Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: A retrospective analysis BACKGROUND Viscoelastic techniques have made it possible to describe specific fibrinolytic phenotypes (physiological, hyperfibrinolysis and shutdown) and to establish a relationship of these phenotypes with outcome. However, there remains a debate as to whether shutdown is a state of hypercoagulability or rather a coagulopathy with moderate fibrinolysis and fibrinogen consumption. OBJECTIVES Our objectives were to describe the relationship between fibrinolytic phenotypes and outcomes, and to report the effects of tranexamic acid (TXA) administration. DESIGN This was a retrospective analysis of prospectively acquired data from a trauma registry. SETTING An academic level 1 trauma centre in the Lyon Region, from March 2011 to December 2016. PATIENTS We included all injured patients who had a rotational thromboelastometry analysis at admission. Fibrinolytic phenotypes were determined according to the maximum lysis: shutdown less than 3%, physiological 3 to 15%, hyperfibrinolysis more than 15%. MAIN OUTCOME MEASURE Mortality at 24 h and at hospital discharge. RESULTS During the study period, 473 patients were included with the following phenotypes: physiological (344 patients, 73%), shutdown (107 patients, 23%) and hyperfibrinolysis (22 patients, 5%). There was an increase in injury severity, prothrombin time ratio, fibrin degradation products and transfusion requirements from the physiological to the shutdown and hyperfibrinolysis phenotypes. Prehospital TXA administration increased the rate of shutdown and decreased the maximum lysis value at admission. After adjustment, multivariate analysis showed that fibrinolytic phenotypes, but not TXA, were independently associated with an increased risk of early death and death before hospital discharge: shutdown [odds ratio (95% confidence interval)] 2.4 (1.2 to 4.8) and hyperfibrinolysis 67.9 (7.4 to 624.2). CONCLUSION The results of the current study suggest that shutdown, which is associated with injury severity and mortality, probably reflects a moderate form of coagulopathy and fibrinolysis rather than a hypercoagulopathy. Therefore, the observation of shutdown fibrinolysis on thromboelastography/rotational thromboelastometry should not lead to withholding but rather to the administration of TXA. Correspondence to Jean-Stephane David, Département d’Anesthésie Réanimation, Centre Hospitalier Lyon Sud, F-69495 Lyon, France E-mail: js-david@univ-lyon1.fr © 2019 European Society of Anaesthesiology

A novel method for ultrasound-guided radial artery cannulation in neonates by trainee anaesthesiologists: A randomised controlled trial BACKGROUND The modified dynamic needle tip positioning (MDNTP) technique for ultrasound-guided radial artery cannulation (MDNTP-US technique) in neonates can be technically challenging for trainee anaesthesiologists. We hypothesised that by associating the MDNTP-US technique with hypodermic 0.9% sodium chloride (Saline MDNTP-US technique), which increases the subcutaneous radial artery depth, the procedure would become easier for trainee anaesthesiologists. OBJECTIVE To compare the Saline MDNTP-US technique, with the MDNTP-US technique for radial artery catheterisation in neonates by trainee anaesthesiologists with limited experience. DESIGN Randomised controlled trial. PATIENTS Ninety-six neonates scheduled to undergo major abdominal surgery requiring continuous arterial pressure monitoring between May 2018 and December 2018 at the Children's Hospital of Chongqing Medical University were enrolled. Neonates with signs of skin erosions or haematomas at or near the insertion site, as well as those with low noninvasive blood pressure values, were excluded. INTERVENTION Neonates were randomised to the Saline MDNTP-US and MDNTP-US groups in a 1 : 1 ratio. Twelve trainees performed the cannulation procedures. MAIN OUTCOME MEASURES Duration of procedure, first attempt success rate, rate of success within 10 min, and the incidence of haematoma and thrombosis. RESULTS The median [IQR] time to perform cannulation was less for the Saline MDNTP-US technique than for the MDNTP-US technique: 203 [160 to 600] vs. 600 s [220 to 600]; P = 0.005. The rate of success within 10 min, 72.9 vs. 47.9%; P = 0.012, was higher in the Saline MDNTP-US group than in the MDNTP-US group. The incidence of haematoma on postoperative day 1 was lower in the Saline MDNTP-US group than in the MDNTP-US group: 8.3 vs. 22.9%; P = 0.049. CONCLUSION Trainee anaesthesiologists can achieve higher success rates by using the Saline MDNTP-US technique instead of the MDNTP-US technique for radial artery catheterisation in neonates, taking less time with a lower incidence of complications. TRIAL REGISTRATION ChiCTR-IOR-17014119 (Chinese Clinical Trial Registry). Correspondence to Dr Lifei Liu, Department of Anesthesiology, Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yu Zhong District, Chongqing 400014, PR China Tel: +86 18996218065; fax: +86 2363632143; e-mail: lifeiliu@hospital.cqmu.edu.cn © 2019 European Society of Anaesthesiology

Neuroanesthesia: A Problem-Based Learning Approach No abstract available

Association between intra-operative fentanyl dosing and postoperative nausea/vomiting and pain: A prospective cohort study BACKGROUND Postoperative nausea and/or vomiting (PONV) is one of the anaesthesia-related effects most dreaded by patients and may delay hospital discharge. Although scores and risk factors are established, many were developed before contemporary anaesthesia regimens and without focussing on modifiable anaesthesia-related variables. OBJECTIVE To examine whether, in association with a contemporary anaesthesia regimen, there is an association between intra-operative fentanyl dose and PONV, and, second, postoperative pain within the first 24 h. DESIGN Prospective, observational cohort. As informed consent was waived, neither patients nor treating physicians were aware of the study. SETTING Single-centre university hospital. PATIENTS Inclusion criteria were opioid-naive patients without chronic pain and with a simplified Apfel score at least 2 undergoing abdominal, gynaecological or otorhinolaryngological inpatient surgery. INTERVENTION None. MAIN OUTCOME MEASURE With logistic regression, we examined three models of increasing complexity exploring the relationship between PONV and fentanyl dosing: Model 1, simplified Apfel score + intra-operative fentanyl; Model 2, Model 1 + pre-emptive antiemetic prophylaxis; Model 3, Model 2 + postoperative morphine. Model 1 was the primary analysis. Second, we explored whether or not postoperative pain scores were associated with intra-operative fentanyl dosing. RESULTS From the 363 patients, 163 (45%) experienced PONV, despite the use of total intravenous anaesthesia with propofol in more than 80% of the cohort, and some 66% of patients receiving additional antiemetic agents. After adjusting for the simplified Apfel score, higher intra-operative fentanyl dose was associated with PONV: odds ratio per μg h−1, 1.006 [95% confidence interval (CI) 1.002 to 1.010]. Including intra-operative fentanyl in the simplified Apfel score also increased the area under the receiver operator characteristics curve [0.601 (95% CI 0.555 to 0.662) vs. 0.651 (95% CI 0.594 to 0.707); P = 0.016]. Finally, a higher intra-operative fentanyl dose was associated with higher 24 h pain scores (P = 0.001) and a trend towards higher 24 h morphine requirements (P = 0.055). CONCLUSION Even when using propofol and antiemetic agents, PONV within the first 24 h remained higher than expected. Intra-operative fentanyl, a modifiable risk factor, is associated with the incidence of PONV and postoperative pain. TRIAL REGISTRATION ClinicalTrials.gov, NCT03201315. Correspondence to Eckhard Mauermann, Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland E-mail: Eckhard.Mauermann@usb.ch Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation: A randomised controlled study BACKGROUND Orthotopic liver transplantation is associated with a risk of bleeding. Coagulation in cirrhotic patients is difficult to assess with standard coagulation tests because of rebalanced coagulation. This can be better assessed by thromboelastometry which can detect coagulation impairments more specifically in such patients. OBJECTIVES Our first objective was to compare the number of units of blood products transfused during liver transplantation when using an algorithm based on standard coagulation tests or a thromboelastometry-guided transfusion algorithm. DESIGN Prospective randomised controlled trial. SETTING Single-centre tertiary care hospital in France, from December 2014 to August 2016. PARTICIPANTS A total of 81 adult patients undergoing orthotopic liver transplantation were studied. Patients were excluded if they had congenital coagulopathies. INTERVENTION Transfusion management during liver transplantation was guided either by a standard coagulation test algorithm or by a thromboelastometry-guided algorithm. Transfusion, treatments and postoperative outcomes were compared between groups. MAIN OUTCOME MEASURES Total number of transfused blood product units during the operative period (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets). RESULTS Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U, P = 0.005). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3%, P = 0.002 and 27.5 vs. 58.5%, P = 0.005), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%, P < 0.001). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, P = 0.448), RBCs (3 [2 to 5] vs. 4 [2 to 6] U, P = 0.330) and platelets (1 [1 to 2] vs. 1 [1 to 2] U, P = 0.910) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups. CONCLUSION A transfusion algorithm based on thromboelastometry assessment of coagulation reduced the total number of blood product units transfused during liver transplantation, particularly FFP administration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02352181. Correspondence to Dr Aurélie Bonnet, Département d’Anesthésie et Réanimation, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France Tel: +33 4 26 10 93 35; e-mail: aurelie.bonnet@chu-lyon.fr © 2019 European Society of Anaesthesiology

Preparation of anaesthesia workstation for trigger-free anaesthesia: Activated charcoal filters and prolonged low-flow ventilation BACKGROUND Trigger-free anaesthesia is required for patients who are susceptible to malignant hyperthermia. Therefore, all trace of volatile anaesthetics should be removed from anaesthetic machines before induction of anaesthesia. Because the washout procedure is time consuming, activated charcoal filters (ACFs) have been introduced, but never tested under minimal flow conditions. OBJECTIVE(S) The current study aims to investigate performance of ACFs during long duration (24 h) simulated ventilation. DESIGN A bench study. SETTING A Primus anaesthesia machine (Dräger) was contaminated with either 4% sevoflurane or 8% desflurane by ventilating a test lung for 90 min. The machine was briefly flushed according to manufacturer instructions, ACFs were inserted and a test lung was ventilated in a 24 h test. Trace gas concentrations were measured using a closed gas loop high-resolution ion mobility spectrometer with gas chromatographic preseparation. During the experiment reduced fresh gas flows (FGFs) were tested. At the end of each experiment the ACFs were removed and the machine was set to standby for 10 min to test for residual contamination within the circuit. and then the ACFs were reconnected into the circuit to test their ability to continue removing volatile anaesthetics (functional test) from the gas. Control experiments were conducted without ACFs. MAIN OUTCOME MEASURES Absolute concentrations of desflurane and sevoflurane. RESULTS The concentration of volatile anaesthetics dropped to less than 5 ppm (parts per million) following insertion of ACFs. In the desflurane experiments at least 1 l min−1 FGF was needed to keep the concentration below an acceptable level (<5 ppm): 0.5 l min−1 FGF was required in sevoflurane experiments. While ACFs in the sevoflurane tests passed the functional test after 24 h, ACFs in the desflurane tests failed. CONCLUSION ACFs meet the requirements for trigger-free low flow (1 l min−1) ventilation over 24 h. Minimal flow (0.5 l min−1) ventilation may be possible for sevoflurane contaminated machines. Correspondence to Dr Sebastian Heiderich, Clinic of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany E-mail: heiderich.sebastian@mh-hannover.de © 2019 European Society of Anaesthesiology

Preventing hypothermia in outpatient plastic surgery by self-warming or forced-air-warming blanket: A randomised controlled trial BACKGROUND In our outpatient post anaesthesia unit patients reported that they were feeling cold with or without shivering. Anaesthetic agents cause reduced thermoregulation, initially by redistribution of blood flow from core to periphery, later by negative balance between thermogenesis and heat loss. Even mild peri-operative hypothermia increases the risk of surgical wound infections, bleeding, impaired cardiac function, shivering, and decreases comfort. OBJECTIVE(S) We aimed to evaluate which of our current active warming measures, self-warming blanket or forced-air-warming blanket, were most effective in preventing inadvertent intraoperative heat loss. Secondarily, we assessed whether they prevented inadvertent peri-operative hypothermia when defined as core body temperature below 36 °C. DESIGN Randomised controlled trial, parallel group design. SETTING Aleris Solsiden hospital for outpatient surgery, Trondheim, Norway, from March to June 2016. PATIENTS A total of 112 consecutive patients planned for outpatient plastic surgery. Reasons for noninclusion: failing to meet the criteria for outpatient surgery according to the standard of the national society of anaesthesiology. INTERVENTION(S) Patients were randomised to active warming by a self-warming blanket or a forced-air-warming blanket. All patients received routine measures to prevent hypothermia with a high temperature in the operation theatres, prewarmed fluids, cotton blankets and surgical draping outside the surgical field. MAIN OUTCOMES Temperature, measured pre-operatively, every 10 min during general anaesthesia and postoperatively with a zero-heat-flux temperature sensor. RESULTS Core temperature was significantly lower in the self-warming blanket compared with the forced-air-warming blanket group during anaesthesia, P less than 0.0001. Hypothermia (<36 °C) was recorded in 47%, n = 22, patients in the self-warming blanket group and 25%, n = 16, in the forced-air-warming blanket group during the registration period, P = 0.02. CONCLUSION An underbody forced-air-warming blanket reduced heat loss to a greater extent than a self-warming blanket. But none of the interventions were sufficient to prevent inadvertent peri-operative hypothermia. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03163563. Correspondence to Stig S. Tyvold, Aleris Solsiden, Innherredsveien 74, N-7014 Trondheim, Norway Tel: +47 73 87 20 00; e-mail: stig.tyvold@aleris.no © 2019 European Society of Anaesthesiology

Core topics in anaesthesia and peri-operative care of the morbidly obese surgical patient No abstract available

Effects of depth of neuromuscular block on postoperative pain during laparoscopic gastrectomy: A randomised controlled trial BACKGROUND Evidence on whether the use of deep neuromuscular block (NMB) influences postoperative pain after laparoscopic surgery is limited, and existing studies have shown conflicting results. We studied the effect of the depth of NMB during laparoscopic gastrectomy on postoperative pain. OBJECTIVE The aim of this study was to evaluate the effect of depth of NMB during laparoscopic gastrectomy on postoperative pain by allocating patients randomly to either deep or moderate NMB with a standard-pressure pneumoperitoneum. DESIGN A randomised, controlled, double-blind study. SETTING A university-affiliated hospital. PARTICIPANTS One hundred patients. INTERVENTIONS Patients were allocated randomly to receive either deep (posttetanic count 1 to 2) or moderate (train-of-four count 1 to 2) levels of NMB. Following surgery, the patients were asked to rate their pain every 10 min using a visual analogue scale (VAS) (0 = no pain, 10 = most severe pain) in the postanaesthesia care unit (PACU). Patients received intravenous oxycodone, 2 mg every 10 min, until the pain intensity (VAS) had decreased to less than 3 at rest and less than 5 on wound compression, at which point the minimum effective analgesia dose (MEAD) of oxycodone was determined. MAIN OUTCOME MEASURES The primary endpoint was the MEAD of oxycodone. Secondary endpoints included area under the curve of VAS for wound pain, VAS scores for wound and shoulder pain at 6 and 24 h after the end of surgery, rescue analgesics, a five-point surgical rating scale, Rhodes index of nausea vomiting retching at 6 and 24 h after the end of surgery and duration of pneumoperitoneum. RESULTS The median value for the MEAD of oxycodone was 8 mg in both groups. Area under the curves of VAS over time were similar in both groups. Variables associated with postoperative pain including mean VAS at PACU and frequency of rescue analgesics in the ward did not differ significantly between the two groups. The duration of pneumoperitoneum was a significant variable in determining the MEAD of oxycodone (linear regression, R2 = 0.07, P = 0.008). The number of patients who reached the acceptable surgical score was not significantly different between the two groups. However, the moderate NMB group did have a significantly higher proportion of cases that required additional muscle relaxants (P < 0.001). CONCLUSION Deep, compared with moderate, NMB did not significantly reduce the MEAD of oxycodone administered in the PACU. The duration of pneumoperitoneum was positively correlated with the MEAD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03266419. Correspondence to Byung-Moon Choi, MD, PhD, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea Tel: +82 2 3010 1704; fax: +82 2 3010 6790; e-mail: byungmoonchoi7@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Incidence and risk factors of postoperative delirium in patients admitted to the ICU after elective intracranial surgery: A prospective cohort study BACKGROUND Postoperative delirium (POD) has been confirmed as an important complication after major surgery. However, neurosurgical patients have usually been excluded in previous studies. To date, data on POD and risk factors in patients after intracranial surgery are scarce. OBJECTIVES To determine the incidence and risk factors of POD in patients after intracranial surgery. DESIGN Prospective cohort study. SETTING A neurosurgical ICU of a university-affiliated hospital, Beijing, China. INTERVENTIONS Adult patients admitted to the ICU after elective intracranial surgery under general anaesthesia were consecutively enrolled between 1 March 2017 and 2 February 2018. Delirium was assessed using the Confusion Assessment Method for the ICU. POD was diagnosed as Confusion Assessment Method for the ICU positive on either postoperative day 1 or day 3. Patients were classified into groups with or without POD. Data were collected for univariate and multivariate analyses to determine the risk factors for POD. RESULTS A total of 800 patients were included. POD was diagnosed in 157 patients (19.6%, 95% confidence interval 16.9 to 22.4%). Independent risk factors for POD included age, nature of intracranial lesion, frontal approach craniotomy, duration of surgery, presence of an episode of low pulse oxygenation at ICU admission, presence of inadequate emergence and emergence delirium, postoperative pain and presence of immobilising events. POD was associated with adverse outcomes and high costs. CONCLUSION POD is prevalent in patients after elective intracranial surgery. The identified risk factors for and the potential association of POD with adverse outcomes suggest that a comprehensive strategy involving screening for predisposing factors and early prevention of modifiable factors should be established in this population. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (NCT03087838). Correspondence to Jian-Xin Zhou, Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing 100050, China Tel: +86 10 67098019; fax: +86 10 67098019; e-mail: zhoujx.cn@icloud.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology