Epidural steroid injections are routinely performed under fluoroscopic guidance, but could also be performed using preprocedure ultrasound spine examination. To compare ultrasound-assisted and fluoroscopy-controlled epidural steroid injections with regard to technical feasibility (accuracy, average procedure time) and outcome (pain relief and degree of disability score). A randomised study. University hospital between January 2010 and September 2012. One hundred and twelve patients with axial chronic lower back and extremity pain diagnosed with degenerative diseases of the spine, receiving three lumbar interlaminar epidural steroid injections, were randomly assigned between two groups. In the fluoroscopic group, injections were performed under fluoroscopic guidance, and in the ultrasound group, ultrasound scanning of the lumbar spine was performed before the injection to determine the puncture site, depth of the epidural space and needle trajectory. Procedure time, numbers of needle insertion attempts and needle passes, visual analogue scale for pain and Oswestry disability index at 1 and 3 months posttreatment. There was no significant difference between the two groups in mean procedure time, number of needle insertion attempts or needle passes. The mean pain intensity and degree of disability scores before the procedure, and at 1 and 3 months postprocedure, were similar in the two groups. Neither group had serious complications. We have demonstrated the feasibility of ultrasound-assisted epidural steroid injections.

Background and Objectives: Postoperative cognitive disturbances (POCD) can significantly alter postoperative recovery. Inadequate intraoperative cerebral oxygen supply is one of the inciting causes of POCD. Near-infrared spectroscopy (NIRS) devices monitor cerebral oxygen saturation continuously and can help to guide intraoperative patient management. The aim of the study was to evaluate the applicability of the NIRS-based clinical algorithm during spinal neurosurgery and to find out whether it can influence postoperative cognitive performance. Materials and Methods: Thirty four patients scheduled for spinal neurosurgery were randomized into a study group (n = 23) and a control group (n = 11). We monitored regional cerebral oxygen saturation (rScO2) throughout surgery, using a NIRS device (INVOS 4100). If rScO2 dropped bilaterally or unilaterally by more than 20% from baseline values, or under an absolute value of 50%, the NIRS-based algorithm was initiated in the study group. In the control group, rScO2 was monitored blindly. To evaluate cognitive function, Montreal-Cognitive Assessment (MoCA) scale was used in both groups before and after the surgery. Results: In the study group, rScO2 dropped below the threshold in three patients and the NIRS-based algorithm was activated. Firstly, we verified correct positioning of the head; secondly, we increased mean systemic arterial pressure in the three patients by injecting repeated intravenous bolus doses of Ephedrine, ultimately resulting in an rScO2 increase above the approved threshold level. None of the three patients showed POCD. In the control group, one patient showed a drop in rScO2 of 34% from baseline and presented with a POCD. RScO2 drop occurred with other stable intraoperative measurements. Conclusions: A significant rScO2 drop may occur during spinal surgery in prone position despite other intraoperative measurements remaining stable, allowing it to stay otherwise unrecognized. Use of the NIRS-based clinical algorithm can help to avoid POCD in patients after spinal surgery.

Conduit arteries, especially the aorta, play a major role in ensuring efficient cardiac function and optimal microvascular flow due to their viscoelastic properties. Studies in animals and on isolated arteries show that acute systemic inflammation can cause aortic stiffening which affects hemodynamic efficiency. Carotid-femoral pulse wave velocity, a measure of aortic stiffness, may be useful as a bedside investigational method in patients with early sepsis admitted to intensive care, as circulatory changes can lead to multiple organ failure and increased mortality. This study aims to investigate arterial stiffness in early sepsis and its association with clinical outcomes. This prospective observational study included adult patients with severe sepsis or septic shock admitted to our intensive care unit (n = 45). Their carotid-femoral pulse wave velocity was measured within 24 h of admission. We assessed the progression of multiple organ as well as cardiovascular failure by sequential SOFA scores. Prediction models for the progression of multiple organ and cardiovascular failure were constructed using multivariate logistic regression with pulse wave velocity and vasopressor use as predictors. A Cox proportional hazards model was used to examine the relationship between pulse wave velocity and survival time. The median pulse wave velocity for the cohort was 14.6 (8.1–24.7) m/s. There was no association between pulse wave velocity and the progression of multiple organ failure, before or after adjustment for vasopressor use. No association was found between pulse wave velocity and subsequent improvement in cardiovascular failure in the subgroup of patients who had cardiovascular instability at baseline. Cox regression and survival analyses with age, APACHE II, and baseline SOFA as confounders showed a shorter hospital survival time for patients with pulse wave velocity > 24.7 m/s (HR = 9.45, 95% CI 1.24–72.2; P = 0.03). Patients with severe sepsis and septic shock admitted to intensive care have higher arterial stiffness than in the general population. No convincing association was found between pulse wave velocity at admission and the progression of multiple organ or cardiovascular failure, although the group with pulse wave velocity > 24.7 m/s had shorter survival time.

Enhanced bleeding remains a serious problem after cardiac surgery, and fibrinolysis is often involved. We speculate that lower plasma concentrations of plasminogen activator inhibitor – 1 (PAI-1) preoperatively and tissue plasminogen activator/PAI-1 (t-PA/PAI-1) complex postoperatively might predispose for enhanced fibrinolysis and increased postoperative bleeding.

Surgery with and without hypervolaemia may cause shedding (breakdown) of the endothelial glycocalyx layer, but the severity of this problem is unclear. In this preliminary report of a larger clinical trial, the plasma and urine concentrations of three biomarkers of glycocalyx shedding (syndecan-1, hyaluronic acid and heparan sulfate) were measured in seven patients before, during, and after open hysterectomy. The fluid therapy consisted of 25 ml/kg (approximately 2 l) of Ringer’s lactate, which was infused over 30 min when the surgery started. The resulting plasma volume expansion at the end of the infusion was estimated from the haemodilution. The mean plasma concentration of syndecan-1 was 21.7 ng/ml before surgery and averaged 19.7 ng/ml during and after the surgery. The plasma concentration of hyaluronic acid decreased from 38.0 to 27.7 ng/ml (P < 0.05), while heparan sulfate increased from 3.4 to 5.5 μg/ml (P < 0.05). The urine concentrations of syndecan-1 decreased significantly, while they increased for hyaluronic acid and heparan sulfate. Despite the vigorous fluid load, the urine flow did not exceed 1 ml/min. No clear evidence was found for shedding of the endothelial glycocalyx layer when 2 l of Ringer’s lactate was infused over 30 min during abdominal hysterectomy. Urine analyses yielded patterns of changes that differed from those in plasma. ISRCTN81005631 . Registered May 17, 2016.