Background The ventral horn is a major substrate in mediating the immobilizing properties of the volatile anesthetic sevoflurane in the spinal cord. In this neuronal network, action potential firing is controlled by GABA A and glycine receptors. Both types of ion channels are sensitive to volatile anesthetics, but their role in mediating anesthetic-induced inhibition of spinal locomotor networks is not fully understood. Methodology/Principal Findings To compare the effects of sevoflurane on GABAergic and glycinergic inhibitory postsynaptic currents (IPSCs) whole-cell voltage-clamp recordings from ventral horn interneurons were carried out in organotypic spinal cultures. At concentrations close to MAC (minimum alveolar concentration), decay times of both types of IPSCs were significantly prolonged. However, at 1.5 MAC equivalents, GABAergic IPSCs were decreased in amplitude and reduced in frequency. These effects counteracted the prolongation of the decay time, thereby decreasing the time-averaged GABAergic inhibition. In contrast, amplitudes and frequency of glycinergic IPSCs were not significantly altered by sevoflurane. Furthermore, selective GABA A and glycine receptor antagonists were tested for their potency to reverse sevoflurane-induced inhibition of spontaneous action potential firing in the ventral horn. These experiments confirmed a weak impact of GABA A receptors and a prominent role of glycine receptors at a high sevoflurane concentration. Conclusions At high concentrations, sevoflurane mediates neuronal inhibition in the spinal ventral horn primarily via glycine receptors, and less via GABA A receptors. Our results support the hypothesis that the impact of GABA A receptors in mediating the immobilizing properties of volatile anesthetics is less essential in comparison to glycine receptors.

The aim of the study was to evaluate peri-interventional complications and in-hospital complications in different team settings when performing transfemoral aortic valve replacement (TAVR) under local anaesthesia. We performed TAVR under local anaesthesia with a minimalist Heart Team consisting of two interventional cardiologists, an echocardiographer and two cardiac catheterisation laboratory nurses. In August 2015, new guidelines for TAVR were issued by the National Federal Joint Committee. In accordance with these guidelines, we began to perform TAVR using a complete Heart Team, consisting of two interventional cardiologists, an echocardiographer, a cardiac surgeon, an anaesthesiologist, a cardiovascular perfusionist, two cardiac catheterisation laboratory nurses, a surgical nurse and an anaesthetist nurse. In this study, we retrospectively analysed periprocedural and in-hospital outcomes. Two hundred and ninety-two (55.1%) patients were treated by the minimalist Heart Team, whereas 238 (44.9%) were treated by the complete Heart Team. There were no significant differences in periprocedural (1.4% vs. 1.3%, p=1.0) and in-hospital mortality (4.8% vs. 5.0%, p=0.9) as well as in conversion to open heart (0.3% vs. 0.8%, p=0.59) or immediate vascular surgery (0.3% vs. 2.1%, p=0.1) for minimalist versus complete Heart Team, respectively. TAVR under local anaesthesia can be safely performed by a minimalist Heart Team. We did not observe any differences in fatal periprocedural complications and mortality when compared with those of a complete Heart Team.

Background: In cases of terrorism, disasters, or mass casualty incidents, far-reaching life-and-death decisions about prioritizing patients are currently made using triage algorithms that focus solely on the patient’s current health status rather than their prognosis, thus leaving a fatal gap of patients who are under- or overtriaged. Objective: The aim of this proof-of-concept study is to demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aim to improve the prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods, and the availability of rescue resources. Methods: We designed a mathematical model that allows dynamic simulation of the time course of a patient’s vital parameters, depending on individual baseline vital signs and injury severity. The 2 variables were integrated using the well-established Revised Trauma Score (RTS) and the New Injury Severity Score (NISS). An artificial patient database of unique patients with trauma (N=82,277) was then generated and used for analysis of the time course modeling and triage classification. Comparative performance analysis of different triage algorithms was performed. In addition, we applied a sophisticated, state-of-the-art clustering method using the Gower distance to visualize patient cohorts at risk for mistriage. Results: The proposed triage algorithm realistically modeled the time course of a patient’s life, depending on injury severity and current vital parameters. Different casualties were ranked by their anticipated time course, reflecting their priority for treatment. Regarding the identification of patients at risk for mistriage, the model outperformed the Simple Triage And Rapid Treatment’s triage algorithm but also exclusive stratification by the RTS or the NISS. Multidimensional analysis separated patients with similar patterns of injuries and vital parameters into clusters with different triage classifications. In this large-scale analysis, our algorithm confirmed the previously mentioned conclusions during simulation and descriptive analysis and underlined the significance of this novel approach to triage. Conclusions: The findings of this study suggest the feasibility and relevance of our model, which is unique in terms of its ranking system, prognosis outline, and time course anticipation. The proposed triage-ranking algorithm could offer an innovative triage method with a wide range of applications in prehospital, disaster, and emergency medicine, as well as simulation and research.

Background: Perioperative hemodynamic instability is one of the most common adverse events in patients undergoing adrenalectomy for pheochromocytoma. The aim of this study was to analyze the impact of perioperative severe hemodynamic instability. Methods: We present a retrospective, single-center analysis in a major tertiary hospital of all consecutive patients undergoing elective adrenalectomy from 2005 to 2019 for pheochromocytoma. Severe perioperative hypertension and hypotension were evaluated, defined as changes in blood pressure larger than 30% of the preoperative patient-specific mean arterial pressure (MAP). Results: Unilateral adrenalectomy was performed in 67 patients. Intraoperative episodes of hemodynamic instability occurred in 97% of all patients (n = 65), severe hypertension occurred in 24 patients (36%), and severe hypotensive episodes occurred in 62 patients (93%). Patients with more than five severe hypotensive episodes (n = 29) received higher preoperative alpha-adrenergic blockades (phenoxybenzamine 51 ± 50 mg d⁻¹ vs. 29 ± 27 mg d⁻¹; p = 0.023) and had a longer mean ICU stay (39.6 ± 41.5 h vs. 20.6 ± 19.1 h, p = 0.015). Conclusion: Intraoperative hypotensive, rather than hypertensive, episodes occurred during adrenalectomy. The occurrence of more than five hypotensive episodes correlated well with a significantly longer hospital stay and ICU time.

Context: European and German consensus guidelines advocate preoperative therapy with α-adrenoreceptor antagonists in symptomatic patients with catecholamine-producing pheochromocytomas and paragangliomas (PPGLs) to avoid hypertensive crisis during adrenalectomy. This practice has been questioned recently. Objective: This work aimed to assess current preoperative management of PPGLs across disciplines. Methods: The study was conducted from November 2023 to February 2024 using the Delphi technique. Two consecutive surveys were conceived by a steering group and 46 experts were consulted using REDCap web application (response: 74%). Results: There was general agreement about diagnostic tools and indication for adrenalectomy. In contrast, 20% of the panelists routinely administered α-adrenoreceptor antagonists to all patients, 50% only in case of symptoms, and about one-third of experts abandoned preoperative α-adrenoreceptor blockade. The prevention of anticipated intraoperative hypertensive crisis and cardiovascular complications (75%) as well as medicolegal considerations (25%) were the main motivations. Despite availability of short-acting α-adrenoreceptor antagonists, most experts (63%) continued to use phenoxybenzamine. Half of the experts preferred pretreatment in an outpatient setting, 13% routinely treated in the hospital, and 37% combined outpatient and inpatient treatment. Intraoperatively, urapidil and nitroprusside natrium were mainly used for blood pressure control. Postoperatively, around 60% of the experts routinely admitted patients to an intensive care or intermediate care unit. Conclusion: Current guideline recommendations for preoperative treatment with α-adrenoreceptor antagonists in patients with PPGLs are generally adopted by treating teams but current practice is very heterogeneous even among expert centers. With the improvement of surgical techniques and intraoperative management, a more individualized approach may be considered.