthesia. We therefore conclude that sevoflurane-based anaesthesia does not contribute to a 'double-hit' phenomenon on cerebral perfusion. Clinical trial registration: NCT 03071432.Copyright © 2018 Database: EMBASE

275. Volume of ropivacaine 0.2% and common peroneal nerve block duration: a randomised, double-blind cohort trial in healthy volunteers Author(s): Christiansen C.B.; Madsen M.H.; Rothe C.; Andreasen A.M.; Lundstrom L.H.; Lange K.H.W. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:The volume-duration relationship using low concentrations of ropivacaine for peripheral nerve blocks is unknown, even though low concentrations of ropivacaine are increasingly used clinically. We investigated the effect of ropivacaine 0.2% on common peroneal nerve block duration. With ethical committee approval, 60 consenting, healthy volunteers were randomly allocated to receive one of five volumes of ropivacaine 0.2% (2.5, 5.0, 10, 15 or 20 ml) administered by ultrasound-guided, catheter-based injection (at 10 ml.min-1) near the common peroneal nerve. Our primary outcome was duration of sensory block, defined by insensitivity to a cold stimulus. Our secondary outcome was duration of motor block. Outcomes were assessed every hour from onset of block to complete remission. Intergroup differences were tested using one-way ANOVA followed by regression analyses using the 20 ml intervention group as reference. Block durations varied significantly (p < 0.0001) between groups. Mean (SD) sensory block durations were 9.2 (3.3), 12.5 (3.0), 15.5 (4.4), 17.3 (3.5) and 17.3 (4.6) h. Mean (SD) motor block durations were 3.3 (2.1), 7.2 (2.5), 9.2 (2.2), 12.7 (2.5) and 12.5 (2.5) h. Regression analysis showed that the effect of volume on block duration was progressively smaller with increasing volume, reaching a threshold volume above which there was no effect on nerve block duration (10 ml for sensory block and 15 ml for motor block). We conclude that there is a ceiling effect of increasing volume of ropivacaine 0.2% on both sensory and motor block duration of the common peroneal nerve.Copyright © 2018 Association of Anaesthetists Database: EMBASE

276. Characteristics of children aged 2-17 years undergoing anaesthesia in Danish hospitals 2005- 2015: a national observational study Author(s): Strom C.; Lohse N.; Lundstrom L.H.; Afshari A. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Provision of paediatric anaesthesia requires careful consideration of the child's cognitive state, unique body composition and physiology. In an observational cohort study, we describe the population characteristics and conduct of anaesthesia in children aged 2-17 years from 1 January 2005 to 31 December 2015. Children were identified from the Danish Anaesthesia Database. We recorded the following variables: age; sex; comorbidities; indications for anaesthesia; practice of anaesthesia; and complications. Results are presented for two age groups: 2-5 and 6-17 years. In total, 32,840 (61% male) children aged 2-5 years received 50,484 anaesthesia episodes and 91,418 (54% male) children aged 6-17 years received 141,082 anaesthesia episodes. The younger children, compared with the older children, were more frequently anaesthetised at a university hospital (50% vs. 36%) and for non-surgical procedures (24% vs. 8%). For both age groups, general anaesthesia was the primary choice of anaesthesia regardless of the reason for anaesthesia. For surgery, general anaesthesia using inhalational agents in addition to intravenous agents or alone was more frequently used in younger children (49% vs. 15%), whereas older children commonly received total intravenous anaesthesia (50% vs. 83%). Regional anaesthesia was infrequently utilised. Complications occurred in 3.3% of anaesthesia episodes among 2-5 year olds compared with 3.7% of anaesthesia episodes among children aged 6-17 years. In conclusion, we found younger children (aged 2-5), compared with older children (aged 6-17) were more frequently anaesthetised for non- surgical reasons, at a university hospital and using inhalational agents. Complications were rare.Copyright © 2018 Association of Anaesthetists Database: EMBASE

277. Predicting Procedure-Specific Morphine Consumption of Intravenous Patient-Controlled Analgesia with Random Effects Model Approach Author(s): Lin S.-P.; Chang K.-Y.; Tsou M.-Y.; Chen H.-H. Source: Clinical Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Introduction: Surgical procedure is an important predictor for analgesic consumptions of intravenous patient-controlled analgesia (IV-PCA) for acute pain. Objectives: To better fit the analgesic consumptions of IV-PCA regarding to the different surgical procedures. Methods: A statistical model (random effect model) was proposed to develop procedure-specific morphine consumptions for various surgical procedures of IV-PCA. After model was developed, an independent dataset was used for external validation. Results: The results showed a significant influence for morphine consumption coming from surgical procedures. Different surgical procedures result in a wide range of morphine consumptions. Surgical procedure using the highest morphine consumption is the resection of pancreas with open approach (76.92 mg) while the lowest one is the excision of uterus with open method (34.3 mg). The external validation showed good of model performance. The quantitative rank for surgical procedures were also presented. Discussion: Adopted IV-PCA regimens for different surgical procedures are therefore strongly recommended and incorporated into postoperative acute pain management.Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. Database: EMBASE

278. Effect of Intravenous Oxycodone in Combination with Different Doses of Dexmedetomdine on Sleep Quality and Visceral Pain in Patients after Abdominal Surgery: A Randomized Study Author(s): Jiang Z.; Song Q.; Bao C.; Chen Z.; Zhou G.; Wang H. Source: Clinical Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: Oxycodone or dexmedetomidine (DEX) alone are widely used in clinical practice. The aim of this study was to observe the effect of two oxycodone and DEX combinations on postoperative sleep quality. Methods: This was a prospective and randomized clinical study. 99 patients underwent laparoscopic assisted operations on stomach and intestines with general anesthesia were enrolled and randomly divided into three groups according to postoperative analgesic protocol (n=33 each). The analgesic protocol were as follows after the surgery. In group C, 0.6 mg/kg oxycodone alone was diluted to 100 mL in 0.9% saline. In group D1 or D2, 0.6 mg/kg oxycodone combined with 2.4 mug/kg or 4.8 mug/kg DEX was diluted to 100 mL in 0.9% saline respectively. The intravenous patient controlled analgesia device was set up to deliver a continuous infusion of 3 mL/h and a bolus of 1 mL, with a 12-minute lockout interval. The primary outcome was the percentage of stage 2 non-rapid eye movement (stage N2) sleep. Polysomnography was performed the night before operation (PSG-night0), the first (PSG-night1) and second (PSG-night2) nights after surgery. Results: 97 patients were included in the final analysis. Compared with group C, N2 sleep were higher in groups D1 and D2 on PSG-night1 (54+/-9% and 53+/-10%, respectively) and PSG-night2(55+/-7% and 56+/-8%, respectively) (P<0.001 for the comparisons).No differences were observed regarding N1 and N2 sleep between groups D1 and D2 on PSG-night1 and PSG- night2(P>0.05). Group C had higher percentage of N1 sleep on PSG-night1(37+/-5%) and PSG- night2(33+/-3%) when compared to groups D1 and D2 (P<0.001 for the comparisons). Groups D1 and D2 required lower rates of rescue analgesia (5% and 4.7%, respectively, P = 0.012) and effective pressing times (10.7+/-4.8 times and 9.9+/-2.6 times, respectively, P<0.05)when compared to group C, whereas no statistical significance was found between groups D1 and D2.Furthermore,there were no significant difference about resting visual analogue scales at 4, 6, and 12 hours postoperatively between groups D1 and D2.In comparison with the other two groups, group D2 had a higher occurrence of postoperative hypotension (24.2%) (P<0.05), though without significant sinus bradycardia. Discussion: DEX combined with oxycodone can improve sleep quality and provide good visceral analgesia. However, larger doses of DEX does not further improve sleep but increases the risk of hypotension.Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited. Database: EMBASE

279. Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI >= 40): A retrospective observational study from the National Trauma Data Bank Author(s): Carson J.T.; Shah S.G.; Ortega G.; Thamyongkit S.; Hasenboehler E.A.; Shafiq B. Source: Patient Safety in Surgery; Aug 2018; vol. 12 (no. 1) Publication Date: Aug 2018 Publication Type(s): Article Available at Patient safety in surgery - from ProQuest (Hospital Premium Collection) - NHS Version Available at Patient safety in surgery - from BioMed Central Available at Patient safety in surgery - from Europe PubMed Central - Open Access Available at Patient safety in surgery - from Pubmed Central - Open Access Available at Patient safety in surgery - from springer.com Abstract:Background: There have been no large-scale epidemiological studies of outcomes and perioperative complications in morbidly obese trauma patients who have sustained closed pelvic ring or acetabular fractures. We examined this population and compared their rate of inpatient complications with that of control patients. Methods: We retrospectively reviewed the records of patients treated for closed pelvic ring or acetabular fracture, aged 16-85 years, with Injury Severity Scores <=15 from the National Trauma Data Bank Research Dataset for the years 2007 through 2010. The primary outcome of interest was rate of in-hospital complications. Secondary outcomes were length of hospital stay and discharge disposition. Unadjusted differences in complication rates were evaluated using Student t tests and Chi-squared analyses. Multiple logistic and Poisson regression were used to analyze binary outcomes and length of hospital stay, respectively, adjusting for several variables. Statistical significance was defined as p < 0.05. Results: We included 46,450 patients in our study. Of these patients, 1331 (3%) were morbidly obese (body mass index >=40) and 45,119 (97%) were used as controls. Morbidly obese patients had significantly higher odds of complication and longer hospital stay in all groups considered except those with pelvic fractures that were treated operatively. In all groups, morbidly obese patients were more likely to be discharged to a skilled nursing/rehabilitation facility compared with control patients. Conclusions: Morbidly obese patients had higher rates of complications and longer hospital stays and were more likely to be discharged to rehabilitation facilities compared with control patients after pelvic ring or acetabular fracture.Copyright © 2018 The Author(s). Database: EMBASE

280. Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction? Author(s): Bennett S.; Grawe E.; Jones C.; Josephs S.A.; Mechlin M.; Hurford W.E. Source: Current opinion in anaesthesiology; Apr 2018; vol. 31 (no. 2); p. 165-171 Publication Date: Apr 2018 Publication Type(s): Review PubMedID: 29341963 Abstract:PURPOSE OF REVIEW: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined.RECENT FINDINGS: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value.SUMMARY: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes. Database: EMBASE

281. Transfusion practices in traumatic brain injury Author(s): East J.M.; Viau-Lapointe J.; McCredie V.A. Source: Current opinion in anaesthesiology; Apr 2018; vol. 31 (no. 2); p. 219-226 Publication Date: Apr 2018 Publication Type(s): Review PubMedID: 29369066 Available at Current Opinion in Anaesthesiology - from PubMed Central Available at Current Opinion in Anaesthesiology - from Unpaywall Abstract:PURPOSE OF REVIEW: The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI.RECENT FINDINGS: Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI.SUMMARY: Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion. Database: EMBASE

282. Cardiac dysfunction in critical illness Author(s): Dalton A.; Shahul S. Source: Current opinion in anaesthesiology; Apr 2018; vol. 31 (no. 2); p. 158-164 Publication Date: Apr 2018 Publication Type(s): Review PubMedID: 29351144 Abstract:PURPOSE OF REVIEW: Sepsis and septic shock are prevalent conditions that are likely to increase in prevalence in the future. Given the high mortality and morbidity associated with sepsis and sepsis-induced cardiac dysfunction, we must continue to make advances in knowledge of the complex physiologic interactions and how we may target specific mediators for potential therapeutic options in the future.RECENT FINDINGS: Multiple biomarkers have been discovered, which when assayed in sepsis-induced cardiomyopathy predict morbidity and mortality. With increased sensitivity of echocardiography, we can diagnose subclinical cardiac dysfunction, which may have future implications for slowing or preventing progressive dysfunction.SUMMARY: Sepsis-induced cardiomyopathy is the result of complicated interactions between the pathogen, the body's response to infection, and iatrogenic injury. Interplay between inflammatory, metabolic, and adrenergic systems results in direct and indirect myocardial injury leading to decreases in both systolic and diastolic cardiac function. As the interactions are further elucidated with additional research into other proteins and mediators, new treatment options can be researched. VIDEO ABSTRACT. Database: EMBASE

283. Minocycline Before Aortic Occlusion Reduces Hindlimb Motor Impairment, Attenuates Spinal Cord Damage and Spinal Astrocytosis, and Preserve Neuronal Cytoarchitecture in the Rat Author(s): Drenger B.; Blanck T.J.J.; Piskoun B.; Jaffrey E.; Recio-Pinto E.; Sideris A. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Spinal cord ischemia secondary to trauma or a vascular occlusive event is a threatening phenomenon. The neuroprotective properties of minocycline have been shown in several models of central nervous system diseases and after spinal cord ischemia; however, the benefit of using the drug requires additional confirmation in different animal models. Astrocytes are essential as regulators of neuronal functions and for providing nutrients. The authors hypothesized that astrocytes in the spinal cord may be an important target for minocycline action after ischemia and thus in the prevention of secondary spreading damage. Design: A prospective, randomized animal study. Setting: University research laboratory, single institution. Participants: Adult male Sprague Dawley rats, weighing between 400 and 450 g. Interventions: A model of spinal cord ischemia in the rat was used for this study to determine whether a single, high-dose (10 mg/kg) of minocycline protects against damage to the neuronal cytoskeleton, both in the white and gray matter, and whether it reduces glial fibrillary acidic protein levels, which is an index for prevention of astrocyte activation during ischemia. Thirty minutes before thoracic aorta occlusion, minocycline was administered for 18 minutes using a 2 F Fogarty catheter. Measurements and Main Results: Minocycline given prophylactically significantly mitigated severe hindlimb motor impairment and reduced glial fibrillary acidic protein plus astrocytosis in both the white and gray matter of the spinal cord, caudal to the occlusion. Neuronal histologic cytoarchitecture, which was severely and significantly compromised in control animals, was preserved in the minocycline-treated animals. Conclusions: This study's data imply that minocycline may attenuate reactive astrocytosis in response to injury with better neurologic outcome in a model of spinal cord ischemia in rats. The data suggest that future use of minocycline, clinically, might be advantageous in surgeries with a potential risk for paraplegia due to spinal cord ischemia.Copyright © 2018 Elsevier Inc. Database: EMBASE

284. Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study Author(s): Kim H.S.; Adsul N.; Paudel B.; Kim K.J.; Choi S.H.; Kim J.H.; Chung S.K.; Choi J.-H.; Jang J.-S.; Yudoyono F.; Jang I.-T.; Oh S.-H. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Available at Pain research & management - from Publishers' website (via doi.org) Abstract:Background. Chronic low back pain (CLBP) arising from degenerative disc disease continues to be a challenging clinical and diagnostic problem whether treated with nonsurgical, pain intervention, or motion-preserving stabilization and arthrodesis. Methods. Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnab's criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval. Results. The mean age was 46 +/- 9.95 years. The mean symptoms duration was 21.21 +/- 21.87 months. The mean follow-up was 15.3 +/- 2.67 months. The preoperative VAS score of 7.79 +/- 0.97 changed to 1.92 +/- 1.38, postoperatively (P<0.01). As per Macnab's criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes. Conclusion. The transforaminal epiduroscopic basivertebral nerve laser ablation (TEBLA) appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes.Copyright © 2018 Hyeun Sung Kim et al. Database: EMBASE

285. Permissive Hypercapnia, Alveolar Recruitment and Low Airway Pressure (PHARLAP): a protocol for a phase 2 trial in patients with acute respiratory distress syndrome Author(s): Hodgson C.; Cooper D.J.; Bennett V.; Murray L.; Young M.; Nichol A.D.; Arabi Y.; Bersten A.; Brickell K.; Fahey C.; Davies A.; Fraser J.; McGuinness S.; Parke R.; Tuxen D.; Vallance S. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 139-149 Publication Date: Jun 2018 Publication Type(s): Article PubMedID: 29852853 Abstract:BACKGROUND: Mechanical ventilation is a life-saving intervention that maintains gas exchange in patients with acute respiratory distress syndrome (ARDS); however, it is associated with high mortality and it may augment, or even initiate, lung injury. An open lung ventilation strategy that combines alveolar recruitment manoeuvres with individually titrated positive end-expiratory pressure (PEEP) and targeting lower tidal volumes, or driving pressures by a permissive approach to hypercapnia, may reduce the lung injury associated with mechanical ventilation. This protocol reports the rationale, study design and analysis plan of the Permissive Hypercapnia, Alveolar Recruitment and Low Airway Pressure (PHARLAP) trial.METHODS AND DESIGN: PHARLAP is a phase 2, international, multicentre, prospective, randomised, controlled, parallel-group clinical trial, which aims to determine if staircase alveolar recruitment and individually titrated PEEP, when combined with permissive hypercapnia and low airway pressures, increases ventilator-free days to Day 28 when compared with conventional mechanical ventilation (Acute Respiratory Distress Syndrome Clinical Network [ARDSNet] strategy) in patients with moderate to severe ARDS. This study will enrol 340 patients. The intervention group will receive daily staircase alveolar recruitment manoeuvres with incremental PEEP to a maximum of 40 cmH2O and peak pressures to a maximum of 55 cmH2O. PEEP will be titrated individually against peripheral oxygen saturation, targeting lower tidal volumes by a permissive approach to hypercapnia. In the control group, patients will receive mechanical ventilation following the ARDSNet-ARMA trial protocol, including PEEP titrated with a PEEP/fraction of inspired oxygen (FiO2) chart. Both groups will receive airway pressures <=30 cmH2O and tidal volumes of <= 6 mL/kg predicted bodyweight or less. The primary outcome is ventilator-free days to Day 28. Secondary outcomes include oxygenation and lung compliance, intensive care unit (ICU) and hospital length of stay, use of rescue therapies for refractory hypoxaemia, rate of barotrauma, mortality (ICU, hospital and at 28, 90 and 180 days), quality of life and a health economic analysis at 6 months.DISCUSSION: The PHARLAP trial will determine whether the intervention strategy is effective in increasing ventilator-free days in patients with ARDS. If the PHARLAP strategy is proven to improve ventilator-free days, it will provide a strong impetus to conduct an international phase 3 trial to determine the effects of this strategy on mortality.TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01667146. Database: EMBASE

286. The comparative effects of 3% saline and 0.5M sodium lactate on cardiac function:a randomised, crossover study in volunteers Author(s): Nalos M.; Orde S.; Seppelt I.; McLean A.S.; Huang S.; Kholodniak E.; Smith L.; Ting I.; Slama M. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 124-130 Publication Date: Jun 2018 Publication Type(s): Article PubMedID: 29852851 Abstract:OBJECTIVE: To investigate the metabolic and cardiac effects of intravenous administration of two hypertonic solutions - 3% saline (SAL) and 0.5M sodium lactate (LAC).DESIGN, SETTING AND PARTICIPANTS: A randomised, doubleblind, crossover study in ten human volunteers. Intravenous bolus of either SAL or LAC at 3 mL/kg over 20 min followed by a 2 mL/kg infusion over 60 min.MAIN OUTCOME MEASURES: Acid base parameters and echocardiographic indices of cardiac function, cardiac output (CO), left ventricular ejection fraction (LVEF) and mitral annular peak systolic velocity (Sm) before and after infusion of SAL or LAC.RESULTS: Despite haemodilution, we observed an increase in sodium (139 +/- 2 mmol/L to 142 +/- 2 mmol/L in both groups) and respective anions, chloride (106 +/- 2 mmol/L to 112 +/- 3 mmol/L) and lactate (1.01 +/- 0.28 mmol/L to 2.38 +/- 0.38 mmol/L) with SAL and LAC, respectively. The pH (7.37 +/- 0.03 to 7.45 +/- 0.03; P < 0.01) and simplified strong ion difference (SID) (36.3 +/- 4.6 mmol/L to 39.2 +/- 3.6 mmol/L; P < 0.01) increased during the LAC infusion. The pH was unchanged, but SID decreased during SAL infusion (36.3 +/- 2.5 mmol/L to 33.9 +/- 3.1 mmol/L; P = 0.01). Both solutions led to an increase in preload and cardiac function, CO (4.36 +/- 0.79 L/min to 4.98 +/- 1.37 L/ min v 4.62 +/- 1.30 L/min to 5.13 +/- 1.44 L/min), LVEF (61 +/- 6% to 63 +/- 8% v 64 +/- 6% to 68 +/- 7%). The averaged Sm improved in the LAC group as compared with the SAL group (0.088 +/- 0.008 to 0.096 +/- 0.016 v 0.086 +/- 0.012 to 0.082 +/- 0.012; P = 0.032).CONCLUSIONS: The administration of SAL or LAC has opposing effects on acid base variables such as SID. Hypertonic fluid infusion lead to increased cardiac preload and performance with Sm, suggesting better left ventricular systolic function during LAC as compared with SAL. Lactated hypertonic solutions should be evaluated as resuscitation fluids. Database: EMBASE

287. Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug-resistant organism acquisition Author(s): Urbancic K.F.; Martensson J.; Glassford N.; Eyeington C.; Robbins R.; Ward P.B.; Williams D.; Johnson P.D.; Bellomo R. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 109-116 Publication Date: Jun 2018 Publication Type(s): Article PubMedID: 29852849 Abstract:BACKGROUND: Chlorhexidine gluconate (CHG) bathing has been reported to decrease bloodstream infections and colonisation of multidrug-resistant organisms (MROs) in intensive care units (ICUs). However, its effectiveness in an Australian setting has not been assessed.OBJECTIVE: To test whether the introduction of ICU-wide CHG bathing in place of triclosan would affect rates of the primary outcome of central line-associated bloodstream infections (CLABSI), or the secondary outcomes of ICU-acquired positive blood cultures or other clinical specimens, and MRO colonisation including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).METHODS: We conducted a single-centre, sequential, before-and-after observational study. Patient microbiological and clinical data were compared in the 12 months before and after the introduction of CHG bathing in the ICU.RESULTS: A total of 4262 ICU admissions were studied, 2117 before and 2145 during the CHG-bathing period. There were no significant changes in the rates of CLABSI (from 1.69/1000 central venous catheter-days [95% CI, 0.68-3.48] to 1.33 [95% CI, 0.49-2.90]; P = 0.68), or ICU-acquired positive blood cultures (from 5.14/1000 patientdays [95% CI, 3.45-7.39] to 4.45 [95% CI, 3.00-6.36]; P = 0.58). However, we observed a lower incidence of MRSA acquisition during the CHG-bathing period (mean difference, -2.13 [95% CI, -3.65 to -0.60] per 1000 patientdays; P = 0.007). There was no difference in the rate of isolates involving other pathogens including VRE.CONCLUSIONS: In a tertiary Australian ICU, routine CHG bathing compared with triclosan did not affect the rates of ICU-acquired CLABSI or positive blood cultures. However, it significantly decreased the incidence of MRSA acquisition. Database: EMBASE

288. Ventilation management in Victorian intensive care unit patients without acute respiratory distress syndrome Author(s): Eyeington C.T.; Glassford N.J.; Casamento A.; Knott C.; Dunnachie C.; Crisman M.; Musci J.; Woinarski N.; Eastwood G.M.; Bellomo R.; Karalapillai D.; Darvall J.; Haydon T.; Taori G.; McGain F.; Vetro J.; Simpson N.; Lynham R.; Sarode V.; Richardson A. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 101-108 Publication Date: Jun 2018 Publication Type(s): Article PubMedID: 29852848 Abstract:METHODS: We performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCO2) management where hypercapnia was potentially physiologically contraindicated.RESULTS: We recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VT was 500 mL (33%), and this proportion did not differ according to sex (32% male, 34% female). Moreover, 38% of patients were exposed to initial VT per predicted body weight (VT-PBW) > 8.0 mL/kg. VT-PBW in this range were more likely to occur in females, those with a lower height, lower ideal body weight or in those for whom hypercapnia was potentially physiologically contraindicated. As a consequence, females were more frequently exposed to a lower PaCO2 and higher pH.CONCLUSIONS: In adults without ARDS undergoing CMV in Australian ICUs, the initial VT was a stereotypical 500 mL in one-third of participants, irrespective of sex. Moreover, around 40% of patients were exposed to an initial VT-PBW > 8.0 mL/kg. Finally, women were more likely to be exposed to a high VT and hyperventilation.BACKGROUND: The setting of tidal volume (VT) during controlled mechanical ventilation (CMV) in critically ill patients without acute respiratory distress syndrome (ARDS) is likely important but currently unknown. We aimed to describe current CMV settings in intensive care units (ICUs) across Victoria. Database: EMBASE

289. Hypercapnia and hypercapnic acidosis in sepsis: harmful, beneficial or unclear? Author(s): Tiruvoipati R.; Gupta S.; Pilcher D.; Bailey M. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 94-100 Publication Date: Jun 2018 Publication Type(s): Review PubMedID: 29852847 Abstract:Mortality related to sepsis among critically ill patients remains high. Recent literature suggests that hypercapnia may affect the pathophysiology of sepsis. The effects of hypercapnia on sepsis are largely related to the direct effect of hypercapnic acidosis on immune function and, as a consequence, of increased cardiac output that subsequently leads to improved tissue oxygenation. Appropriate management of hypercapnia may aid in improving the outcomes of sepsis. Our aim was to review the effects of compensated hypercapnia and hypercapnic acidosis on sepsis, with a specific focus on critically ill patients. Hypercapnic acidosis has been extensively studied in various in vivo animal models of sepsis and ex vivo studies. Published data from animal experimental studies suggest that the effects of hypercapnic acidosis are variable, with benefit shown in some settings of sepsis and harm in others. The effects may also vary at different time points during the course of sepsis. There are very few clinical studies investigating the effects of hypercapnia in prevention of sepsis and in established sepsis. It appears from these very limited clinical data that hypercapnia may be associated with adverse outcomes. There are no clinical studies investigating clinical outcomes of hypercapnic acidosis or compensated hypercapnia in sepsis and septic shock in critical care settings, thus extrapolation of the experimental results to guide critical care practice is difficult. Clinical studies are needed, especially in critically ill patients, to define the effects of compensated hypercapnia and hypercapnic acidosis that may aid clinicians to improve the outcomes in sepsis. Database: EMBASE

290. The search for biomarkers in the critically ill: a cautionary tale Author(s): Moran J.L.; Solomon P.J. Source: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine; Jun 2018; vol. 20 (no. 2); p. 85-93 Publication Date: Jun 2018 Publication Type(s): Article PubMedID: 29852846 Abstract:The search for biomarkers has been described as a dismal patchwork of fragmented research. We review biomarkers in sepsis in the critically ill in terms of conventional single circulating proteins. Despite sepsis biomarker publications trebling over the past 6 years, currently only one, procalcitonin, has materialised promise. We survey genomic biomarker initiatives, single nucleotide polymorphisms (SNPs) and gene signatures. Despite many SNP associations with sepsis susceptibility and a limited number of genome-wide association studies, the status of these associations is that of genomic signposts only. The standing of gene signatures in the paradigmatic discipline, breast cancer, is described. Uncertainties in the understanding of the sepsis process are documented - the dissociation between blood and tissue element activity, or compartmentalisation. The paradox of the active search for gene signatures to refine the sepsis phenotype and discover target subtypes for new therapies in the absence of such therapies is presented. Database: EMBASE

291. A Rare Case of Recurrent Coronary Cameral Fistula: A Unique Surgical Challenge Author(s): Dhawan R.; Prakash A.; Singh N.; Kundu A.; Ahlawat V.; Yadav A.; Yadava O.P.; Mishra R. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

292. The Relationship of Endocannabinoidome Lipid Mediators With Pain and Psychological Stress in Women With Fibromyalgia: A Case-Control Study Author(s): Stensson N.; Ghafouri N.; Gerdle B.; Ghafouri B.; Ernberg M.; Mannerkorpi K.; Kosek E. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Characterized by chronic widespread pain, generalized hyperalgesia, and psychological stress, fibromyalgia (FM) is difficult to diagnose and lacks effective treatments. Endocannabinoids- arachidonoylethanolamide (AEA), 2-arachidonoylglycerol (2-AG), and the related oleoylethanolamide (OEA), palmitoylethanolamide (PEA), and stearoylethanolamide (SEA)-are endogenous lipid mediators with analgesic and anti-inflammatory characteristics, in company with psychological modulating properties (eg, stress and anxiety), and are included in a new emerging "ome," the endocannabinoidome. This case-control study compared the concentration differences of AEA, OEA, PEA, SEA, and 2-AG in 104 women with FM and 116 healthy control subjects. All participants rated their pain, anxiety, depression, and current health status. The relationships between the lipid concentrations and the clinical assessments were investigated using powerful multivariate data analysis and traditional bivariate statistics. The concentrations of OEA, PEA, SEA, and 2-AG were significantly higher in women with FM than in healthy control subjects; significance remained for OEA and SEA after controlling for body mass index and age. 2-AG correlated positively with FM duration and body mass index, and to some extent negatively with pain, anxiety, depression, and health status. In FM, AEA correlated positively with depression ratings. The elevated circulating levels of endocannabinoidome lipids suggest that these lipids play a role in the complex pathophysiology of FM and might be signs of ongoing low-grade inflammation in FM. Although the investigated lipids are significantly altered in FM, their biological roles are uncertain with respect to the clinical manifestations of FM. Thus plasma lipids alone are not good biomarkers for FM. Perspective: This study reports about elevated plasma levels of endocannabinoidome lipid mediators in FM. The lipids' suitability to work as biomarkers for FM in the clinic were low; however, their altered levels indicate that a metabolic asymmetry is ongoing in FM, which could serve as a baseline during explorative FM pain management.Copyright © 2018 the American Pain Society Database: EMBASE

293. Ward monitoring 3.0 Author(s): Michard F.; Sessler D.I. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

294. Development of a practical prediction score for chronic kidney disease after cardiac surgery Author(s): Legouis D.; Jamme M.; Galichon P.; Hertig A.; Provenchere S.; Boutten A.; Buklas D.; Hanouz J.-L. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Chronic kidney disease (CKD) is a frequent and serious complication of cardiac surgery. This study was designed to establish a scoring system, calculated in the immediate postoperative period, to assess the risk of CKD at 1 yr in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We conducted a cohort study including patients with preoperative estimated glomerular filtration rate above 60 ml min-1 (1.73 m)-2 who underwent cardiac surgery with cardiopulmonary bypass. We identified risk factors for de novo CKD at 1 yr using logistic regression. We derived a risk score for CKD, and externally validated this score in a second cohort. Results: The incidence of CKD was 18% and 23% in the derivation and validation cohorts, respectively. We developed a scoring system that included (i) the occurrence of postoperative acute kidney injury according to the Kidney Disease: Improving Global Outcomes criteria, (ii) age older than 65 yr, (iii) preoperative glomerular filtration rate <80 ml min-1 (1.73 m)-2, (iv) aortic cross-clamping time longer than 50 min, and (v) the type of surgery (aortic or cardiac transplantation). This score predicted CKD with good accuracy (area under the receiver operating characteristic curve: 0.81; 95% confidence interval: 0.77-0.86 in the derivation cohort), and with fair accuracy in the validation cohort (area under the receiver operating characteristic curve: 0.78; 95% confidence interval: 0.72- 0.83). Conclusions: We provide an easy-to-calculate scoring system to identify patients at high risk of developing CKD after cardiac surgery with cardiopulmonary bypass. This system might help clinicians to target more accurately patients requiring monitoring of renal function after cardiac surgery, and to design appropriate interventional trials aimed at preventing CKD or mitigating its consequences.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

295. Lung Isolation Techniques in Patients With Early-Stage or Long-Term Tracheostomy: A Case Series Report of 70 Cases and Recommendations Author(s): Campos J.H.; Musselman E.D.; Hanada S.; Ueda K. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: Lung isolation techniques are designed to facilitate surgical exposure in thoracic surgical patients and provide one-lung ventilation (OLV). Some patients have a tracheostomy in situ, which makes the management of the airway and OLV difficult. The objective of this retrospective study was to review cases that had a tracheostomy prior to thoracic surgery and evaluate the clinical use and efficiency with the airway management and lung isolation devices. Design: This was a retrospective data analysis. Setting: Tertiary care university hospital. Interventions: After institutional review board approval, the authors reviewed 3,225 charts of patients who had thoracic surgery involving OLV. Seventy patients were identified who had tracheostomy in situ. Each case was reviewed regarding airway management and lung isolation technique. Measurements and Main Results: The authors identified 70 patients who had a tracheostomy in situ. The cases were divided into 2 groups: a fresh tracheostomy stoma <7 days (n = 6) or long-term stoma >7 days (n = 64). The authors collected information regarding the devices used to manage the airway and lung isolation techniques. The devices used to manage the airway include the Shiley cuffed low pressure tracheostomy tube, single-lumen endotracheal tube (SLT), or double-lumen endotracheal tube (DLT). Devices used to manage OLV included SLTs, with or without bronchial blockers, or DLTs. Flexible fiberoptic bronchoscopy was used to assess the airway and confirm the position of the lung isolation device. Six cases had an early-stage fresh tracheostomy stoma where the Shiley tracheostomy tube was used for ventilation followed by the use of a bronchial blocker. In contrast, for the patients who had a long-term stoma, the following devices were used: (1) a SLT plus a bronchial blocker in 38 cases, a Shiley tracheostomy tube plus bronchial blocker in 15 cases, use of a SLT guided into a selective bronchus in 7 cases, and use of a DLT in 4 cases. In all cases, flexible fiberoptic bronchoscopy was used and no complications occurred secondary to airway management or OLV. Conclusion: In patients undergoing thoracic surgery and OLV, and with a fresh tracheostomy stoma in situ, the authors recommend the use of the Shiley tracheostomy tube plus a bronchial blocker. In patients with a long-term tracheostomy stoma, a SLT can be used selectively to intubate 1 bronchus. In addition, an SLT or a Shiley tube can be used in conjunction with an independent bronchial blocker, such as the Arndt wire-guided bronchial blocker, Cohen tip-deflecting blocker, Fuji Uniblocker, or EZ-Blocker. DLTs are the least frequently used device for OLV in tracheostomized patients.Copyright © 2018 Elsevier Inc. Database: EMBASE

296. Assessing Symptoms, Concerns, and Quality of Life in Noncancer Patients at End of Life: How Concordant Are Patients and Family Proxy Members? Author(s): Hack T.F.; McClement S.E.; Chochinov H.M.; Thompson G.N.; Enns M.W.; Dufault B.; Johnston W.; Harlos M.; Damant R.W.; Ramsey C.D.; Zacharias J.; Campbell-Enns H.J.; Davison S.N.; Strang D. Source: Journal of Pain and Symptom Management; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Context: It has become commonplace to use family caregivers as proxy responders where patients are unable to provide information about their symptoms and concerns to health care providers. Objectives: The objective of this study was to determine the degree of concordance between patients' and family members' reports of patient symptoms and concerns at end of life. Methods: Sample dyads included a mix of patients residing at home, in a nursing home, in a long- term care facility, or in hospice. Diagnoses included patients with amyotrophic lateral sclerosis (n = 75), chronic obstructive pulmonary disease (n = 52), end-stage renal disease (n = 42), and institutionalized, cognitively intact frail elderly (n = 49). Dyads completed the Patient Dignity Inventory (PDI), the modified Structured Interview Assessment of Symptoms and Concerns in Palliative Care, and Graham and Longman's two-item Quality of Life Scale. Results: Concordance was less than 70% for seven of the 25 PDI items, with the lowest concordance (65.1%) for the item "not being able to continue with my usual routines." For all but one PDI item, discordance was in the direction of family members reporting that the patient was worse off than the patient had indicated. Where discordance was observed on the Structured Interview Assessment of Symptoms and Concerns in Palliative Care and Quality of Life Scales, the trend toward family members overreporting patient distress and poor quality of life continued. Conclusion: Understanding discordance between patients and family member reports of symptoms and concerns is a valuable step toward minimizing patient and family burden at end of life.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

297. Bleeding, Thrombosis, and Transfusion With Two Heparin Anticoagulation Protocols in Venoarterial ECMO Patients Author(s): Mazzeffi M.A.; Tanaka K.; Roberts A.; Rector R.; Deatrick K.B.; Kaczorowski D.; Griffith B.; Menaker J.; Herr D.; Kon Z. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objective: To compare the incidence of bleeding and thrombosis between adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients managed with an activated clotting time (ACT)-guided heparin anticoagulation protocol and activated partial thromboplastin time (aPTT) protocol. Design: Retrospective cohort study. Setting: Tertiary care, academic medical center. Participants: Consecutive adult VA ECMO patients during a 6-year period. Interventions: None. Measurements and Main Results: Demographic, medical, transfusion, and ECMO data were collected for all patients. Primary study outcomes were bleeding and thrombosis. Secondary outcomes were stroke and in-hospital mortality. One hundred twenty-one patients were included in the cohort. Fifty patients had ACT monitoring, and 71 had aPTT monitoring. There was no difference in the incidence of bleeding or thrombosis between the 2 groups (78.0% v 67.6% for bleeding [p = 0.21] and 16.0% v 19.7% for thrombosis [p = 1.0]). After adjusting for age and total ECMO days, patients managed with ACT received approximately 30% more red blood cell, fresh frozen plasma, and platelet transfusion (all p < 0.05). Conclusion: There is no apparent difference in the incidence rate of bleeding or thrombosis between VA ECMO patients managed with an ACT- or aPTT-guided heparin anticoagulation protocol. Patients managed with an ACT-guided protocol received more blood transfusion, which could reflect greater total bleeding. Future randomized controlled trials would help to elucidate optimal anticoagulation strategies for VA ECMO patients.Copyright © 2018 Elsevier Inc. Database: EMBASE

298. The Adolescent Minor and Urgent Aortic Surgery: Challenges and Solutions With Capacity and Competence in Informed Consent Author(s): Kirpekar M.K.; Silvay G.; Augoustides J.G.; Leong R.; Castillo J.G.; Sibbald R.; Bainbridge D.; Bishop C.E.; Fernando R.J.; Morris B. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

299. Perioperative Management of Mild Hemophilia B During and After Coronary Artery Bypass Grafting: Challenges and Solutions Author(s): Fernando R.J.; Farmer B.E.; Gardner J.C.; Johnson S.D.; Augoustides J.G.; Ha B.; Friess J.- O.; Luedi M.M.; Erdoes G.; Miller P.J.; Ripat C.; Fabbro M. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

300. Adjunct medications for peripheral and neuraxial anesthesia Author(s): Emelife P.I.; Kaye A.D.; Eng M.R.; Menard B.L.; Myers A.S.; Cornett E.M.; Urman R.D. Source: Best Practice and Research: Clinical Anaesthesiology; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Regional and neuraxial anesthesia can provide a safer perioperative experience, greater satisfaction, reduced opioid consumption, and reduction of pain, while minimizing side effects. Ultrasound technology has aided clinicians in depositing local anesthetic medication in precise proximity to targeted peripheral nerves. There are a plethora of adjuvants that have been utilized to prolong local anesthetic actions and enhance effects in peripheral nerve blocks. This manuscript describes the current state of the use of adjuncts, e.g., dexmedetomidine, dexamethasone, clonidine, epinephrine, etc., in regional anesthesia. Additionally, evidence behind dosing and block prolongation is summarized along with patient outcomes, adverse effects, and future directions.Copyright © 2018 Elsevier Ltd Database: EMBASE

301. A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation Author(s): Rogerson A.; Partridge J.S.L.; Dhesi J.K. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:We established an innovative Foundation placement in peri-operative medicine for older patients in response to the need for training in 'whole patient' medicine and the challenge of fewer Foundation doctors in acute surgical roles. The placement and underpinning curriculum were co- designed with junior doctors and other clinical stakeholders. This resulted in a modular design offering acute and community experience and dedicated quality improvement project time. To evaluate the placement we used a mixed methods study based on Kirkpatrick's model of workplace learning. Level 1 (trainee reaction) was evaluated using Job Evaluation Study Tool questionnaires and nominal group technique. Levels 2 and 3 (trainee learning/behaviour) were assessed using a Likert- style survey mapped to curriculum objectives, e-portfolio completion, nominal group technique and documentation of completed quality improvement projects and oral/poster presentations. Sixty- eight foundation trainees underwent the new placement. A similar-sized 'control' sample (n = 57) of surgical Foundation trainees within the same Trust was recruited. The trainees in the peri-operative placement attained both generic Foundation and specific peri-operative curriculum competencies, and gave higher job satisfaction scores than trainees in standard surgical placements. The top three ranked advantages from the nominal group sessions were senior support, clinical variety and project opportunities. Universal project completion resulted in high rates of poster and platform presentations, and in sustained service changes at hospital level.Copyright © 2018 Association of Anaesthetists Database: EMBASE

302. A case report of sustained resolution of cancer pain by continuous perineural infusion of local anaesthetic Author(s): Fuzier R.; Izard P.; Daboussi A.; Pouymayou J.; Pierre S. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Opioids are currently offered as first-line treatment for chronic pain from cancer. Continuous regional analgesia could be an alternative to opioids. However, the required duration of catheterization and the sustained analgesic effects of this technique after catheter removal have yet to be clarified. Case Report: We report the case of a patient with a shoulder desmoid tumour for which monitoring of tumour progression was the sole therapeutic strategy. Analgesia took the form of patient-controlled infusion of local anaesthetics through an interscalene catheter. Due to the need of an MRI control 45 days later, the pump was stopped. The persistence of pain relief 48 hr later led to the decision to remove the perineural catheter. No pain was reported by the patient over the following 42 days. Conclusions: In this patient, it would seem that continuous analgesia allowed for a sustained resolution of pain from the shoulder-located tumour. One hypothesis is that local anaesthetics play a direct role in the erasure of pain memory. This hypothesis needs to be tested with a large patient cohort. Significance: This case report provides new insights into the treatment of cancer pain. The most interesting finding is that the pain did remained absent after 45 days of continuous infusion of local anaesthetics through an interscalene catheter. We postulated that local anaesthetic drugs have an impact on pain memory.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

303. Elevated serum S-100beta in patients with septic shock is associated with delirium Author(s): Erikson K.; Ala-Kokko T.I.; Koskenkari J.; Liisanantti J.H.; Kamakura R.; Herzig K.H.; Syrjala H. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: A high prevalence of delirium is observed in sepsis, yet specific markers for this brain dysfunction in sedated patients are still lacking. Cytoplasmic low molecular weight calcium-binding protein, S-100beta, is a commonly used nonspecific marker for brain injury. Here, we evaluated whether delirium is associated with increases in S-100beta levels. Methods: This observational study included 22 patients with septic shock. Delirium was assessed by CAM-ICU and blood samples were obtained to measure inflammatory (CRP, PCT, IL-6, IL-17, TNF-alpha) and cerebral biomarkers (S-100beta, NSE, HAB42, SUBP). Patients were categorized according to the presence of delirium. Results: Delirium was present in 10/22 of the patients (45.5%). Serum S- 100beta levels were above the laboratory cutoff value of 0.15 mug/L in 13/22 (59.1%) of the patients. The odds ratio for risk of developing delirium in cases with an S-100beta >0.15 mug/L was 18.0 (95%CI, 1.7-196.3, P = 0.011). Patients with delirium had higher plasma levels of IL-6 compared to those without; 138.3 pg/mL [28.0-296.7] vs 53.6 pg/mL [109.3-505, P = 0.050]. There was a positive correlation between S100 beta and IL-6 levels (r = 0.489, P = 0.021). Delirium patients had higher SOFA scores; 10 [5-9] vs 7[8-10.5], P = 0.036. Conclusions: Delirium in septic shock was associated with an elevated protein S-100beta when using a laboratory cutoff value of 0.15 mug/L and with more severe organ dysfunction during the ICU stay.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

304. Echocardiographic determination of resting haemodynamics and optimal positioning in term pregnant women Author(s): Dennis A.T.; Leeton L.; Buckley A.; Mahendrayogam T.; Castro J.M. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Optimal positioning for anaesthesia in pregnant women involves balancing the need for ideal tracheal intubation conditions (achieved by the head elevated ramped position), with the prevention of reduced cardiac output from aortocaval compression (achieved by left lateral pelvic tilt). No studies have examined the effect on cardiac output of left lateral pelvic tilt in the ramped position. We studied non-labouring, non-anaesthetised healthy term pregnant women who underwent baseline (left lateral decubitus) cardiac assessment using transthoracic echocardiography. We then compared cardiac output, maternal physiological variables, fetal heart rate and comfort scores in three positions: left lateral decubitus; ramped position with wedge; and ramped position alone. Thirty women completed the study. Mean (SD) age, gestation and body mass index were 33.5 (3.93) years, 38.5 (0.94) weeks and 29.0 (4.0) kg.m-2, respectively. Mean ejection fraction, left ventricular internal diameter and mitral valve E/e' were 55.2 (6.8) %, 4.70 (0.43) cm and 7.50 (1.82), respectively. There were no differences in cardiac output between the positions (p = 0.503). There were no differences in systolic (p = 0.955) or diastolic (p = 0.987) blood pressure, maternal heart rate (p = 0.133), oxygen saturation, respiratory rate (p = 0.964) or fetal heart rate (p = 0.361) between ramped with wedge and ramped alone positions. Left lateral decubitus was most comfortable (p = 0.001), however, there were no differences in comfort levels between ramped with wedge and ramped alone positions. The ramped position without left lateral tilt is safe and acceptable in non-labouring, non-anaesthetised, healthy term pregnant women. Left lateral pelvic tilt may be unnecessary in the head elevated ramped position in term pregnant women.Copyright © 2018 Association of Anaesthetists Database: EMBASE

305. Long-Term Outcome Following Implanted Pulse Generator Change in Patients Treated With Sacral Nerve Modulation for Fecal Incontinence Author(s): Le Fouler A.; Duchalais E.; Loong T.-H.; Baayen C.; Wyart V.; Kubis C.; Meurette G.; Lehur P.-A. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Long-term outcome of sacral nerve modulation (SNM) patients after implanted pulse generator (IPG) change for fecal incontinence (FI) is unknown. This study reported the outcome and long-term satisfaction after a change of an exhausted IPG, questioning the need to concurrently change the electrode and looking for factors involved in the maintenance of treatment efficiency. Methods: Patients with fecal incontinence and with a Medtronic IPG implanted in a single center (2001-2016) were prospectively followed up. Satisfaction was graded according to a patient- reported outcome measure from 0 to 10. A pre- and postreplacement FI severity score (Cleveland Clinic Fecal Incontinence Score) and Fecal Incontinence Quality of Life questionnaire were also collected. Results: In 170 patients with SNM, 39 had an IPG replacement. At a median of 29 month after replacement, 32 and 7 patients reported respectively a similar and reduced satisfaction (7.6 +/- 1.62 vs. 5.5 +/- 0.87), p <.001. Satisfied patients were younger (65 years vs. 76 years, p <.001). Cleveland Clinic Fecal Incontinence Scores were not significantly different, but the satisfied group had a significantly better Fecal Incontinence Quality of Life score (p =.047). Only 5 patients needed an electrode change at the time of the IPG replacement or later. Conclusions: Patient satisfaction and efficiency remain high after IPG replacement. Older age has a negative impact on the outcome. Electrode replacement is rarely required and does not need to be performed routinely when an IPG is exhausted. Conflict of interest: Paul-Antoine Lehur has a consulting agreement with Medtronic SA. This had no impact with the results of the study. The other authors have no conflict of interests to declare.Copyright © 2018 International Neuromodulation Society Database: EMBASE

306. Effect of a single pre-operative 125 mg dose of methylprednisolone on postoperative delirium in hip fracture patients; a randomised, double-blind, placebo-controlled trial Author(s): Clemmesen C.G.; Lunn T.H.; Foss N.B.; Kristensen M.T.; Palm H. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Postoperative delirium is common after hip fracture surgery, and may have a neuro- inflammatory cause. We conducted a single-centre, randomised, double-blind, placebo-controlled trial of 117 older hip fracture patients to see if a single, pre-operative intravenous dose of 125 mg methylprednisolone could reduce the severity and/or incidence of postoperative delirium, assessed using the Confusion Assessment Method delirium severity score. Modified intention-to-treat analysis found no significant difference in our primary outcome, median (IQR [range]) cumulative Confusion Assessment Method delirium severity score over the first three postoperative days between the methylprednisolone and placebo groups (1 (0-6 [0-39]) vs. 2 (0-10 [0-32]), p = 0.294). Both the prevalence of postoperative delirium (Confusion Assessment Method delirium severity score >= 5, 10/59 vs. 19/58, p = 0.048) and the median (IQR [range]) cumulated postoperative (by day 3) fatigue scores (5 (2-6 [0-11]) vs. 6 (4-8 [0-16]), p = 0.008) were significantly lower in the methylprednisolone compared with the placebo group. There were no significant between-group differences in the rate of completing physiotherapy, postoperative pain, the administration of antipsychotic drugs, infection, length of inpatient stay or 30- and 90-day mortality. No major adverse reactions related to methylprednisolone were recorded. We conclude that a single, pre-operative dose of 125 mg methylprednisolone does not reduce the severity of postoperative delirium, but may reduce both the prevalence of delirium and the severity of fatigue after hip fracture surgery in older patients, enabling remobilisation and recovery.Copyright © 2018 Association of Anaesthetists Database: EMBASE

307. Performance of cardiac output monitoring in the peri-operative setting Author(s): Gillies M.A.; Edwards M.R. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Database: EMBASE

308. Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study Author(s): Ilfeld B.M.; Said E.T.; Finneran J.J.; Sztain J.F.; Abramson W.B.; Gabriel R.A.; Khatibi B.; Swisher M.W.; Jaeger P.; Covey D.C.; Robertson C.M. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. Materials and Methods: Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5-min crossover period, and then continuous active stimulation until lead removal postoperative Day 14-28. Statistics were not applied to the data due to the small sample size of this feasibility study. Results: During the initial 5-min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5-min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1-3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. Conclusions: This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.Copyright © 2018 The Authors. Neuromodulation: Technology at the Neural Interface published by Wiley Periodicals, Inc. on behalf of International Neuromodulation Society. Database: EMBASE

309. The Safety and Efficacy of Using the O-Arm Intraoperative Imaging System for Deep Brain Stimulation Lead Implantation Author(s): Frizon L.A.; Shao J.; Maldonado-Naranjo A.L.; Lobel D.A.; Nagel S.J.; Fernandez H.H.; Machado A.G. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6); p. 588-592 Publication Date: Aug 2018 Publication Type(s): Article Available at Neuromodulation : journal of the International Neuromodulation Society - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Accurate electrode implantation is a major goal of deep brain stimulation (DBS) surgery. Intraoperative physiology with microelectrode recording (MER) is routinely used to refine stereotactic accuracy during awake electrode implantation. Recently, portable imaging systems such as the O-arm have become widely available and can be used in isolation or in association with MER to guide DBS lead placement. The aim of this study was to evaluate how the routine use of the O-arm affected DBS surgery safety, efficiency, and outcomes. Methods: Two cohorts of patients with Parkinson's disease who underwent MER-guided awake subthalamic DBS lead implantation with and without O-arm were compared. We examined the total number of microelectrode and macroeletrode passes during each surgery, procedure duration, surgical complications, lead revisions, and motor outcomes. Results: A total of 50 procedures in 41 unique patients were analyzed, of which 26 were performed without O-arm and 24 performed without the O-arm. The mean number of microelectrode passes was 2.46 (SD = 0.99) in the group without O-arm utilization, compared to 1.29 (SD = 0.75) in the group with O-arm usage (p < 0.001). A significant reduction was also found in procedure duration (p = 0.016). No differences were found in motor outcomes between groups. Conclusion: The use of the O-arm during DBS lead implantation was associated with significantly fewer brain cannulations for microelectrode recording as well as reduced surgical time.Copyright © 2017 International Neuromodulation Society Database: EMBASE

310. Subthalamic Stimulation Improves Quality of Life of Patients Aged 61 Years or Older With Short Duration of Parkinson's Disease Author(s): Dafsari H.S.; Reker P.; Perrier E.; Weis L.; Timmermann L.; Reddy P.; Rizos A.; Ashkan K.; Samuel M.; Ray-Chaudhuri K.; Silverdale M.; Evans J.; Pilleri M.; Antonini A.; Martinez-Martin P.; Visser-Vandewalle V. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6); p. 532-540 Publication Date: Aug 2018 Publication Type(s): Article Available at Neuromodulation : journal of the International Neuromodulation Society - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objective: The optimal timing of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) is a topic of ongoing debate. In patients with short disease duration an improvement of quality of life (QoL) has been demonstrated for patients aged younger than 61 years. However, this has not been systematically investigated in older patients yet. We hypothesized that patients aged 61 years or older experience a significant QoL improvement after STN-DBS with no difference in effect sizes for groups of patients with short and longer disease duration. Materials and Methods: From four centers (Cologne, London, Manchester, Venice) we identified "older patients" aged 61 years or older with short (<=8 years) or longer disease duration and compared QoL, motor impairment, complications, medication requirements, and Mini-Mental State Examination (MMSE) on baseline and five months after surgery. Results: Mean age/disease duration in 21 subjects with shorter disease duration were 65.5/6.3 years compared to 66.8/14.6 in 33 subjects with longer disease duration. The short disease duration group was affected by less baseline motor complications (p = 0.002). QoL in the short/longer disease duration group improved by 35/20% (p = 0.010/p = 0.006), motor complications by 40/44% (p = 0.018/p < 0.001), and medication requirements by 51/49% (both p < 0.001). MMSE remained unchanged in both groups. Conclusion: Patients aged 61 years or older benefited from STN-DBS regardless of short (<=8 years) or longer (>8 years) disease duration. Our results contribute to the debate about DBS selection criteria and timing and call for prospective confirmation in a larger cohort.Copyright © 2017 International Neuromodulation Society Database: EMBASE

311. Post-Operative Localization of Deep Brain Stimulation Electrodes in the Subthalamus Using Transcranial Sonography Author(s): Ispierto L.; Latorre P.; Davalos A.; Alvarez R.; Munoz J.; Cladellas J.M.; Cuadras P.; Capellades J.; Vancamp T. Source: Neuromodulation; Aug 2018; vol. 21 (no. 6); p. 574-581 Publication Date: Aug 2018 Publication Type(s): Article Available at Neuromodulation : journal of the International Neuromodulation Society - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: The correct positioning of deep brain stimulation electrodes determines the success of surgery. In this study, we attempt to validate transcranial sonography (TCS) as a method for early postoperative confirmation of electrode location in the subthalamic nucleus (STN). Materials and Methods: Nineteen patients diagnosed with Parkinson's disease were enrolled in the study. Postoperative TCS was applied to measure the distance between the implanted electrodes and the third ventricle in the axial plane. Whether the electrodes were positioned within or outside the substantia nigra (SN) was evaluated through measurements in the coronal plane. The obtained metrics through TCS were compared with those from postoperative computed tomography (CT) and magnetic resonance imaging (MRI). Results: A statistically significant correlation between distances from electrode to third ventricle by TCS and CT/MRI (r = 0.75, p < 0.01) was observed. Distances from third ventricle to electrodes tips were different when sonographically they showed to be inside or outside the SN (p < 0.01). A cut-off value of 8.85mm in these distances was the most sensitive (100%) and specific (90.5%) to predict if electrodes were positioned inside the SN (CI 95% 0.81- 10.30, p = 0.001). Conclusions: Transcranial sonography is a useful technique to reliably identify targeted positioning of deep brain stimulation electrodes in or out of the SN.Copyright © 2017 International Neuromodulation Society Database: EMBASE

312. Massive venous air embolism Author(s): Moman R.N.; Kapurch C.J.; Whalen F.X.; Barbara D.W. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 (no. 9); p. 1068-1069 Publication Date: Sep 2018 Publication Type(s): Article Database: EMBASE

313. Optimised dosing of vancomycin in critically ill Indigenous Australian patients with severe sepsis Author(s): Tsai D.; Hewagama S.; Krishnaswamy S.; Wallis S.C.; Lipman J.; Roberts J.A.; Stewart P.C. Source: Anaesthesia and intensive care; Jul 2018; vol. 46 (no. 4); p. 374-380 Publication Date: Jul 2018 Publication Type(s): Article PubMedID: 29966110 Abstract:Vancomycin is a commonly used antibiotic due to the high burden of methicillin-resistant Staphylococcus aureus infections. This study aimed to describe the pharmacokinetics (PK) of vancomycin in Australian Indigenous patients with severe sepsis, and advise an optimal dosing strategy. A population PK study was conducted in a remote Australian intensive care unit (ICU). Serial plasma samples were collected over one to two dosing intervals and assayed by validated chromatography. Concentration-time data collected were analysed using Pmetrics software. The final population PK model was then used for Monte Carlo dosing simulations to determine optimal loading and intermittent maintenance doses. Fifteen Indigenous subjects were included for analysis with a median (interquartile range, IQR) age, weight and creatinine clearance (CrCL) of 43 (34-46) years, 73 (66-104) kg and 99 (56-139) ml/minute respectively. A two-compartment model described the data adequately. Vancomycin clearance (CL) and volume of distribution of the central compartment (Vc) were described by CrCL and patient weight respectively. Median (IQR) CL, Vc, distribution rate constants from central to peripheral, and from peripheral to central compartments were 4.6 (3.8-5.6) litres per hour, 25.4 (16.1-31.3) litres, 0.46 (0.28-0.52)/hour and 0.25 (0.12- 0.37)/hour respectively. No significant interethnic PK differences were observed in comparison to published data. Therapeutic loading doses were significantly dependent on both weight and CrCL, whereas maintenance doses were dependent on CrCL. In the absence of severe renal impairment, initiation of maintenance dose eight hours post-loading dose achieved higher probability of target attainment at 24 hours. This is the first report of vancomycin PK in this patient group. Database: EMBASE

314. A clinical audit of an office-based anaesthesia service for dental procedures in Victoria Author(s): Silvers A.; Licina A.; Jolevska L. Source: Anaesthesia and intensive care; Jul 2018; vol. 46 (no. 4); p. 404-413 Publication Date: Jul 2018 Publication Type(s): Article PubMedID: 29966115 Abstract:There is an increasing number of specialties performing office-based procedures, with many different providers practising in this field. Office Based Anaesthesia Solutions is a private enterprise designed to be a high-quality general anaesthesia and sedation service delivering care across 18 dental practices in Victoria. We undertook a criterion-based audit of our practice standards and outcomes. Following ethics approval, we retrospectively reviewed consecutive patients managed by our service between March 2014 and July 2017. We collected demographic data, information about anaesthesia technique, and surgical features. We assessed our findings against the Australian and New Zealand College of Anaesthetists (ANZCA) day surgery policy documents. During the specified period, we provided anaesthesia or sedation for 1,323 patients. Their ages ranged from two to 93 years (mean [standard deviation] 33.3 [18.6] years). Ninety-three percent of patients were American Society of Anesthesiologists (ASA) physical status classification 1 or 2. Patient demographics were in line with ANZCA day surgical policy documents. Total intravenous anaesthesia was used in 1,054 of the 1,096 documented general anaesthesia cases. There were three unplanned hospital transfers (annual incidence 0.07%). As this was the first Australian criteria- based audit of office-based anaesthesia (OBA) for dental procedures, we cannot compare our findings directly to previous studies. However, we feel that our patient demographics fell within acceptable ANZCA day procedure standards and our adverse event rate was both very low and similar to other published international adverse event rates. Our audit indicates that with careful screening processes, patient selection and medical governance, OBA is a viable model of care for patients undergoing dental procedures. Database: EMBASE

315. Audit of ten years of donation after circulatory death experience in Queensland: observations of agonal physiology following withdrawal of cardiorespiratory support Author(s): Cook D.A.; Widdicombe N. Source: Anaesthesia and intensive care; Jul 2018; vol. 46 (no. 4); p. 400-403 Publication Date: Jul 2018 Publication Type(s): Article PubMedID: 29966114 Abstract:An audit of ten years' experience in all patients undergoing withdrawal of cardiorespiratory support (WCRS) in the context of donation after circulatory death (DCD) was conducted in Queensland, Australia (2008 to 2017). One hundred and seventy-one patients proceeded to donation after declaration of death by circulatory criteria with loss of pulsatile arterial blood pressure (circulatory arrest) for five minutes. The demographics, times and haemodynamic observations were abstracted, de-identified and collated. The average age of patients was 43 years (standard deviation 16.1 years) and 63% were male. The median and mean times to an agonal systolic blood pressure below 50 mmHg were 10 and 11 minutes and the median and mean times from WCRS to circulatory arrest were 14 and 16 minutes. After systolic blood pressure fell to 50 mmHg or lower, 33 patients (19.3%) had spontaneous return of systolic pressure to above 50 mmHg. Following periods of circulatory arrest, five patients were documented to have spontaneous return of pulsatile arterial pressure. Two patients had return of circulation after two minutes, but less than five minutes of circulatory arrest and three patients had return of circulation where circulatory arrest had been documented for less than two minutes. Following WCRS, transient restoration of circulation following circulatory arrest may occur, even following two minutes of circulatory asystole, albeit rarely. Database: EMBASE

316. Remifentanil suppresses increase in interleukin-6 mRNA in the brain by inhibiting cyclic AMP synthesis Author(s): Maeda S.; Higuchi H.; Andoh T.; Onishi R.; Tomoyasu Y.; Miyawaki T. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: Neuronal inflammation is caused by systemic inflammation and induces cognitive dysfunction. IL-6 plays a crucial role in therapies for neuronal inflammation and cognitive dysfunction. Remifentanil, an ultra-short-acting opioid, controls inflammatory reactions in the periphery, but not in the brain. Therefore, the anti-inflammatory effects of remifentanil in neuronal tissue and the involvement of cAMP in these effects were investigated in the present study. Methods: Mice were divided into 4 groups: control, remifentanil, LPS, and LPS + remifentanil. Brain levels of pro-inflammatory cytokine mRNA, and serum levels of corticosterone, catecholamine and IL-6 were measured in the 4 groups. The co-localization of IL-6 and astrocytes in the mouse brain after the LPS injection was validated by immunostaining. LPS and/or remifentanil-induced changes in intracellular cAMP levels in cultured glial cells were measured, and the effects of cAMP on LPS- induced IL-6 mRNA expression levels were evaluated. Results: Remifentanil suppressed increase in IL-6 mRNA levels in the mouse brain, and also inhibited the responses of plasma IL-6, corticosterone, and noradrenaline in an inflammatory state. In the hypothalamus, IL-6 was localized in the median eminence, at which GFAP immunoreactivity was specifically detected. In cultured cells, remifentanil suppressed increase in IL-6 mRNA levels and intracellular cAMP levels after the administration of LPS, and this enhanced IL-6 mRNA expression in response to LPS. Conclusion: Remifentanil suppressed increase in IL-6 mRNA levels in the brain in an inflammatory state, and this effect may be attributed to its direct action on neuronal cells through the inhibition of intracellular cAMP rather than corticosterone.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

317. Randomized comparative study between two different techniques of intercostobrachial nerve block together with brachial plexus block during superficialization of arteriovenous fistula Author(s): Moustafa M.A.; Kandeel A.A. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: This study compared proximal and distal approaches of intercostobrachial nerve block (ICBNB) combined with infraclavicular brachial plexus block (ICBPB) during superficialization of arteriovenous fistula. Methods: Seventy adult patients were randomized to receive ICBPB and 6 ml 0.25% bupivacaine at the level of the 3rd rib in the anterior axillary line between pectoralis minor and serratus anterior muscles (group P) or subcutaneously along the medial side of the upper arm (group D). The primary outcome was the achievement of complete sensory block. Secondary outcomes were onset of analgesia, volume of local anesthetic (LA) supplementation, fentanyl administration, success rate, and conversion to general anesthesia (GA). Results: Complete sensory block in the medial side of the upper arm was achieved in 91% of patients in group P and 51% in group D. Failure rate of ICBNB was higher in group D (49%) than group P (14%). Conversion to GA was determined by the attending anesthesiologist in 26% of patients in group D and 0% in group P. LA supplementation was required in 5 patients in group P and 11 patients in group D, and the mean volume of LA was statistically higher in group D than group P (9.5 +/- 1.5, 7.5 +/- 2 ml, respectively). Onset of sensory block was faster in group P than group D (8.75 +/- 1.67 and 10 +/- 2.14 min, respectively). No differences were observed regarding fentanyl administration. Conclusion: ICBNB proximal approach provides a high success rate with less amount of rescue analgesia compared to the distal approach.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

318. A pilot study to record visual evoked potentials during prone spine surgery using the SightSaverTM photic visual stimulator Author(s): Soffin E.M.; Cheng J.; Beckman J.D.; Emerson R.G.; Mercado K.; Smith K. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 889-895 Publication Date: Oct 2018 Publication Type(s): Article Abstract:This is a pilot study to assess the clinical safety and efficacy of recording real-time flash visual evoked potentials (VEPs) using the SightSaver TM Visual Stimulator mask during prone spine surgery. A prospective, observational pilot study. Twenty patients presenting for spine surgery (microdiscectomy, 1-2 level lumbar fusion, or > 2 levels thoraco-lumbar fusion) were enrolled. The SightSaverTM Visual StimulatorTM was used to elicit VEPs throughout surgery. Somatosensory evoked potentials (SSEPs) were simultaneously recorded. All patients underwent general anesthesia with a combination of intravenous and inhaled agents. The presence, absence, and changes in VEP were qualitatively analyzed. Reproducible VEPs were elicited in 18/20 patients (36/40 eyes). VEPs were exquisitely sensitive to changes in anesthesia and decayed with rising MAC of isoflurane and/or N2O. Decrements in VEPs were observed without concomitant changes in SSEPs. The mask was simple to apply and use and was not associated with adverse effects. The SightSaverTM mask represents an emerging technology for monitoring developing visual insults during surgery. The definitive applications remain to be determined, but likely include use in select patients and/or surgeries. Here, we have validated the device as safe and effective, and show that VEPs can be recorded in real time under general anesthesia in the prone position. Future studies should be directed towards understanding the ideal anesthetic regimen to facilitate stable VEP recording during prone spine surgery.Copyright © 2017, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

319. Corticosteroid and Cortisol Serum Levels Following Intra-articular Triamcinolone Acetonide Lumbar Facet Joint Injections Author(s): Dickson R.R.; Nicholson W.T.; Lamer T.J.; Hooten W.M.; Reid J.M. Source: Pain Practice; Sep 2018; vol. 18 (no. 7); p. 864-870 Publication Date: Sep 2018 Publication Type(s): Article Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Facet joint steroid injections are used to treat chronic low back pain. However, little is known about the systemic absorption and serum levels of steroids following intra- articular facet joint injections. The primary objective of this preliminary study was to investigate the pharmacokinetics of triamcinolone acetonide following fluoroscopically guided intra-articular lumbar facet joint injections in a cohort of patients with chronic low back pain. A secondary aim was to investigate the effects of triamcinolone on serum cortisol levels following lumbar facet joint injections. Methods: The study cohort included 5 patients undergoing fluoroscopically guided intra- articular lumbar facet joint injections at a pain medicine specialty clinic. Blood was collected prior to the injections and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injections. Results: The terminal elimination half-life of triamcinolone in a noncompartmental analysis was 213 hours. The peak median triamcinolone concentration of 3.6 ng/mL was detected within 24 hours after the injections. Serum cortisol levels were < 30 ng/mL for an average of 4.4 days. The maximum effect of triamcinolone on cortisol suppression was observed with triamcinolone serum levels of > 1.9 ng/mL. Conclusions: The peak serum concentration of triamcinolone following intra-articular facet joint injections occurred within 24 hours. The median terminal elimination half-life was 213 hours, but baseline cortisol levels were suppressed for an average of 4.4 days. Clinically, the prolonged half-life and endocrine effects of triamcinolone could increase the risk for serious drug-drug interactions in patients taking medications that inhibit corticosteroid metabolism.Copyright © 2018 World Institute of Pain Database: EMBASE

320. Prevention and Treatment of Postoperative Pain after Lumbar Spine Procedures: A Systematic Review Author(s): Terracina S.; Prete A.; Sergi P.G.; Bilotta F.; Robba C. Source: Pain Practice; Sep 2018; vol. 18 (no. 7); p. 925-945 Publication Date: Sep 2018 Publication Type(s): Review Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background and Objective: In the past 2 decades, in developed countries, spine procedures (surgical and percutaneous) had the highest absolute increase in case volume trend. The optimal approach to prevent and treat postoperative pain is continuously evolving. This systematic literature review presents evidence on safety and efficacy of pharmacological and nonpharmacological therapies to prevent and treat postoperative pain after lumbar spine procedures. Databases and Data Treatment: Publications listed in PUBMED and EMBASE were considered to identify randomized clinical trials suitable for inclusion in this systematic review. Key words for literature search were selected, with authors' agreement, using the PICOS approach (participants, interventions, comparisons, outcomes, and study design). Results: Fifty-nine randomized clinical trials (involving a total of 4,238 patients, with ages ranging from 18 to 86 years) published between January 2012 and September 2017 were retrieved. Data are presented according to the timing of therapy administration. Conclusion and Recommendations: Clinical evidence on perioperative pain management in patients undergoing spine procedures have significantly evolved after the review published in 2012. The aim of this systematic review was to report the latest evidence published. These include the preoperative use of dexamethasone, which was shown to be able to reduce pain at mobilization but not to reduce pain at rest or total morphine consumption; the use of gabapentinoids as part of a multimodal analgesic approach; and the safety and effectiveness of the intraoperative use of ketamine, dexketoprofen, and tramadol. Finally, electrical nerve stimulation is gaining interest and is potentially suitable for clinical needs.Copyright © 2018 World Institute of Pain Database: EMBASE

321. Temporal and Spatial Quantification of Pain- Related Small Fiber Functionality Assessed Using Laser Speckle Contrast Analysis Author(s): Unal-Cevik I. Source: Pain Practice; Sep 2018; vol. 18 (no. 7); p. 824-838 Publication Date: Sep 2018 Publication Type(s): Article Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: This study aimed to establish a practical method for assessing pain symptomatology and develop criteria for quantifying small fiber functions using laser speckle contrast analysis (LASCA). Methods: Axon flare responses, which reflect small fiber functions, were induced either by histamine or capsaicin applied to the volar surface of the skin of the left forearm. To inhibit small fiber function, local anesthetic cream was applied to the skin of right forearm. The effects on pain symptomatology (severity/timing) and axon flare responses (temporal/spatial characteristics) were measured using LASCA. To highlight the clinical relevance, this method was applied to 3 different types of patients with small fiber dysfunction. Results: Forty-four forearms of 22 healthy volunteers were tested. Eutectic mixture local anesthetic cream reduced the severity and duration of pain, abolishing or prolonging the latency to reach 3-fold higher levels of basal skin microcirculation levels, and decreasing the area and intensity of flare responses. There were positive correlations between pain symptomatology and flare response characteristics in the control forearm. Similar results were confirmed in neuropathic pain patients. Conclusions: Pain-related small fiber functions and symptomatology (two-in-one method) can be assessed via histamine- or capsaicin-evoked axon flare responses in as little as 15 minutes. The reduction of small fiber functions are characterized by decrease in flare size/intensity at 5 minutes after stimulation and prolongation/abolishment of the latency to reach 3-fold higher levels of baseline skin microcirculation. LASCA may be applied in the clinic to aid early diagnosis, monitor disease progression, and objectively assess treatment efficacy in patients with neuropathic pain.Copyright © 2018 World Institute of Pain Database: EMBASE

322. Bloc du plan des muscles erecteurs du rachis thoracique bas pour analgesie perioperatoire dans la chirurgie du rachis lombosacre : une serie de casLow thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series Author(s): Melvin J.P.; Schrot R.J.; Chu G.M.; Chin K.J. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 (no. 9); p. 1057-1065 Publication Date: Sep 2018 Publication Type(s): Article Abstract:Purpose: Severe postoperative pain following spine surgery is a significant cause of morbidity, extended length of facility stay, and marked opioid usage. The erector spinae plane (ESP) block anesthetizes the dorsal rami of spinal nerves that innervate the paraspinal muscles and bony vertebra. We describe the use of low thoracic ESP blocks as part of multimodal analgesia in lumbosacral spine surgery. Clinical features: We performed bilateral ESP blocks at the T10 or T12 level in six cases of lumbosacral spine surgery: three lumbar decompressions, two sacral laminoplasties, and one coccygectomy. Following induction of general anesthesia, single-injection ESP blocks were performed in three patients while bilateral continuous ESP block catheters were placed in the remaining three. All six patients had minimal postoperative pain and very low postoperative opioid requirements. There was no discernible motor or sensory block in any of the cases and no interference with intraoperative somatosensory evoked potential monitoring used in two of the cases. Conclusions: The ESP block can contribute significantly to a perioperative multimodal opioid-sparing analgesic regimen and enhance recovery after lumbosacral spine surgery.Copyright © 2018, Canadian Anesthesiologists' Society. Database: EMBASE

323. Validity and Test-Retest Reliability of the Dutch Modified Perceived Deficits Questionnaire to Examine Cognitive Symptoms in Women with Chronic Whiplash, Chronic Idiopathic Neck Pain, and Fibromyalgia Author(s): Lenoir D.; De Pauw R.; Schumacher C.; Kregel J.; Coppieters I.; Ickmans K.; Timmers I. Source: Pain Practice; Sep 2018; vol. 18 (no. 7); p. 850-863 Publication Date: Sep 2018 Publication Type(s): Article Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Until now, only reliability and validity of the English version of the modified Perceived Deficits Questionnaire (mPDQ) have been investigated. Objective: The aim of this study was to translate the mPDQ into Dutch and evaluate its validity and reliability as an assessment tool for self-perceived cognitive problems in patients with chronic whiplash-associated disorders (CWAD), chronic idiopathic neck pain (CINP), and fibromyalgia (FM). Methods: A case-control study was performed with a volunteer sample of 13 women with CWAD, 18 with CINP, and 33 with FM, and 33 women who were healthy and free of pain. The mPDQ was first translated into Dutch, and its test-retest reliability, internal consistency, and discriminative power were examined. Results: The intraclass correlation coefficients were higher than 0.74. Cronbach's alpha values ranged between 0.71 and 0.95. Total mPDQ scores were significantly higher (P < 0.017) in FM and CWAD patients compared to healthy controls. Furthermore, participants performed the Stroop task and the psychomotor vigilance task (PVT), 2 neuropsychological computer-based cognitive performance tests. Correlations between the mPDQ total score and the cognitive performance tests were evaluated. Significant moderate to high correlations were found in all study samples between total mPDQ score and objective cognitive tests (Spearman correlation coefficient = 0.35 to 0.80; P < 0.05). Conclusion: Therefore, the Dutch version of the mPDQ showed high test-retest reliability and high internal consistency, and was able to distinguish CWAD and FM patients from healthy controls. Perspective: This article presents the validity and test-retest reliability of the Dutch mPDQ. This measure could help clinicians who seek a reliable and user-friendly way to assess cognitive symptoms in chronic pain patients.Copyright © 2018 World Institute of Pain Database: EMBASE

324. Can thyromental distance be measured accurately? Author(s): Wang B.; Yao W.; Guo L.; Jin X.; Peng H. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 915-920 Publication Date: Oct 2018 Publication Type(s): Article Available at Journal of clinical monitoring and computing - from Publishers' website (via doi.org) Available at Journal of clinical monitoring and computing - from Unpaywall Abstract:Using the thyromental distance (TMD) measured based on the ultrasonographic location of the thyroid cartilage prominence as the criterion, we investigated the accuracy of TMD measurement by surface landmark identification of the thyroid cartilage prominence. Twenty-nine anesthetist resident volunteers were recruited, including 10 first-year residents, 9 second-year residents and 10 third-year residents. Each volunteer measured the other 28 volunteers' TMD. Then, the thyroid cartilage prominence of each volunteer was identified by ultrasonography of the junction of the vocal cord and thyroid cartilage, and the TMD was measured precisely. The error of the TMD measurement was determined by the minimal detectable difference (MDD) compared to the ultrasound measurement. A difference of greater than 5.4 mm between the TMD measured by volunteers and that based on ultrasound localization was defined as a measurement error. The measurement error rate of females' TMD was significantly higher than that of males' (50 vs 10%, P < 0.001). The error rates of anesthetist residents of first-year, second-year and third-year were 34, 27, and 31%, respectively, and were not significantly different. The error of TMD measurement by surface landmark identification is often, especially for women. More clinic experience don't improve it.Copyright © 2017, The Author(s). Database: EMBASE

325. Ultrasound-Guided Intercostal Nerve Block Following Esophagectomy for Acute Postoperative Pain Relief in the Postanesthesia Care Unit Author(s): Zhu M.; Gu Y.; Sun X.; Liu X.; Chen W.; Miao C. Source: Pain Practice; Sep 2018; vol. 18 (no. 7); p. 879-883 Publication Date: Sep 2018 Publication Type(s): Article Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objective: To explore the feasibility, effectiveness, and safety of ultrasound-guided intercostal nerve block (ICNB) for immediate relief of moderate and severe pain following esophagectomy in a postanesthesia care unit (PACU). Methods: Eighty-one patients who complained of moderate to severe pain on arrival to the PACU after an Ivor Lewis esophagectomy were randomly assigned to 2 groups: a sufentanil treatment group (Group A, n = 41) and an intercostal nerve block treatment group (Group B, n = 40). The visual analog scale (VAS) pain scores at rest and on cough at 1, 2, 4, 12, 24, and 48 hours after treatment were monitored. The heart rate, blood pressure, and pulse oxygen saturation (SpO2) 2 hours after treatment and the patients' length of stay in the PACU after treatment were recorded. Patient-controlled intravenous analgesia consumption and the incidence of nausea, vomiting, and other adverse reactions were also recorded. Results: Ultrasound-guided ICNB was performed successfully in all patients in Group B without puncture-related complications. The VAS pain scores at rest and on cough at 1, 2, and 4 hours after treatment in Group B were significantly lower than those in Group A (P < 0.05). The consumption of sufentanil and the incidence of nausea and vomiting were significantly decreased in Group B compared with those in Group A. Conclusion: Ultrasound-guided ICNB could provide effective and safe pain relief for patients who suffer from moderate to severe pain (VAS score >= 5) after esophagectomy in the PACU.Copyright © 2018 World Institute of Pain Database: EMBASE

326. Clinical and echocardiographic risk factors for extubation failure in infants with congenital diaphragmatic hernia Author(s): Schroeder L.; Reutter H.; Mueller A.; Kipfmueller F.; Gembruch U.; Berg C. Source: Paediatric Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pediatric Anesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Infants after surgical correction of congenital diaphragmatic hernia are at high risk for extubation failure, but little is known about contributing factors. Therefore, our study aimed to analyze clinical and echocardiographic parameters. Materials and Methods: Data of 34 infants with congenital diaphragmatic hernia treated at our department (July 2013-December 2015) were analyzed. Inclusion criteria were: presence of congenital diaphragmatic hernia and echocardiography performed within 48 hours before the first, and, in case of reintubation, the final extubation attempt. Infants were allocated to group A (extubation failure) and group B (extubation successful). Results: Extubation failure occurred in 12/34 infants (35%). Infants in group A had a higher proportion of intrathoracic liver herniation (P = 0.001, OR 17 [2.8/104.5]) and lower rates of the lung-to-head ratio (P = 0.042, 95% CI [-0.4/20]), even as higher rates of extracorporeal membrane oxygenation (P = 0.001, 95% CI [2.7/80.9]). The oxygenation index and the PaO2/FiO2 ratio differed significantly between both groups (both P = 0.000; 95% CI [-11/-4.1] and [79/215], respectively). The mean airway pressure and fraction of inspired oxygen prior to extubation was significantly higher in group A (P = 0.008; 95% CI [-3.9/-1.4]; P = 0.000; 95% CI [-0.6/-0.2], respectively). In addition, the respiratory severity score was higher in group A (P = 0.000; 95% CI [- 7.3/-2.6]). In group A, administration of sildenafil and the vasoactive inotropic score were significantly higher (P = 0.037; OR 9 [0.9/88.6] and P = 0.013; 95% CI [-14/-1.8], respectively). More infants in group A had need for a surgical patch repair of the diaphragm (P = 0.017; OR 7.2 [1.3/41.1]) and showed higher rates of relevant pleural effusions prior the extubation (P = 0.021; OR 6 [1.2/29.5]). The total duration of the ventilation and the length of hospital stay were longer in group A (P = 0.004; 95% CI [-915/-190] and P = 0.000; 95% CI [-110/-39], respectively). The prevalence of pulmonary hypertension was more frequent in group A (P = 0.012; OR 12 [1.3/114]), the time to peak velocity in the main pulmonary artery was significantly lower in group A (P = 0.024; 95% CI [2/25.6]), and these infants suffered more often from cardiac dysfunction (P = 0.007; OR 10 [1.6/63.1]). Conclusion: Our results demonstrate that extubation failure in infants with a congenital diaphragmatic hernia is associated with several clinical and echocardiographic risk factors.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

327. Off-hour admission and impact on neurological outcome in endovascular treatment for acute ischemic stroke Author(s): Lowhagen Henden P.; Oras J.; Ricksten S.-E.; Rentzos A.; Karlsson J.-E.; Rosengren L. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background and Purpose: In the new era of endovascular treatment for acute ischemic stroke, one of the main predictors of good neurological outcome is a short time interval from stroke onset to recanalization of the occluded vessel. In this study, we examined the effect of on-hour vs off-hour admittance on the time intervals from stroke onset to recanalization in patients with acute ischemic stroke (AIS) undergoing endovascular treatment (EVT). Methods: One-hundred-ninety-eight patients receiving EVT for anterior AIS between 2007 and 2016 were included. Time of day and weekday for stroke admittance were recorded as well as several time intervals. Age, sex, comorbidities, admission National Institutes of Health Stroke Scale (NIHSS), intraprocedural blood pressure, blood glucose, modified Thrombolysis in Cerebral Ischemia score (mTICI) and neurological outcome at 3 months, measured as modified Rankin Scale (mRS), were registered. On-hour was defined as 8 am-4 pm weekdays, and off-hour as weekdays outside these hours and weekends. Results: The time interval from CT (computed tomography) to recanalization was longer during off- hours, while no difference was seen in the time interval from stroke onset to CT. No statistically significant difference was seen in neurological outcome between the on- and off-hour groups in a univariate analysis. Conclusions: Stroke admittance during off-hours is associated with longer time interval from CT examination to vessel recanalization. The study highlights the need of logistic improvement and probably more resources off-hour in order to deliver an effective stroke care around the clock.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

328. Pneumococcal sepsis requiring mechanical ventilation: Cohort study in 38 patients with rapid progression to septic shock Author(s): Ursin Rein P.; Jacobsen D.; Dunlop O.; Ormaasen V. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: The aim was to study the course of severe pneumococcal sepsis in patients who rapidly developed septic shock with multiorgan failure. Methods: Combined retrospective and prospective cohort study of all patients with pneumococcal sepsis requiring mechanical ventilation admitted to our Medical Intensive Care Unit at Oslo University Hospital Ullevaal, during an 8-year period (01 January 2016 to 31 December 2013). The inclusion criteria were growth of Streptococcus pneumoniae in blood culture and respiratory failure treated with invasive mechanical ventilation. Results: Thirty-eight patients were included. Median age was 57 years (interquartile range 49-68, range 22-79). For 84% (32/38), it took <24 hours from the first medical evaluation until they were in septic shock. Initial clinical features were variable; none were treated with antibiotics before hospital admission. Median Sequential Organ Failure Assessment (SOFA) score at admission was 11 (range 1-15) and maximum 15 (range 5-22), all patients developed multiorgan failure. Mutilating complications were seen in 47% (18/38) of the patients: six with amputations, 11 had adverse neurological complications and one patient both. In-hospital mortality was 40% (15/38), 20% (8/38) survived with sequelae and 40% (15/38) returned to their habitual state. Poor outcome was associated with meningitis, disseminated intravascular coagulation, and gastrointestinal symptoms. Conclusion: In this patient cohort with pneumococcal sepsis and respiratory failure rapid development of septic shock was seen in all cases, even in young healthy individuals. Initial clinical features were variable; none were treated with antibiotics before admission. Mortality was high (40%), as was morbidity with limb amputations and neurological complications.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

329. The effect of haemodynamic and peripheral vascular variability on cardiac output monitoring: thermodilution and non-invasive pulse contour cardiac output during cardiothoracic surgery Author(s): Truijen J.; Stok W.J.; Westerhof B.E.; Kim Y.-S.; de Mol B.A.; Preckel B.; Hollmann M.W.; van Lieshout J.J. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:While haemodynamic variability interferes with the assumption of constant flow underlying thermodilution cardiac output calculation, variability in (peripheral) arterial vascular physiology may affect pulse contour cardiac output methods. We compared non-invasive finger arterial pressure- derived continuous cardiac output measurements (Nexfin) with cardiac output measured using thermodilution during cardiothoracic surgery and determined the impact of cardiovascular variability on either method. We compared cardiac output derived from non-invasive finger arterial pressure with cardiac output measured by thermodilution at four grades (A-D) of cardiovascular variability. We defined Grade A data as heart rate and mean arterial pressure variability < 5% and the absence of arrhythmias (implying stable flow) and Physiocal interval (as measure of variability in finger arterial physiology) > 30 beats. Grade B included all levels of heart rate/mean arterial pressure variability and arrhythmias (Physiocal < 30 excluded). Grade C included all Physiocal intervals (heart rate/mean arterial pressure variability > 5% and arrhythmias excluded). Grade D included all data. Comparison results were quantified as percentage errors. We analysed measurements in 27 patients undergoing coronary artery bypass surgery. Before extracorporeal circulation, the percentage error was 23% (n = 14 patients) in grade A, 28% (n = 20) in grade B, 32% (n = 22) in grade C and 37% (n = 26) in grade D, with a significant increase in variance (p = 0.035). Bias did not differ between grades. After extracorporeal circulation (n = 27), percentage errors became larger, but were not different between grades. Variability during cardiothoracic surgery affected the comparison between thermodilution and non-invasive finger arterial pressure-derived cardiac output. When the main sources of variability were included, percentage errors were large. Future cardiac output methodology comparison studies should report haemodynamic variability.Copyright © 2018 The Association of Anaesthetists Database: EMBASE

330. Environmental safety: Air pollution while using MIRUSTM for short-term sedation in the ICU Author(s): Herzog-Niescery J.; Vogelsang H.; Gude P.; Weber T.P.; Bellgardt M.; Seipp H.-M.; Uhl W. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: MIRUSTM is a device for target-controlled inhalational sedation in the ICU in combination with use of isoflurane, or sevoflurane, or desflurane. The feasibility of this device has recently been proven; however, ICU staff exposure may restrict its application. We investigated ICU ambient room pollution during daily work to estimate ICU personnel exposure while using MIRUSTM. Methods: This observational study assessed pollution levels around 15 adult surgical patients who received volatile anaesthetics-based sedation for a median of 11 hours. Measurements were performed by photoacoustic gas monitoring in real-time at different positions near the patient and in the personnel's breathing zone. Additionally, the impact of the Clean AirTM open reservoir scavenging system on volatile agent pollution was evaluated. Results: Baseline concentrations [ppm] during intervention and rest periods were isoflurane (Formula presented.) = 0.58 +/- 0.49, (Formula presented.) = 5.72; sevoflurane (Formula presented.) = 0.22 +/- 0.20, (Formula presented.) = 7.93; and desflurane (Formula presented.) = 0.65 +/- 0.57, (Formula presented.) = 6.65. Refilling MIRUSTM with liquid anaesthetic yielded gas concentrations of (Formula presented.) = 2.18 +/- 1.48 ppm and (Formula presented.) = 13.03 +/- 9.37 ppm in the personnel's breathing zone. Air pollution in the patient's room was approximately five times higher without a scavenging system. Conclusion: Ambient room pollution was minimal in most cases, and the measured values were within or below the recommended exposure limits. Caution should be taken during refilling of the MIRUSTM system, as this was accompanied by higher pollution levels. The combined use of air-conditioning and gas scavenging systems is strongly recommended.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

331. Evaluating Dorsal Root Ganglion Stimulation in a Prospective Dutch Cohort Author(s): Huygen F.J.P.M.; Liem L.; Nijhuis H.; Cusack W.; Kramer J. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: Dorsal root ganglion (DRG) stimulation is a recent neuromodulation option that has delivered safe, effective pain relief for a number of etiologies. This prospective observational study was intended to establish the effectiveness of this treatment in a typical real-world clinical context. Materials and Methods: Participants with chronic, intractable pain of the trunk or lower limbs were recruited from multiple pain clinics in the Netherlands. Subjects were trialed and implanted with DRG stimulation systems. Pain, function, mood, and quality of life, ratings were collected through 12 months postimplant. Results: Of the 66 subjects enrolled, failed back surgery syndrome, peripheral nerve injury, and complex regional pain syndrome formed the largest etiologies. Permanent implants were placed in 86.2% subjects (56/65). After 12 months of treatment, average pain ratings in subjects' primary area of pain decreased from 8.0 cm at baseline to 4.1 cm, and 49% of subjects had >=50% reduction in pain (visual analog scale). In addition, functional capacity was increased, and mood and quality of life improved. No confirmed lead migrations were observed, and there was a low rate of infection. Conclusions: DRG stimulation significantly reduced the severity of subjects' pain and enabled participatory changes that improved quality of life through 12-months postimplant.Copyright © 2018 International Neuromodulation Society Database: EMBASE

332. Modeling the pharmacokinetics and pharmacodynamics of sevoflurane using compartment models in children and adults Author(s): Cortinez L.I.; Anderson B.J. Source: Paediatric Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pediatric Anesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Sevoflurane pharmacokinetics have been traditionally described using physiological models, while pharmacodynamics employed the use of minimal alveolar concentration. Aims: The integrated pharmacokinetic-pharmacodynamic relationship of sevoflurane in both adults and children was reviewed using compartment models. We wished to delineate age-related changes in both pharmacokinetics and pharmacodynamics. Methods: The bispectral index and sevoflurane endtidal concentration were continuously measured in 50 patients, aged 3-71 years, scheduled for minor surgery. During maintenance of anesthesia and after stable bispectral index values of 60-65 were obtained, the inspired concentration of sevoflurane was increased to 5 vol % for 5 minutes or until BIS 40 and then decreased. Data were analyzed using mammillary compartments with nonlinear mixed effects population modeling. The covariate effects of age and size were investigated. Results: A three-compartment PK model adequately described sevoflurane pharmacokinetics. Size standardization using allometry explained clearance and volume changes with age. The equilibration half-time (1.48 minutes) increased with age, but could be predicted using allometry in those under 40 years. The effect site concentration eliciting half the maximum response at age 40 years was 1.3% (95%CI 1.22, 1.42) decreased with age from 1.6% at 3 years to 1.1% at 70 years. Conclusion: Pharmacokinetic compartment models offer an alternative method to describe inhalation anesthetic drug disposition and effects.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

333. Prescription opioid analgesic use in France: Trends and impact on morbidity-mortality Author(s): Chenaf C.; Kabore J.-L.; Delorme J.; Pereira B.; Mulliez A.; Zenut M.; Delage N.; Ardid D.; Eschalier A.; Authier N. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: While data from USA and Canada demonstrate an opioid overdose epidemic, very little nation-wide European studies have been published on this topical subject. Methods: Using a nationally representative sample of the French Claims database (>700,000 patients), the exhaustive nationwide hospital discharge database, and national mortality registry, all patients dispensed at least one prescription opioid (PO) in 2004-2017 were identified, to describe trends in PO analgesic use, shopping behaviour, opioid-related hospitalizations and deaths. Annual prevalence of PO use and shopping behaviour (>=1 day of overlapping prescriptions from >=2 prescribers, dispensed by >=3 pharmacies) was estimated. Results: In 2004-2017, the annual prevalence of weak opioid use codeine, tramadol and opium rose by 150%, 123%, and 244%, respectively (p < 0.05). Strong opioid use increased from 0.54% to 1.1% (+104%, p < 0.05), significantly for oxycodone (+1950%). Strong opioid use in chronic noncancer pain rose by 88% (p < 0.05) and 1180% for oxycodone. Opioid shopping increased from 0.50% to 0.67% (+34%, p < 0.05), associated with higher mortality risk HR = 2.8 [95% confidence interval (CI): 1.2-6.4]. Opioid-related hospitalizations increased from 15 to 40 per 1,000,000 population (+167%, 2000-2017), and opioid-related deaths from 1.3 to 3.2 per 1,000,000 population (+146%, 2000-2015). Conclusions: This study provided a first European approach to a nationwide estimation with complete access to several national registries. In 2004-2017 in France, PO use excluding dextropropoxyphene more than doubled. The increase in oxycodone and fentanyl use, and nontrivial increasing trend in opioid-related morbidity- mortality should prompt authorities to closely monitor PO consumption in order to prevent alarming increases in opioid-related morbidity-mortality. Significance: In 2004-2017, prescription opioid use in France at least doubled and oxycodone use increased particularly, associated with a nontrivial increase in opioid-related morbidity-mortality. Although giving no indication for an 'opioid epidemic,' these findings call for proper monitoring of opioid use.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

334. Comparison of blood pressure monitoring by applanation tonometry and invasively assessed blood pressure in cardiological patients Author(s): Greiwe G.; Hoffmann S.; Winkler M.S.; Trepte C.J.; Behem C.R.; Petzoldt M.; Herich L.; Reuter D.A.; Haas S.A. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 817-823 Publication Date: Oct 2018 Publication Type(s): Article Abstract:The aim of this study was to evaluate the accuracy and precision of non-invasive continuous blood pressure measurement by applanation tonometry (AT) in awake or anaesthetised cardiological intensive care patients. Patients suffering from highly impaired left ventricular function atrial fibrillation or severe aortic valve stenosis were included into the study. Arterial blood pressure was recorded by applanation tonometry (T-Line 400, Tensys Medical, USA) and an arterial line in awake or anaesthetised patients. Discrepancies in mean (MAP), systolic (SAP), and diastolic (DAP) arterial pressure between the two methods were assessed as bias, limits of agreement and percentage error respectively. In 31 patients a total of 27,900 measurements were analyzed. The concordance correlation coefficient was 0.23, 0.45 and 0.06 for MAP, SAP and DAP, respectively. For all patients bias for MAPAT compared to MAPAL was 14.96 mmHg (SAPAT 4.51 mmHg; DAPAT 19.12 mmHg) with limits of agreement for MAPAT of 46.25 and - 16.33 mm Hg (SAPAT 48.00 and - 38.98 mmHg; DAPAT 50.12 and - 11.89 mmHg). Percentage error for MAPAT was 56.8% (42.7% for SAPAT; 75.2% for DAPAT). We conclude that the AT method is not reliable in ICU patients with severe cardiac comorbidities.Copyright © 2017, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

335. Evaluation of the use of the fourth version FloTrac system in cardiac output measurement before and after cardiopulmonary bypass Author(s): Lin S.-Y.; Chou A.-H.; Tsai Y.-F.; Yang M.-W.; Ting P.-C.; Chen C.-Y.; Chang S.-W. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 807-815 Publication Date: Oct 2018 Publication Type(s): Article Abstract:The FloTrac system is a system for cardiac output (CO) measurement that is less invasive than the pulmonary artery catheter (PAC). The purposes of this study were to (1) compare the level of agreement and trending abilities of CO values measured using the fourth version of the FloTrac system (CCO-FloTrac) and PAC-originated continuous thermodilution (CCO-PAC) and (2) analyze the inadequate CO-discriminating ability of the FloTrac system before and after cardiopulmonary bypass (CPB). Fifty patients were included. After exclusion, 32 patients undergoing cardiac surgery with CPB were analyzed. All patients were monitored with a PAC and radial artery catheter connected to the FloTrac system. CO was assessed at 10 timing points during the surgery. In the Bland-Altman analysis, the percentage errors (bias, the limits of agreement) of the CCO-FloTrac were 61.82% (0.16, - 2.15 to 2.47 L min) and 51.80% (0.48, - 1.97 to 2.94 L min) before and after CPB, respectively, compared with CCO-PAC. The concordance rates in the four-quadrant plot were 64.10 and 62.16% and the angular concordance rates (angular mean bias, the radial limits of agreement) in the polar- plot analysis were 30.00% (17.62degree, - 70.69degree to 105.93degree) and 38.63% (- 10.04degree, - 96.73degree to 76.30degree) before and after CPB, respectively. The area under the receiver operating characteristic curve for CCO-FloTrac was 0.56, 0.52, 0.52, and 0.72 for all, >= +/- 5, >= +/- 10, and >= +/- 15% CO changes (DELTACO) of CCO-PAC before CPB, respectively, and 0.59, 0.55, 0.49, and 0.46 for all, >= +/- 5, >= +/- 10, and >= +/- 15% DELTACO of CCO-PAC after CPB, respectively. When CO < 4 L/min was considered inadequate, the Cohen kappa coefficient was 0.355 and 0.373 before and after CPB, respectively. The accuracy, trending ability, and inadequate CO-discriminating ability of the fourth version of the FloTrac system in CO monitoring are not statistically acceptable in cardiac surgery.Copyright © 2017, Springer Science+Business Media B.V. Database: EMBASE

336. Assessment of liver perfusion and function by indocyanine green in the perioperative setting and in critically ill patients Author(s): Sakka S.G. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 787-796 Publication Date: Oct 2018 Publication Type(s): Review Abstract:Indocyanine green (ICG) is a water-soluble dye that is bound to plasma proteins when administered intravenously and nearly completely eliminated from the blood by the liver. ICG elimination depends on hepatic blood flow, hepatocellular function and biliary excretion. ICG elimination is considered as a useful dynamic test describing liver function and perfusion in the perioperative setting, i.e., in liver surgery and transplantation, as well as in critically ill patients. ICG plasma disappearance rate (ICG-PDR) which can be measured today by transcutaneous systems at the bedside is a valuable method for dynamic assessment of liver function and perfusion, and is regarded as a valuable prognostic tool in predicting survival of critically ill patients, presenting with sepsis, ARDS or acute liver failure.Copyright © 2017, Springer Science+Business Media B.V. Database: EMBASE

337. Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures Author(s): Morse J.; Hannam J.A.; Blackburn L.; Anderson B.J.; Voss L. Source: Paediatric Anaesthesia; Aug 2018; vol. 28 (no. 8); p. 686-693 Publication Date: Aug 2018 Publication Type(s): Review Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Postoperative wound infections represent an important source of morbidity and mortality in children. Perioperative antibiotic prophylaxis has been shown to decrease the risk of developing infections and hospital guidelines surrounding antibiotic use exist to standardize patient care. Despite supporting evidence, rates of compliance with guidelines vary. Quality improvement initiatives have been introduced to improve compliance with intraoperative antibiotic guidelines. Thorough infection surveillance, including antibiotic provision in presurgical checklists, computerized voice antibiotic administration prompts, and national feedback systems are now increasingly common. Few studies have been conducted investigating the effectiveness of prophylactic antibiotics in children. Outcome measures such as morbidity and mortality and return to the operating room can be used to examine the relationship between antibiotic use and patient outcome but these measures are limited in that they occur infrequently or are subjective and difficult to measure. Metrics such as days alive out of hospital and length of hospital stay may be useful alternatives for ongoing monitoring of infections and identifying improvements in patient outcomes. Guidelines on antibiotic prophylaxis have facilitated an increase in the correct provision of perioperative antibiotics and a reduction in the incidence of postoperative infection. Measures of patient outcome such as days alive out of hospital and length of hospital stay are easy to collect and calculate but further work is needed to confirm the utility of these measures for monitoring infection rates.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

338. Randomized Controlled Trial of Nurse-Delivered Cognitive-Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain Author(s): Rutledge T.; Atkinson J.H.; Holloway R.; Chircop-Rollick T.; D'Andrea J.; Patel S.; Weickgenant A.L.; Garfin S.R.; Penzien D.B.; Wallace M.; Slater M. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 1033-1039 Publication Date: Sep 2018 Publication Type(s): Article Abstract:This study evaluated a nurse-delivered, telehealth intervention of cognitive-behavioral therapy (CBT) versus supportive psychotherapy for chronic back pain. Participants (N = 61) had chronic back pain (pain "daily">=6 months at an intensity of >=4 of 10 scale) and were randomized to an 8-week, 12-session, CBT or to supportive care (SC) matched for frequency, format, and time, with each treatment delivered by a primary care nurse. The primary outcome was the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included the numeric rating scale (NRS) and the Patient Global Impressions Scale (CGI). CBT participants (n = 30) showed significant improvements on the RMDQ (mean = 11.4 [SD = 5.9] vs 9.4 [SD = 6.1] at baseline and posttreatment, respectively, P <.05; d =.33), NRS (mean = 4.9 [SD = 2.1] vs 4.0 [SD = 1.9], respectively, P <.05; d =.45), and on the CGI (39.1% reporting "much improved" or "very much improved"). SC participants (n = 31) also showed significant improvements on the RMDQ (mean = 11.1 [SD = 5.4] vs 9.1 [SD = 5.2], respectively, P <.05; d =.38), the NRS, (mean = 5.0 [SD = 1.9] vs 3.8 [SD = 2.1], respectively, P <.05; d =.60), and 26.7% reporting "much improved" or "very much improved" on the CGI. Between groups comparisons of CBT and SC showed no differences on the study outcomes (Ps >.10). The results suggest that telehealth, nurse-delivered CBT, and SC treatments for chronic back pain can offer significant and relatively comparable benefits. Perspective: This article describes the benefits of training primary care nurses to deliver evidence-based behavioral therapies for low back pain. Because of the high prevalence of chronic pain and the growing emphasis on nonopioid therapies, training nurses to provide behavior therapies could be a cost-effective way to improve pain management.Copyright © 2018 Database: EMBASE

339. Video-based heart rate monitoring across a range of skin pigmentations during an acute hypoxic challenge Author(s): Addison P.S.; Jacquel D.; Foo D.M.H.; Borg U.R. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 871-880 Publication Date: Oct 2018 Publication Type(s): Article Available at Journal of clinical monitoring and computing - from Publishers' website (via doi.org) Available at Journal of clinical monitoring and computing - from Unpaywall Abstract:The robust monitoring of heart rate from the video-photoplethysmogram (video-PPG) during challenging conditions requires new analysis techniques. The work reported here extends current research in this area by applying a motion tolerant algorithm to extract high quality video- PPGs from a cohort of subjects undergoing marked heart rate changes during a hypoxic challenge, and exhibiting a full range of skin pigmentation types. High uptimes in reported video-based heart rate (HRvid) were targeted, while retaining high accuracy in the results. Ten healthy volunteers were studied during a double desaturation hypoxic challenge. Video-PPGs were generated from the acquired video image stream and processed to generate heart rate. HRvid was compared to the pulse rate posted by a reference pulse oximeter device (HRp). Agreement between video-based heart rate and that provided by the pulse oximeter was as follows: Bias = - 0.21 bpm, RMSD = 2.15 bpm, least squares fit gradient = 1.00 (Pearson R = 0.99, p < 0.0001), with a 98.78% reporting uptime. The difference between the HRvid and HRp exceeded 5 and 10 bpm, for 3.59 and 0.35% of the reporting time respectively, and at no point did these differences exceed 25 bpm. Excellent agreement was found between the HRvid and HRp in a study covering the whole range of skin pigmentation types (Fitzpatrick scales I-VI), using standard room lighting and with moderate subject motion. Although promising, further work should include a larger cohort with multiple subjects per Fitzpatrick class combined with a more rigorous motion and lighting protocol.Copyright © 2017, The Author(s). Database: EMBASE

340. Catastrophizing, Solicitous Responses From Significant Others, and Function in Individuals With Neuropathic Pain, Osteoarthritis, or Spinal Pain in the General Population Author(s): Glette M.; Woodhouse A.; Borchgrevink P.C.; Landmark T.; Butler S.; Stiles T.C.; Jensen M.P. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 983-995 Publication Date: Sep 2018 Publication Type(s): Article Abstract:That certain psychological factors are negatively associated with function in patients with chronic pain is well established. However, few studies have evaluated these factors in individuals with chronic pain from the general population. The aims of this study were to: 1) evaluate the unique associations between catastrophizing and perceived solicitous responses and psychological function, physical function, and insomnia severity in individuals with neuropathic pain, osteoarthritis, or spinal pain in the general population; and 2) determine if diagnosis moderates the associations found. Five hundred fifty-one individuals from the general population underwent examinations with a physician and physiotherapist, and a total of 334 individuals were diagnosed with either neuropathic pain (n = 34), osteoarthritis (n = 78), or spinal pain (n = 222). Results showed that catastrophizing was significantly associated with reduced psychological and physical function, explaining 24% and 2% of the variance respectively, whereas catastrophizing as well as perceived solicitous responding were significantly and uniquely associated with insomnia severity, explaining 8% of the variance. Perceived solicitous responding was significantly negatively associated with insomnia severity. Moderator analyses indicated that: 1) the association between catastrophizing and psychological function was greater among individuals with spinal pain and neuropathic pain than those with osteoarthritis, and 2) the association between catastrophizing and insomnia was greater among individuals with spinal pain and osteoarthritis than those with neuropathic pain. No statistically significant interactions including perceived solicitous responses were found. The findings support earlier findings of an association between catastrophizing and function among individuals with chronic pain in the general population, and suggest that diagnosis may serve a moderating role in some of these associations. Perspective: When examining persons with pain in the general population, catastrophizing is associated with several aspects of function, and diagnosis serves as a moderator for these associations. The replication of these associations in the general population support their reliability and generalizability.Copyright © 2018 The American Pain Society Database: EMBASE

341. Evaluation of a wireless, portable, wearable multi-parameter vital signs monitor in hospitalized neurological and neurosurgical patients Author(s): Weller R.S.; Harwood T.N.; Foard K.L. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 945-951 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Unrecognized changes in patients' vital signs can result in preventable deaths in hospitalized patients. Few publications or studies instituting routine patient monitoring have described implementation and the setting of alarm parameters for vital signs. We wanted to determine if continuous multi-parameter patient monitoring can be accomplished with an alarm rate that is acceptable to hospital floor nurses and to compare the rate of patient deterioration events to those observed with routine vital sign monitoring. We conducted a prospective, observational, 5-month pilot study in a 26-bed adult, neurological/neurosurgical unit (non-ICU) in an academic medical center. A patient surveillance system employing a wireless body-worn vital signs monitor with automated nursing notification of alarms via smartphones was used to gather data. Data collected included: alarm rates, rapid response team (RRT) calls, intensive care unit (ICU) transfers, and unplanned deaths before and during the pilot study. Average alarm rate for all alarms (SpO2, HR, RR, NIBP) was 2.3 alarms/patient/day. The RRT call rate was significantly reduced (p < 0.05) from 189 to 158 per 1000 discharges. ICU transfers per 1000 discharges were insignificantly reduced from 53 to 40 compared to the previous 5-month period in the same unit. Similar measures of comparison units did not change over the same period. Although unplanned patient deaths in the study unit were also reduced during the intervention period, this was not statistically significant. Continual, multi-parameter vital signs monitoring can be customized to reduce a high alarm rates, and may reduce rapid response team calls.Copyright © 2017, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

342. A Controlled Pilot Trial of PainTracker Self-Manager, a Web-Based Platform Combined With Patient Coaching, to Support Patients' Self-Management of Chronic Pain Author(s): Sullivan M.; Langford D.J.; Tran C.; Davies P.S.; Vilardaga R.; Cheung G.; McReynolds J.; Yoo D.; Lober W.B.; Tauben D.; Vowles K.E. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 996-1005 Publication Date: Sep 2018 Publication Type(s): Article Abstract:The objective of this study was to develop and pilot test a chronic pain empowerment and self-management platform, derived from acceptance and commitment therapy, in a pain specialty setting. A controlled, sequential, nonrandomized study design was used to accommodate intervention development and to test the efficacy of the PainTracker Self-Manager (PTSM) intervention (Web-based educational modules and outcome tracking combined with tailored patient coaching sessions and provider guidance). Generalized estimating equations evaluated changes over time (baseline, 3 months, 6 months) in pain self-efficacy (primary outcome), chronic pain acceptance (activity engagement and pain willingness), perceived efficacy in patient-provider interactions, pain intensity and interference, and overall satisfaction with pain treatment (secondary outcomes) between intervention (n = 48) and usual care control groups (n = 51). The full study sample (N = 99) showed greater improvements over time (significant Group x Time interactions) in pain self-efficacy and satisfaction with pain treatment. Among study completers (n = 82), greater improvement in activity engagement as well as pain intensity and interference were also observed. These preliminary findings support the efficacy of the PTSM intervention in a pain specialty setting. Further research is needed to refine and expand the PTSM intervention and to test it in a randomized trial in primary care settings. Perspective: We developed a Web-based patient empowerment platform that combined acceptance and commitment therapy-based educational modules and tailored coaching sessions with longitudinal tracking of treatments and patient-reported outcomes, named PTSM. Pilot controlled trial results provide preliminary support for its efficacy in improving pain self-efficacy, activity engagement, pain intensity and interference, and satisfaction with pain treatment.Copyright © 2018 The American Pain Society Database: EMBASE

343. A Comparison of the Assay Sensitivity of Average and Worst Pain Intensity in Pharmacologic Trials: An ACTTION Systematic Review and Meta-Analysis Author(s): Smith S.M.; Dworkin R.H.; Jensen M.P.; He H.; Kitt R.; Koch J.; Pan A.; Burke L.B.; Farrar J.T.; McDermott M.P.; Turk D.C. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 953-960 Publication Date: Sep 2018 Publication Type(s): Review Abstract:Identifying methods to improve assay sensitivity in randomized clinical trials (RCTs) may facilitate the discovery of efficacious pain treatments. RCTs evaluating pain treatments typically use average pain intensity (API) or worst pain intensity (WPI) as the primary efficacy outcome. However, little evidence is available comparing the assay sensitivity of these 2 measures. In this systematic review and meta-analysis, we comprehensively reviewed all low back pain, osteoarthritis pain, fibromyalgia, diabetic peripheral neuropathy pain, and postherpetic neuralgia RCTs that used a parallel group design. Eligibility required: 1) primary RCT report published between 1980 and 2016, 2) comparing 1 or more active, efficacious pharmacologic pain treatment(s) with placebo, and 3) providing data on the standardized effect size (SES) for API as well as WPI for all treatment arms. Twenty-seven active versus placebo comparisons were identified in 23 eligible articles. Using a random-effects meta-analysis, API SES and WPI SES did not differ significantly (difference = -.021, 95% confidence interval = -.047 to.004, P =.12). The findings indicate that, depending on the objectives of the study, either API or WPI could be used as a primary outcome measure in clinical trials for the chronic pain conditions included in this analysis. Perspective: Understanding the comparative assay sensitivity of API and WPI may advance pain treatment research. A meta-analysis of trials of efficacious pharmacologic treatments in 5 pain conditions did not show a statistically significant difference between the assay sensitivity of API and WPI.Copyright © 2018 The American Pain Society Database: EMBASE

344. Pilot Randomized Trial of Integrated Cognitive-Behavioral Therapy and Neuromuscular Training for Juvenile Fibromyalgia: The FIT Teens Program Author(s): Kashikar-Zuck S.; Black W.R.; Pfeiffer M.; Peugh J.; Williams S.E.; Ting T.V.; Thomas S.; Kitchen K.; Myer G.D. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 1049-1062 Publication Date: Sep 2018 Publication Type(s): Article Abstract:Cognitive-behavioral therapy (CBT) improves coping and daily functioning in adolescents with juvenile fibromyalgia (JFM), but is less effective in reducing pain. This pilot trial evaluated the efficacy of a novel intervention (Fibromyalgia Integrative Training for Teens; FIT Teens) which integrates CBT with specialized neuromuscular exercise training to enhance the effect of treatment on reducing pain and disability. Forty adolescents with JFM (12-18 years) were randomized to CBT- only or FIT Teens. Treatment was conducted in group-based sessions over 8 weeks with assessments at baseline, post-treatment, and 3-month follow-up (primary end point). Primary outcomes were pain intensity and functional disability. Secondary outcomes were depressive symptoms, fear of movement, and pain catastrophizing. Thirty-six participants (mean age = 15.33 years; 90% female) completed the program. Intent to treat analysis was conducted to evaluate differences between the FIT Teens and CBT groups from baseline to 3-month follow-up, controlling for baseline group differences. Participants in the FIT Teens group showed significantly greater decreases in pain than the CBT group. FIT Teens participants also showed significant improvements in disability, but did not differ from CBT-only at the 3-month end point. Results provide preliminary evidence that the FIT Teens intervention provides added benefits beyond CBT in the treatment of JFM, particularly in pain reduction. Perspective: Results from this pilot randomized controlled trial of a new combined CBT and specialized neuromuscular exercise intervention (FIT Teens), compared with CBT alone suggested that FIT Teens offers stronger treatment benefits than CBT alone at initial treatment follow-up, especially with respect to the outcome of pain reduction.Copyright © 2018 The American Pain Society Database: EMBASE

345. Effects of ultrasound-guided stellate-ganglion block on sleep and regional cerebral oxygen saturation in patients undergoing breast cancer surgery: a randomized, controlled, double-blinded trial Author(s): Jin F.; Li X.-Q.; Tan W.-F.; Ma H.; Fang B.; Tian A.-Y.; Lu H.-W. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 855-862 Publication Date: Oct 2018 Publication Type(s): Article Available at Journal of clinical monitoring and computing - from ProQuest (Hospital Premium Collection) - NHS Version Abstract:Numerous factors could contribute to sleep disturbances in women with breast cancer. We hypothesized that stellate ganglion block (SGB) during surgery would preserve sleep after surgery and increase intraoperative regional cerebral oxygen saturation (rSO2) on the blocked side in patients undergoing breast cancer surgery. A randomized, double-blinded, controlled trial was conducted at the First Hospital of China Medical University from January 2016 to September 2016. Ninety-six patients who underwent radical breast cancer surgery requiring general anaesthesia were randomly assigned to one of two study groups: a control group that received a saline SGB and a block group that received a 0.25% ropivacaine hydrochloride SGB. The primary outcome measure was the postoperative sleep profile, which was assessed using the bispectral index on the first postoperative night. The secondary outcome measure was the intraoperative rSO2, monitored was throughout surgery using near-infrared spectroscopy. A total of 91 female patients (mean age: 45 years; range 24-51 years) were included in the study. The duration of sleep was significantly increased by 66.3 min in the ropivacaine-SGB group compared with the saline-SGB group. No differences in rSO2 were observed on either the left or right side of the patients in either group 50 min after anaesthesia induction. We conclude that ropivacaine-SGB combined with general anaesthesia might increase the first postoperative sleep duration without influencing the intraoperative rSO2 in female patients undergoing elective breast cancer surgery. Clinical trials.gov identifier NCT02651519.Copyright © 2017, Springer Science+Business Media B.V. Database: EMBASE

346. Pupillary reflex dilation in response to incremental nociceptive stimuli in patients receiving intravenous ketamine Author(s): Sabourdin N.; Giral T.; Louvet N.; Constant I.; Wolk R. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 921-928 Publication Date: Oct 2018 Publication Type(s): Article Abstract:Pupillometry is a non-invasive monitoring technique, which allows dynamic pupillary diameter measurement by an infrared camera. Pupillary diameter increases in response to nociceptive stimuli. In patients anesthetized with propofol or volatile agents, the magnitude of this pupillary dilation is related to the intensity of the stimulus. Pupillary response to nociceptive stimuli has never been studied under ketamine anesthesia. Our objective was to describe pupillary reflex dilation after calibrated tetanic stimulations in patients receiving intravenous ketamine. After written consent, 24 patients of our pediatric burn care unit were included. They received an oral morphine premedication (0.3 mg kg-1) 1 h before their scheduled daily dressing change. Just before the procedure, they received 1 mg kg-1 of intravenous ketamine. Two minutes after this bolus, tetanic stimulations of incremental intensities were performed on the arm of each patient (5-10-20- 30-40-60 mA, 60 s interval between stimulations). Pupillary diameter, heart rate and movements were recorded before and after each stimulation. Tetanic stimulations were associated with changes in pupillary diameter and heart rate. The magnitude of these changes was significantly influenced by the intensity of stimulation (ANOVA for repeated measures, p < 0.001). Movement was associated with a 32% increase in diameter (ROC curves, AUC 0.758) with 65% sensitivity and 77% specificity. In children, pupillary reflex dilation to nociceptive stimuli persists under deep sedation obtained with 1 mg kg-1 of intravenous ketamine combined with a 0.3 mg kg-1 oral morphine premedication, and its magnitude depends on the intensity of the stimulation. Our results confirm that pupillometry could be a relevant way to monitor nociception in anaesthetised subjects, including those receiving ketamine. Trial registration clinicaltrials.gov, NCT 02648412.Copyright © 2017, Springer Science+Business Media B.V. Database: EMBASE

347. Dorsal penile nerve block for circumcision in pediatric patients: A prospective, observer- blinded, randomized controlled clinical trial for the comparison of ultrasound-guided vs landmark technique Author(s): Teunkens A.; Van de Velde M.; Vermeulen K.; Van Loon P.; Rex S.; Bogaert G.; Fieuws S. Source: Paediatric Anaesthesia; Aug 2018; vol. 28 (no. 8); p. 703-709 Publication Date: Aug 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background and aims: Circumcision is a frequently performed procedure in day case pediatric surgery. Dorsal penile nerve block has proven its effectiveness for the management of acute postoperative pain after circumcision. We investigated if the ultrasound-guided placement of a dorsal penile nerve block could reduce opioid requirement as compared to a landmark-based technique. Methods: Three hundred and ten prepubertal children, aged between 52 weeks postconception and 11 years, were included in this prospective, observer-blinded, randomized controlled trial and received either a landmark- or an ultrasound-guided dorsal penile nerve block, using a caudal needle and injecting 0.1 mL/kg levobupivacaine 0.5% bilaterally. A single, experienced investigator performed all blocks. The primary endpoint was the number of patients in need of piritramide postoperatively as triggered by the Objective Pain Scale. Secondary outcome parameters included the cumulative dose of postoperatively administered opioids, the requirement to administer fentanyl intraoperatively, the need for paracetamol and ibuprofen during the first 24 postoperative hours, postoperative pain scores, the incidence of postoperative nausea and vomiting, the anesthesia induction time, and the time to discharge. Results: The proportion of patients requiring postoperative piritramide did not differ significantly between both groups (Landmark: 38% vs Ultrasound: 47%, with a difference in proportion between both conditions (95% CI): 0.09 (0.2 to 0.02); P =.135). In addition, the cumulative doses of postoperative piritramide and intraoperative fentanyl, the postoperative need for paracetamol or ibuprofen, pain scores, the incidence of postoperative nausea and vomiting, and the time to discharge were not different either. However, the anesthesia induction time was significantly longer in the ultrasound-guided dorsal penile nerve block (median time [IQR]: Landmark: 11[9; 13] min vs Ultrasound: 13[11; 15] min, P <.001). Conclusion: Compared with the landmark-guided, the ultrasound-guided dorsal penile nerve block did not reduce the need for postoperative analgesia after circumcision in children, but was associated with an increase in the procedural time.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

348. Effects of remifentanil maintenance during recovery on emergence delirium in children with sevoflurane anesthesia Author(s): Choi E.K.; Lee S.; Park S.-J.; Kim W.J. Source: Paediatric Anaesthesia; Aug 2018; vol. 28 (no. 8); p. 739-744 Publication Date: Aug 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Emergence delirium is a common complication of sevoflurane anesthesia in children. Aims: We examined the effects of maintaining remifentanil infusion during the recovery period on the incidence of emergence delirium in preschool-age children undergoing strabismus surgery under sevoflurane anesthesia. Methods: Eighty children (aged 3-7 years) were randomly assigned to either the control group (group C; intraoperative remifentanil infusion) or the intervention group (group R; intraoperative remifentanil infusion followed by remifentanil maintenance during the recovery phase). Intraoperative remifentanil infusion (0.2 mug/kg/min) was discontinued upon surgery completion in the group C, and was maintained until the discharge criteria were met at a dose of 0.05 mug/kg/min in the group R. The incidence of emergence delirium was assessed using a five-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale after arrival in the postanesthesia care unit. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale. Results: The incidence of emergence delirium according to the five-point agitation scale (scores >= 4) was lower in the group R (33.3%) compared to the group C (68.3%) (odds ratio 0.206; 95% CI 0.080 to 0.531; P = 0.002). Similar results were obtained using the Pediatric Anesthesia Emergence Delirium scale (scores > 12), with an incidence of 5.1% in the group R and 34.0% in the control group (odds ratio 0.104; 95% CI 0.022 to 0.497; P = 0.001). The Children's Hospital of Eastern Ontario Pain Scale scores and occurrence of postoperative adverse events including laryngospasm, desaturation, nausea, and vomiting were similar between the two groups. Conclusion: Maintaining a low dose of remifentanil (0.05 mug/kg/min) throughout the recovery phase attenuated the incidence of emergence delirium in children undergoing strabismus surgery under sevoflurane anesthesia.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

349. Incidence of peripheral nerve injury during shoulder arthroplasty when motor evoked potentials are monitored Author(s): Aleem A.W.; Narzikul A.C.; Williams G.R.; Abboud J.A.; Wilent W.B.; Kuntz A.F.; Chang E.S. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 897-906 Publication Date: Oct 2018 Publication Type(s): Article Abstract:To report the incidence of clinically detectable nerve injuries when utilizing transcranial electrical motor evoked potentials (MEPs) during shoulder arthroplasty. A retrospective review of patients undergoing shoulder arthroplasty with continuous IONM was performed. The criteria for nerve alerts was an 80% amplitude reduction in MEPs. The primary outcome measure was postoperative clinically detectable nerve deficit. An additional retrospective analysis on a subset of cases using an all-or-none (100% amplitude reduction) criterion applied to the deltoid was performed. Two hundred eighty four arthroplasty cases were included. There were no permanent post-operative nerve injuries and two transient nerve injuries (0.7%). MEP alerts occurred in 102 cases (36.2%). Nineteen (6.7%) cases did not have signals return above alert threshold at closure. These cases were significantly associated with post-operative nerve injury (p = 0.03). There were no false negatives, making sensitivity 100% and specificity was 93.9%. In the subset of cases in which an all-or-none criterion was retrospectively applied to just the deltoid, MEP alerts occurred in just 17.9% of cases; specificity improved to 98.0%. We conclude that utilization of the real-time diagnostic MEP data during shoulder arthroplasty aids surgeons in decision making regarding impending peripheral nerve injuries.Copyright © 2017, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

350. Comparison of the accuracy of noninvasive hemoglobin monitoring for preoperative evaluation between adult and pediatric patients: a retrospective study Author(s): Park Y.-H.; Lim S.; Kang H.; Shin H.-Y.; Baek C.W.; Woo Y.C. Source: Journal of Clinical Monitoring and Computing; Oct 2018; vol. 32 (no. 5); p. 863-869 Publication Date: Oct 2018 Publication Type(s): Article Abstract:We measured noninvasive hemoglobin (SpHb) levels during the pre-anesthesia visit in patients planning elective surgery. Differences between SpHb and laboratory-measured hemoglobin (Hblab) were compared between adult and pediatric patients. In the pre-anesthesia visiting office, we routinely monitor noninvasive Hb levels with oxygen saturation and heart rate using Masimo Radical-7 Pulse CO-Oximetry (Masimo Corp., Irvine, CA, USA). We attached the R1 20 (body weight, 10-50 kg) or R1 25 (body weight > 30 kg) probe on the index finger. After signal stabilization, SpHb and perfusion index (PI) were recorded. We retrospectively reviewed the recorded data and included patients who visited the anesthesiologist within 24 h after venous sampling. Bias was calculated by subtracting Hblab from SpHb. We compared the biases of adult and pediatric patients (< 18 years) and evaluated correlation coefficients between the bias and Hblab. Records of 105 patients were reviewed and 100 data points of 50 patients in each group were analyzed. The median +/- interquartile range bias was - 2.6 +/- 2.2 and - 1.2 +/- 1.5 g/dL in adult and pediatric patients, respectively (P < 0.001); the corresponding mean +/- standard deviation PIs were 4.4 +/- 3.1 and 5.9 +/- 2.7, respectively (P = 0.19). Bias was inversely proportional to Hblab irrespective of age. The correlation coefficient between the bias and Hblab was - 0.81 in adults and - 0.54 in pediatric patients (P < 0.001). SpHb and Hblab measured during pre-anesthesia visits showed a smaller difference in pediatric than in adult patients. Lower Hblab corresponded to higher accuracy.Copyright © 2018, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

351. Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy Author(s): Adams M.H.; Dobscha S.K.; Morasco B.J.; Smith N.X.; Yarborough B.J.; Deyo R.A. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 1074-1081 Publication Date: Sep 2018 Publication Type(s): Article Abstract:The pain experience may vary greatly among individuals reporting equally high levels of pain. We sought to examine the demographic and clinical characteristics associated with pain interference in patients with high pain intensity. Among patients with chronic musculoskeletal pain who were prescribed long-term opioid therapy and who were recruited from 2 health care systems, we identified a subset who reported high pain intensity (n = 189). All individuals completed self- report assessments of clinical and demographic factors. Analyses examined characteristics associated with pain interference. Within this group of patients with high reported pain intensity, 16.4% (n = 31) had low pain interference, 39.2% (n = 74) had moderate pain interference, and 44.4% (n = 84) had high pain interference. In bivariate analyses, patients with lower pain interference had fewer symptoms of depression and anxiety, less pain catastrophizing, a better quality of life, and greater self-efficacy for managing pain. In multivariate analyses, variables most strongly associated with low pain interference, relative to high interference, were depression severity (odds ratio 0.90; 95% confidence interval 0.82-0.99) and pain self-efficacy (odds ratio 1.07; 95% confidence interval 1.02-1.12). Study results suggest that chronic pain treatments that address symptoms of depression and enhance pain self-efficacy may be prioritized, particularly among patients who are prescribed long-term opioid therapy. Perspective: This article describes the prevalence and correlates of pain interference categories (low, medium, and high) among patients with high pain intensity who are prescribed long-term opioid therapy. Findings reveal that 16.4% of participants with high pain intensity had low impairment. Multivariate analyses indicate that variables significantly associated with low pain interference were lower depression scores and greater pain self-efficacy.Copyright © 2018 Database: EMBASE

352. "I Was a Little Surprised": Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain Author(s): Matthias M.S.; Donaldson M.T.; Jensen A.C.; Krebs E.E. Source: Journal of Pain; Sep 2018; vol. 19 (no. 9); p. 1082-1090 Publication Date: Sep 2018 Publication Type(s): Article Abstract:Chronic musculoskeletal pain is a major public health problem. Although opioid prescribing for chronic pain has increased dramatically since the 1990s, this practice has come under scrutiny because of increases in opioid-related harms and lack of evidence for long-term effectiveness. The Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial was a pragmatic 12- month randomized trial comparing the benefits and harms of opioid versus nonopioid medications for chronic musculoskeletal pain. The current qualitative study was designed to better understand trial results by exploring patients' experiences, including perceptions of medications, experiences with the intervention, and whether expectations were met. Thirty-four participants who were purposefully sampled based on treatment group and intervention response participated in semistructured interviews. The constant comparison method guided analysis. Results revealed that participants often held strong beliefs about opioid medications, which sometimes changed during the trial as they gained experience with medications; participants described a wide variety of experiences with treatment effectiveness, regardless of study group or their response to the intervention; and participants highly valued the personalized pain care model used in SPACE. Perspective: SPACE trial results indicated no advantage for opioid over nonopioid medications. Qualitative findings suggest that, for both treatment groups, preexisting expectations and anticipated improvement in pain shaped experiences with and responses to medications. The personalized pain care model was described as contributing to positive outcomes in both groups.Copyright © 2018 the American Pain Society Database: EMBASE

353. Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery Author(s): Kloesel B.; Richtsfeld M.; Konia M.; Bass J.L. Source: Seminars in Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.Copyright © The Author(s) 2018. Database: EMBASE

354. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey Author(s): Foy K.E.; Mew E.; Cook T.M.; Bower J.; Kelly F.E.; Knight P.; Dean S.; Herneman K.; Marden B. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.Copyright © 2018 The Association of Anaesthetists Database: EMBASE

355. Fiberoptic intubation of severely obese patients through supraglottic airway: A prospective, randomized trial of the Ambu AuraGainTM laryngeal mask vs the i-gelTM airway Author(s): Moser B.; Keller C.; Dave M.H.; Bruppacher H.R.; Audige L. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Airway management in severely obese patients remains a challenging issue for anaesthetists and may lead to life-threatening situations. Supraglottic airway devices, such as the i-gelTM or the AuraGainTM, were developed, with the possibility to ventilate the patient or use them as a conduit for endotracheal intubation. Methods: In our randomized prospective trial, we hypothesized a 10 seconds faster fiberoptic trans-device intubation time through the AuraGainTM laryngeal mask compared to the i-gelTM laryngeal mask in severely obese patients. We randomly assigned 44 patients to the AuraGain or i-gel group and measured trans-device intubation time after 5 minutes of successful ventilation through the device. Secondary parameters relating to the trans- device intubation success, oropharyngeal leak pressure, and parameters regarding insertion of the supraglottic airway devices were measured. Postoperative airway morbidity was determined 5 hours after surgery. Results: Mean (SD) intubation time was 55.7 (5.8) seconds for the AuraGainTM vs 54.1 (8.5) for i-gelTM mask (95% CI -2.7 to 5.9; P = 0.474), respectively, on a mean body mass index (BMI) of 39.4 kg/m2 in the AuraGainTM group vs 38.9 kg/m2 in i-gelTM group. No difference could be found in the other studied parameters. Conclusions: Time for intubation through both supraglottic airway devices was similar. Attributed to fast possibility of securing the airway with both supraglottic airway devices, we believe that both, AuraGainTM and i-gelTM, can be a good alternative in the airway management in obese patients.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

356. Is cerebrovascular autoregulation associated with outcomes after major noncardiac surgery? A prospective observational pilot study Author(s): Chuan A.; Peng A.Z.Y.; Wen S.Y.B.; Sun A.X.; Ting T.H.; Wan A.S.; Jaeger M.; Aneman A.; Pope L.; Short T.G. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Studies have identified multiple risk factors for development of cognitive decline after surgery. Impaired cerebrovascular autoregulation may be a contributor to postoperative cognitive decline. Methods: One hundred and forty patients admitted for major elective noncardiac surgery were recruited. Near-infrared spectroscopy was used to calculate the tissue oxygenation index of dynamic autoregulation (TOx). The primary endpoint was Day 3 cognitive recovery as assessed using the Postoperative Quality of Recovery Scale. The secondary endpoint was a combined major adverse event of death, acute myocardial infarction, cardiac arrest, stroke, pulmonary embolism, sepsis, and acute kidney injury at Day 30. Results: Higher optimal TOx values, signifying impaired autoregulation, were associated with worse outcomes. Patients who cognitively recovered at Day 3 (n = 47) had lower optimal TOx values (TOxopt) than patients who did not recover (n = 22): 0.06 (0.24) vs 0.18 (0.16) (mean [SD]), P = 0.02. Patients who did not suffer a major adverse event (n = 102) had lower TOxopt than patients who did (n = 17): 0.09 (0.21) vs 0.20 (0.27), P = 0.04. When dichotomized as having impaired or intact autoregulation based on TOxopt levels, a value of TOxopt>=0.1 correctly identified 72.7% of patients who did not cognitively recover, OR 3.3 (1.1-9.9) (Odds ratio, [95% CI]), P = 0.03. TOxopt>=0.1 correctly identified 82.4% of patients who suffered a major adverse event, OR 4.7 (1.3-17.2), P = 0.02. Conclusions: In older and higher risk patients having major noncardiac surgery, impaired cerebrovascular autoregulation was associated with failure of cognitive recovery in the early postoperative period and with 1-month mortality and morbidity.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

357. Infraorbital foramen location in the pediatric population: A guide for infraorbital nerve block Author(s): Zdilla M.J.; Russell M.L.; Koons A.W. Source: Paediatric Anaesthesia; Aug 2018; vol. 28 (no. 8); p. 697-702 Publication Date: Aug 2018 Publication Type(s): Article Available at Paediatric anaesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Infraorbital nerve blocks are often performed for the management of postoperative pain associated with cleft lip correction. Infraorbital nerve block procedures depend on the identification of the infraorbital foramen; however, there is little information regarding the infraorbital foramen location in the pediatric population. Aims: The aim of this study was to identify the location of the infraorbital foramen in the pediatric population relative to a midpoint between the nasospinale and jugale. Methods: The study assessed the location of 152 infraorbital foramina relative to a midpoint between the nasospinale and J on dry crania. Crania were from individuals ranging in age-at-death from 6-month fetal to 18 years. The population was subdivided into fetal/infant (>=6 months fetal age-<2 years), child (>=2-<12 years), and adolescent (>=12-<=18 years) groups for comparison. Results: The average distance of the infraorbital foramen from the nasospinale-to-jugale midpoint was 1.55 +/- 0.78 mm (Mean +/- SD) in the fetal/infant group, 0.80 +/- 0.91 mm in the child group, and 1.31 +/- 1.68 mm in the adolescent group. Furthermore, infraorbital foramina tended to be located medial to the nasospinale-to-jugale midpoint in the fetal/infant population, directly upon or superomedial to the nasospinale-to-jugale midpoint in the child population, and directly upon or superior/superolateral to the nasospinale-to-jugale midpoint in the adolescent population. Conclusions: The infraorbital foramen was located within 2 mm, on average, from the nasospinale-to-jugale midpoint regardless of age group. Therefore, the nasospinale-to-jugale midpoint may serve as useful means of identifying the location of the infraorbital foramen in the pediatric population and aid in optimizing infraorbital nerve block procedures. The information in this report is valuable in general, but may be particularly useful in developing countries where there is a lack of ultrasound training and availability for health care providers; or places where infraorbital nerve block may be the sole anesthetic modality for cleft lip surgery, even among adolescent patients.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

358. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia Author(s): Desta M.; Manaye A.; Tefera A.; Worku A.; Wale A.; Mebrat A.; Gobena N. Source: Patient Safety in Surgery; Aug 2018; vol. 12 (no. 1) Publication Date: Aug 2018 Publication Type(s): Article Available at Patient safety in surgery - from ProQuest (Hospital Premium Collection) - NHS Version Available at Patient safety in surgery - from BioMed Central Available at Patient safety in surgery - from Europe PubMed Central - Open Access Available at Patient safety in surgery - from Pubmed Central - Open Access Available at Patient safety in surgery - from PubMed Central Abstract:Background: Elective surgical case cancellation refers to any elective surgical case that is the list on the day prior to surgery but not operated upon as scheduled. Case cancellation has a major cause of psychological trauma to patients and their families. Despite little is known in Ethiopia. Therefore, this study aimed to assess incidence and reasons of cancellations of elective operation on the intended day of surgery at tertiary referral academic medical center in Ethiopia. Methods: A prospective hospital-based cross-sectional study design was conducted in a tertiary referral academic medical center in Ethiopia among 146 participants. A self-administered questionnaire with an observatory checklist was used for collecting data from the anesthetist, nurse, and surgeons. Result: In this study, 462 patients were scheduled for elective surgical operations. Among those, nearly almost one-third 146 (31.6%) of the operations were cancelled and 316 (68.4%) patients were operated on their planned date. The most common reason for cancellation were surgeon related (35.8%), patient related (28.7%), management related (21.2%) and anesthesia related factors (14. 4%). The cancellation was mainly due to improper scheduling (20.5%%), unavailability of surgeons (8.9%), unavailability of oxygen and blood (8%) and equipment (5.5%). Orthopedic (28.8%) and general surgery (17.1%) were the commonest cancelled cases. Conclusion: The cancellation rate in our academic medical center remains high. Improper scheduling, unavailability of surgeons, medical illness, and unavailability of operating room equipment were the commonest reason for the cancellation of elective operation. Most cancellations were preventable. For this, proper preoperative assessment, proper scheduling, fulfilling necessary operating room equipment's and cross-matched blood by the hospital and other stakeholders, early clear communication with operating room team like surgeons was recommended.Copyright © 2018 The Author(s). Database: EMBASE

359. Spinal Cord Stimulation Infection Rate and Risk Factors: Results from a United States Payer Database Author(s): Falowski S.M.; Provenzano D.A.; Xia Y.; Doth A.H. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objective: Surgical site infections can cause negative clinical and economic outcomes. A recent international survey on Spinal Cord Stimulation (SCS) infection control practices demonstrated low compliance with evidence-based guidelines. This study defines infection rate for SCS implants and identifies infection risk factors. Materials and Methods: A retrospective analysis of the MarketScan Databases identified patients with SCS implant (2009-2014) and continuous health plan enrollment for >=12-months (12 m) preimplant. For logistic regression analysis, patients were enrolled for 12 m postimplant. Kaplan-Meier and Cox Proportional Hazard survival analyses assessed time to infection, with infection rate reported at 12 m postimplant. Logistic regression characterized risk factors based on demographics, comorbidities, and clinical characteristics. Results: In the logistic regression (n = 6615), 12 m device-related infection rate was 3.11%. Infection risk factors included peripheral vascular disease (OR, 1.784; 95% CI: 1.011-3.149; p = 0.0457) and infection in 12 m before implant (OR, 1.518; 95% CI: 1.022-2.254; p = 0.0386). The odds of patients experiencing an infection decreased by 3.2% with each additional year of age (OR, 0.968; 95% CI: 0.952-0.984; p < 0.0001). Survival analysis (n = 13,214) identified prior infection (HR, 1.770; 95% CI: 1.342-2.336; p < 0.0001) as a risk factor. Infection was less likely in older patients (HR, 0.974; 95% CI: 0.962-0.986; p < 0.0001). Expected risk factors including obesity, diabetes, and smoking were not identified as risk factors in this analysis. There was no significant difference between infection rate for initial and replacement implants. Conclusions: The 3.11% SCS-related infection rate within 12 m of implant emphasizes the need for improved infection control practices. Research is needed to limit SCS infections in younger patients and those with infection history.Copyright © 2018 The Authors. Neuromodulation: Technology at the Neural Interface published by Wiley Periodicals, Inc. on behalf of International Neuromodulation Society Database: EMBASE

360. Ultrasound-Guided Neurolysis of Six Genicular Nerves for Intractable Pain from Knee Osteoarthritis: A Case Series Author(s): Ahmed A.; Arora D. Source: Pain Practice; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pain practice : the official journal of World Institute of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Among the elderly population, chronic osteoarthritis of the knee joint is one of the leading causes of disability and causes considerable pain, joint stiffness, and functional limitations. Although knee replacement is a good option for advanced osteoarthritis, many patients could not undergo surgery due to comorbidities or other reasons. Methods: Four patients with severe pain from grade 3 and 4 osteoarthritis of the knee had undergone ultrasound-guided alcohol neurolysis of the 6 genicular nerves after a positive genicular nerve block with local anesthetics. The demographics, pain intensity (NRS), Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and quality of life (SF-36) were analyzed. Results: There was significant improvement in pain intensity at rest, on movement, and on weight bearing after the neurolysis and it has continued for 6 months (P < 0.05). The OKS and WOMAC score had improved from 7.75 +/- 1.25 and 77.75 +/- 4.34 at baseline, to 20.75 +/- 1.70 and 56.25 +/- 3.09 at 1 month, and to 18.25 +/- 0.95 and 52.00 +/- 2.16 at 6 months after the procedure, respectively (P < 0.05). There was also significant improvement in the quality of life after the procedure (P < 0.05). Conclusion: Ultrasound-guided alcohol neurolysis is a good alternative for patients having severe pain from knee osteoarthritis and provides significant pain relief for more than 6 months.Copyright © 2018 World Institute of Pain Database: EMBASE

361. Cutaneous anaesthesia of hip surgery incisions with iliohypogastric and subcostal nerve blockade: A randomised trial Author(s): Nielsen T.D.; Jensen J.M.; Kolsen-Petersen J.A.; Bendtsen T.F.; Moriggl B.; Barckman J.; Soballe K.; Borglum J. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Cutaneous nerve blockade may improve analgesia after hip surgery. Anaesthesia after the lateral femoral cutaneous (LFC) nerve block is too distal for complete coverage of most hip surgery incisions, which requires additional anaesthesia of the adjacent, proximal area. The transversalis fascia plane (TFP) block potentially anaesthetises the iliohypogastric and subcostal nerves. The primary aim of the present study was to investigate, if the TFP block provides cutaneous anaesthesia adjacent to the LFC nerve block. Methods: Active vs placebo TFP blocks were compared in a paired randomised controlled trial (RCT) in 20 volunteers, who all had bilateral LFC nerve blocks. The day preceding the RCT, the area anaesthetised by a novel selective ultrasound guided subcostal nerve block was identified bilaterally in order to assess the contribution of the subcostal nerve to the area anaesthesia by the TFP block. Results: Anaesthesia of the lateral hip region after TFP block was 80%. The cutaneous anaesthesia after active TFP block was in continuity with the LFC nerve block in 65%. Combined TFP and LFC nerve blockade significantly increased the coverage of hip surgery incisions compared to LFC nerve block alone. The success rate of blocking the subcostal nerve was 50% with the TFP block. Conclusion: The TFP block anaesthetises the skin proximal to the LFC nerve block by anaesthetising the iliohypogastric and subcostal nerves. TFP block as a supplement to LFC nerve block improves the coverage of the proximal surgical incisions used for hip surgery.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

362. Efficacy, acceptability and safety of Internet-delivered psychological therapies for fibromyalgia syndrome: A systematic review and meta-analysis of randomized controlled trials Author(s): Bernardy K.; Klose P.; Welsch P.; Hauser W. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:This systematic review aimed at evaluating the efficacy, acceptability and safety of Internet-based psychological therapies (IPTs) in fibromyalgia syndrome (FMS). Clinicaltrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS were searched from inception to January 2018. Randomized controlled trials (RCTs) comparing IPTs with controls were analysed. Primary outcomes were >=50% pain relief, disability, negative mood, acceptability and safety at end of therapy and at 6-month follow up. Effects were summarized by a random effects model using risk differences (RD) or standardized mean differences (SMD) with 95% confidence intervals (CI). Six RCTs using different types of Internet-based cognitive-behavioural therapies [ICBTs] (acceptance-based; exposure-based; traditional) with 493 patients were included. At the end of treatment, ICBTs were superior to controls (waiting list, attention control, treatment as usual) in reducing negative mood (SMD -0.51 [95% CI -0.87 to -0.15]) (moderate quality evidence) and disability (SMD -0.56 [95% CI -1.00 to -0.13]) (moderate quality evidence). There were no statistically significant differences between ICBTs and controls in pain relief of 50% or greater (RD 0.09 [95% CI -0.02 to 0.20] (moderate quality evidence) and acceptability (moderate quality evidence). No data on safety and any outcomes at long-term follow-up compared to controls were found. The data available did not allow statistical comparisons between unguided and guided ICBTs and of ICBTs versus traditional face-to-face therapies. ICBTs provided a clinically relevant benefit over control interventions in reducing negative mood and disability at the end of treatment. Significance: Internet-delivered cognitive behavioural therapies provided a clinically relevant benefit in reducing negative mood and disability in patients with FMS at the end of treatment if compared to waiting list, treatment as usual and attention controls.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

363. Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury Author(s): Pannatier M.; Delhumeau C.; Walder B. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: The primary aim was to investigate the performance of a National Advisory Committee for Aeronautics based predictive model (NACA-BM) for mortality at 14 days and a reference model using motor GCS (GCS-RM). The secondary aim was to compare the models for impaired consciousness of survivors at 14 days (IC-14; GCS <= 13). Methods: Patients >=16 years having sustained TBI with an abbreviated injury scale score of head region (HAIS) of >3 were included. Multivariate logistic regression models were used to test models for death and IC-14. The discrimination was assessed using area under the receiver-operating curves (AUROCs); noninferiority margin was -5% between the AUROCs. Calibration was assessed using the Hosmer Lemeshow goodness-of-fit test. Results: Six hundred and seventy seven patients were included. The median age was 54 (IQR 32-71). The mortality rate was 31.6%; 99 of 438 surviving patients (22.6%) had an IC-14. Discrimination of mortality was 0.835 (95%CI 0.803-0.867) for the NACA-BM and 0.839 (0.807-0.872) for the GCS-RM; the difference of the discriminative ability was -0.4% (-2.3% to +1.7%). Calibration was appropriate for the NACA-BM (chi2 8.42; P = 0. 393) and for the GCS-RM (chi2 3.90; P = 0. 866). Discrimination of IC-14 was 0.757 (0.706-0.808) for the NACA-BM and 0.784 (0.734-0.835) for the GCS-RM; the difference of the discriminative ability was -2.5% (-7.8% to +2.6%). Calibration was appropriate for the NACA-BM (chi2 10.61; P = 0.225) and for the GCS-RM (chi2 6.26; P = 0.618). Conclusions: Prehospital prediction of mortality after TBI was good with both models, and the NACA- BM was not inferior to the GCS-RM. Prediction of IC-14 was moderate in both models.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

364. Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition Author(s): Bowyer A.J.; Heiberg J.; Sessler D.I.; Newman S.; Royse A.G.; Royse C.F. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS), as they would mathematically be scored as recovered. We aimed to validate a novel method to score cognitive recovery in patients with low-baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both the Postoperative Quality of Recovery Scale and an 11-item neuropsychological battery were performed. The Postoperative Quality of Recovery Scale agreed with neuropsychological categorisation of low vs. normal cognition 74% of the time, with all but five incorrectly coded participants deviating by only one neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether the Postoperative Quality of Recovery Scale or neuropsychological methods were used. Discriminant validation was demonstrated in a post-hoc analysis of the steroids in cardiac surgery substudy by allocating groups to normal (n = 246) or low- baseline cognition (n = 231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal mean (SD) (10.4 (10.0) vs. 8.0 (5.9) days, p = 0.02) or low-baseline cognition (12.0 (11.1) vs. 8.2 (4.7) days, p < 0.01). Overall quality, as well as cognitive, emotive and physiological recovery was independent of baseline cognition. The modified scoring method for the Postoperative Quality of Recovery Scale cognitive domain demonstrates acceptable face and discriminant validity.Copyright © 2018 The Association of Anaesthetists Database: EMBASE

365. Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study Author(s): Desgranges F.-P.; Simonin M.; Barnoud S.; Cercueil E.; Erbacher J.; Chassard D.; Bouvet L.; Allaouchiche B.; Zieleskiewicz L. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Emergent obstetrical procedures may require general anaesthesia in parturients at full cervical dilatation or immediately after vaginal birth. This study aimed to determine the prevalence and the predictive factors of higher estimated gastric content in parturients at full cervical dilatation with epidural analgesia and allowed to drink during the labour, and to assess the ability of the antral area measured in the semirecumbent position (SR-CSA) to identify higher estimated gastric content in this setting. Methods: This prospective observational study was conducted between December 2016 and July 2017. Ultrasonographic examination of the antrum was performed at full cervical dilatation, within the hour preceding the beginning of expulsive efforts. Higher estimated gastric content was defined when solid content was observed and/or if the calculated gastric fluid volume was >1.5 mL/kg. Results: Seventeen of 62 parturients (27%) presented higher estimated gastric content. Maximal pain intensity during the last hour of labour and time interval between the insertion of the epidural catheter and ultrasonographic examination were significantly increased in parturients with higher estimated gastric content. The threshold value of the SR-CSA to identify a higher estimated gastric content was 393 mm2, with sensitivity = 88% and specificity = 87%. Conclusion: Around a quarter of parturients with epidural analgesia and free access to clear fluids during labour presented higher estimated gastric content at full cervical dilatation. The SR-CSA may be of interest for the fast ultrasound assessment of the gastric content status in case of emergent obstetrical procedures at full cervical dilatation.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

366. Changes in tissue oxygen tension, venous saturation, and Fick-based assessments of cardiac output during hyperoxia Author(s): Perry D.A.; Thomson L.M.; Polizzotti B.D.; Gauvreau K.; Kheir J.N.; DiNardo J.A.; Pigula F.A.; Nedder A. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Hyperoxemia (arterial oxygen tension >100 mm Hg) may occur in critically ill patients and have effects on mixed venous saturation (SvO2) and on Fick-based estimates of cardiac output (CO). We investigated the effect of hyperoxemia on SvO2 and on assessments of CO using the Fick equation. Methods: Yorkshire swine (n = 14) were anesthetized, intubated, and paralyzed for instrumentation. SvO2 (co-oximetry) and tissue oxygen tension (tPO2, implantable electrodes) in brain and myocardium were measured during systematic manipulation of arterial oxygen tension (PaO2) using graded hyperoxia (fraction of inspired oxygen 0.21 -> 0.8). Secondarily, oxygen- and carbon dioxide-based estimates of CO (FickO2 and FickCO2, respectively) were compared with measurements from a flow probe placed on the aortic root. Results: Independent of changes in measured oxygen delivery, cerebral and myocardial tPO2 increased in proportion to PaO2, as did SvO2 (P < 0.001 for all). Based on mixed model analysis, each 100 mm Hg increase in PaO2 resulted in a 4.8 +/- 0.9% increase in SvO2 under the conditions tested. Because neither measured oxygen consumption, arterial oxyhemoglobin saturation or cardiac output varied significantly during hyperoxia, changes in SvO2 resulted in successively increasing errors in FickO2 during hyperoxia (34% during normoxia, 72% during FiO2 0.8). FickCO2 lacked the progressively worsening errors present in FickO2, but correlated poorly with CO. Conclusion: SvO2 acutely changes following changes in PaO2 even absent changes in measured DO2. This may lead to errors in FickO2 estimates of CI. Further work is necessary to understand the impact of this phenomenon in disease states.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

367. Selective Decrease in Allodynia With High-Frequency Neuromodulation via High-Electrode- Count Intrafascicular Peripheral Nerve Interface After Brachial Plexus Injury Author(s): Duncan C.C.; Kluger D.T.; Davis T.S.; Warren D.J.; Page D.M.; Hutchinson D.T.; Clark G.A. Source: Neuromodulation; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Neuromodulation: Technology at the Neural Interface - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Objectives: Kilohertz high-frequency alternating current (KHFAC) electrical nerve stimulation produces a reversible nerve block in peripheral nerves in human patients with chronic pain pathologies. Although this stimulation methodology has been verified with nonselective extrafascicular electrodes, the effectiveness of producing a selective nerve block with more-selective intrafascicular electrodes has not been well documented. The objective of this study was to examine whether intrafascicular electrodes can block painful stimuli while preserving conduction of other neural activity within the implanted nerve. Materials and Methods: We analyzed the effects of various stimulation waveforms delivered through Utah Slanted Electrode Arrays (USEAs) implanted in the median nerve of a male human subject with a left brachial plexus injury. We compared KHFAC stimulation with a sham control. Results: KHFAC stimulation through USEA electrodes produced a reduction in pain sensitivity in the palmar aspect of the left middle finger. KHFAC had limited effects on the patient's ability to feel tactile probing in the same area or move the digits of his left hand. Other tested stimulation parameters either increased or showed no reduction in pain. Conclusions: KHFAC stimulation in peripheral nerves through intrafascicular electrodes demonstrated a selective reduction in pain sensitivity while preserving other nerve functions. This treatment may benefit patient populations who have chronic pain originating from peripheral nerves, but who do not want to block whole-nerve function in order to preserve sensory and motor function reliant on the implanted nerve. Furthermore, KHFAC may benefit patients who respond negatively to other forms of peripheral nerve stimulation therapy.Copyright © 2018 International Neuromodulation Society Database: EMBASE

368. Endotracheal tube cuff pressure changes during manual cuff pressure control manoeuvres: An in-vitro assessment Author(s): Aeppli N.; Lindauer B.; Dullenkopf A.; Steurer M.P.; Weiss M. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Endotracheal tube (ETT) cuffs are designed to seal the lower airway for precise ventilation and to protect against ingress of pathogens from the pharyngeal space. Therefore, a minimal continuous cuff pressure must be maintained. Aim of this study was to analyse the course of cuff pressure in an in-vitro model during manual cuff pressure control manoeuvres. Methods: An artificial trachea was intubated with an appropriately sized ETT and cuff pressure set to 20 cm H2O. Thirty-two experienced ICU nurses each performed six cuff pressure control manoeuvres (three times in two different ETTs) using a manual cuff pressure manometer. Course of cuff pressure from connecting the manometer to disconnecting it from the cuff pilot balloon was recorded using a pressure transducer. Results: There were 190 cuff pressure control manoeuvres suitable for analysis. In all control manoeuvres a cuff pressure below 20 cm H2O was noted. In 20.0% of the control manoeuvres the cuff pressure dropped below 10 cm H2O. Cuff pressure drops were mainly caused by initially connecting the manometer to the pilot balloon, less frequently by manipulating the pressure gauge of the manometer. Disconnecting the manometer after the control manoeuvre caused a cuff pressure drop in 78.1% of cases, contributing to a final cuff pressure below 20 cm H2O in 31.3% of control manoeuvres. Conclusion: Routine manual cuff pressure control manoeuvres in ETT cuffs result in considerable cuff pressure drops. This may have an impact on silent aspiration of pharyngeal contents passing along the cuff into the lower airway.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

369. The effect of rate of injection on injection pressure profiles measured using in-line and needle-tip sensors: an in-vitro study Author(s): Saporito A.; Quadri C.; Kloth N.; Capdevila X. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Alongside ultrasonic visualisation, measurement of injection pressure is an effective tool for reducing the risk of intraneural injection during peripheral nerve block. The aim of this study was to compare injection pressure profiles when measured along the injection line with the pressure measured directly at the needle tip using different rates of injection. A syringe pump delivered a 5- ml injection of saline into silicone gel at three different speeds (5 ml.min-1, 10 ml.min-1 and 15 ml.min-1). Fibreoptic pressure sensors recorded real-time pressure profiles of the injection pressure directly at the needle tip and along the injection line. A total of 15 injections were successfully performed, five for each injection rate, totalling 30 recorded pressure profiles. More rapid rates of injection caused peak pressure measured in-line to increase, whereas pressure measured at the needle tip remained constant (mean (SD) pressure in-line 30.76 (3.45) kPa vs. 72.25 (1.55) kPa and mean (SD) pressure at needle tip 19.92 (1.22) kPa vs. 20.93 (2.66) kPa at 5 ml.min-1 and 15 ml.min-1, respectively). Injection pressure profiles showed that in-line pressure measurement failed to record precise real-time pressure changes occurring at the needle tip (mean (95%CI) pressure difference 10.8 (6.98-14.70) kPa vs. 51.2 (47.52-54.89) kPa for in-line and needle-tip measures, respectively). We conclude that, in order to accurately monitor the true injection pressure generated, independent from operator and injection parameters, measurement at the needle tip is necessary, as injection pressure measured along the injection line is an unreliable surrogate.Copyright © 2018 The Association of Anaesthetists Database: EMBASE