Emergence delirium in children is not related to intraoperative burst suppression – prospective, observational electrography study

BACKGROUND: Emergence-delirium is the most frequent brain dysfunction in children recovering from general anaesthesia, though the pathophysiological background remains unclear. The presented study analysed an association between emergence delirium and intraoperative Burst Suppression activity in the electroencephalogram, a period of very deep hypnosis during general anaesthesia. METHODS: In this prospective, observational cohort study at the Charité - university hospital in Berlin / Germany children aged 0.5 to 8 years, undergoing planned surgery, were included between September 2015 and February 2017. Intraoperative bi-frontal electroencephalograms were recorded. Occurrence and duration of Burst Suppression periods were visually analysed. Emergence delirium was assessed using the Pediatric Assessment of Emergence Delirium Score. RESULTS: From 97 children being analysed within this study, 40 children developed emergence delirium, and 57 children did not. Overall 52% of the children displayed intraoperative Burst Suppression periods; however, occurrence and duration of Burst Suppression (Emergence delirium group 55% / 261 + 462 s vs. Non-emergence delirium group 49% / 318 + 531 s) did not differ significantly between both groups. CONCLUSIONS: Our data reveal no correlation between the occurrence and duration of intraoperative Burst Suppression activity and the incidence of emergence delirium. Burst Suppression occurrence is frequent; however, it does not seem to have an unfavourable impact on cerebral function at emergence from general anaesthesia in children

Anterior Column Reconstruction of Destructive Vertebral Osteomyelitis at the Thoracolumbar Spine with an Expandable Vertebral Body Replacement Implant: A Retrospective, Monocentric Radiological Cohort Analysis of 24 Cases

Background: Vertebral osteomyelitis (VO) often necessitates surgical intervention due to bone loss-induced spinal instability. Anterior column reconstruction, utilizing expandable vertebral body replacement (VBR) implants, is a recognized approach to restore stability and prevent neurological compromise. Despite various techniques, clinical evidence regarding the safety and efficacy of these implants in VO remains limited. Methods: A retrospective cohort analysis, spanning 2000 to 2020, was conducted on 24 destructive VO cases at a Level 1 orthopedic trauma center. Diagnosis relied on clinical, radiological, and microbiological criteria. Patient demographics, clinical presentation, surgical interventions, and radiological outcomes were assessed. Results: The study included 24 patients (62.5% male; mean age 65.6 ± 35.0 years), with 58% having healthcare-associated infections (HAVO). The mean radiological follow-up was 137.2 ± 161.7 weeks. Surgical intervention significantly improved the bi-segmental kyphotic endplate angle (BKA) postoperatively (mean −1.4° ± 13.6°). However, a noticeable loss of correction was observed over time. The study reported a mortality rate of 1/24. Conclusions: Anterior column reconstruction using expandable VBR effectively improved local spinal alignment in destructive VO. However, the study underscores the necessity for prolonged follow-up and continuous research to refine surgical techniques and postoperative care. Addressing long-term complications and refining surgical approaches will be pivotal as the field progresses

Practical Relevance of Institutional Guidelines in Translational Large Animal Studies of Cartilage Repair—A Multidisciplinary Survey

Background and Objective: Translational large animal models are inevitable to transfer cartilage repair methods into clinical practice. Guidelines for these trials have been published by guiding agencies (FDA, ASTM, EMEA) including recommendations for study descriptors and study outcomes. However, practical adherence to these recommendations is not achieved in all aspects. This study includes an assessment of the recommended aspects regarding practical relevance in large animal models for cartilage repair by professionals in the field. Materials and Methods: In an online based survey, 11 aspects regarding study design and 13 aspects regarding study outcome from previously published guidelines were evaluated (0–10 points, with 10 being most important) by study participants. Additionally, the survey contained questions related to professional experience (years), professional focus (preclinical, clinical, veterinarian, industry) and the preferred translational large animal model for cartilage repair. Results: The total number of survey participants was 37. Rated as most important for study design parameters was lesion size (9.54 pts., SD 0.80) followed by study duration (9.43 pts., SD 1.21); and method of scaffold fixation (9.08 pts., SD 1.30) as well as depth of the lesion (9.03 pts., SD 1.77). The most important aspects of study outcome were considered histology (9.41 pts., SD 0.86) and defect filling (8.97 pts., SD 1.21), while gene expression was judged as the least important (6.11 pts., SD 2.46) outcome. A total of 62.2% of all participants were researchers, 18.9% clinicians, 13.5% veterinarians and 5.4% industry employees. Conclusions: In translational research, recommendations published by guiding agencies receive broad theoretical consensus within the community, including both clinically and preclinically orientated scientists. However, implementation into practical research lacks in major aspects. Ongoing re-evaluation of the guidelines under involvement of all stakeholders and approaches to overcome financial and infrastructural limitations could support the acceptance of the guidance documents and contribute to standardization in the field

SäTechnik : Auslegung und Konstruktion einer 3m-Sämaschine mit dem Hintergrund der Breitsaattechnik

nicht vorhande

Intraoperative EEG Veränderungen bei Kindern und deren Zusammenhang zum Aufwachdelir

Einleitung: Ein Aufwachdelir stellt eine häufige Komplikation bei Kindern nach einer Narkose dar. Durch ein intraoperatives EEG Monitoring ist es möglich, die Narkosetiefe zu monitoren und Besonderheiten während des gesamten operativen Verlaufs zu beobachten. Bei Erwachsenen führt eine zu tiefe Narkoseführung zu einem häufigeren Auftreten von postoperativem Delir. Ob dies bei Kindern auch der Fall ist, wurde noch nicht hinreichend erforscht. Auch Parameter, die mit einem Delir bei Kindern im Zusammenhang stehen könnten, sind wenig publiziert. In früheren Arbeiten wurde das Auftreten von epileptiformen Entladungen während einer Narkoseeinleitung mit Sevofluran dokumentiert, jedoch nicht bei einer Einleitung mit Propofol. Methodik: In dieser prospektiven Kohortenstudie wurden Kinder im Alter zwischen 6 Monaten und 8 Jahren eingeschlossen, die sich einer elektiven Operation von über 60 min unterzogen. Die Narkose erfolgte entweder mit Propofol, Sevofluran oder einer Kombination beider Medikamente nach einer gewichtsadaptierten Prämedikation mit Midazolam und einer intraoperativen Schmerzmedikation mit Remifentanil. Vor Beginn der Narkoseeinleitung wurden bei den Kindern frontale EEG-Elektroden aufgeklebt und während der gesamten Narkose wurde ein EEG abgeleitet. Die EEGs wurden visuell ausgewertet, mit Fokus auf das Auftreten epileptiformer, interiktaler Potentiale und das Auftreten und die Dauer von Burst Suppression Mustern. Im Aufwachraum wurden Delir und Schmerzscores bei den Patienten erhoben. Ergebnisse: In der Propofol Gruppe zeigten sich bei 36% der Kinder epileptiforme Entladungen, in der Sevofluran Gruppe traten diese bei 67% der Kinder im EEG auf (P=0,03). Bei einer höheren Remifentanil Konzentration von über 0.15 μg/kg/min zeigten die Kinder seltener epileptiforme Entladungen (P=0,008). 43,5% (n=27) aller Kinder entwickelten ein Aufwachdelir. Das Auftreten von interiktalen Entladungsmustern wie PED war in der Delir Gruppe mit 48% signifikant häufiger als in der nicht Delir Gruppe mit 14% 4 (P=0,004). 52% der Kinder zeigten intraoperativ eine Burst Suppression Phase im EEG. Das Auftreten und die Länge dieser Muster sind nicht signifikant für ein Delir. Schlussfolgerung: Wir konnten zeigen, dass es auch bei einer TIVA (totale intravenöse Anästhesie) mit Propofol zu epileptiformen Entladungen kommt, wobei diese signifikant seltener auftreten als bei inhalativer Narkose mit Sevofluran. Das signifikant seltenere Auftreten von epileptiformen Entladungen bei einer höheren Dosierung von Remifentanil, lässt die Mutmaßung zu, dass eine Opioid Gabe während der Narkoseeinleitung das Auftreten von epileptiformen Entladungen beeinflusst. Eine tiefe Narkose, bei welcher das Auftreten eines Burst Suppression Musters zu beobachten ist, führt nicht zu einem häufigeren Auftreten eines Aufwachdelirs. Allerdings führt das Auftreten von interiktalen Entladungen signifikant häufiger zu einem Aufwachdelir.Introduction: Emergence delirium is a common complication in children after anaesthesia. Intraoperative EEG monitoring facilitates to monitor the depth of anaesthesia and to observe characteristic EEG pattern during the entire course of the operation. In adults, anaesthesia administration that is too deep leads to a more frequent occurrence of postoperative delirium. It has not yet been sufficiently analysed whether this is also the case in children. Parameters that could be related to emergence delirium in children are also poorly understood. Earlier studies documented the occurrence of epileptiform discharges during induction of anaesthesia with sevoflurane, but not during induction with propofol. Methodology: This prospective cohort study included children between the ages of 6 month and 8 years who underwent elective surgery for more than 60 minutes. Anaesthesia was performed with either propofol or sevoflurane following weight-adapted premedication with midazolam and intraoperative pain medication with remifentanyl. Before the induction of anaesthesia, frontal EEG electrodes were attached to the children’s forehead, recordings were done until the end of anaesthesia. EEG data were visual analysed, focusing in particular on epileptiform, interictal discharges as well as the occurrence and duration of burst suppression phases. Postoperatively, delirium and pain scores were recorded during stay in the recovery room. Results: In the propofol group, epileptiform discharges appeared in 36% of the children, in the sevoflurane group these EEG pattern occurred in 67% of the children (P = 0.03). Patients receiving a higher remifentanyl concentration (> 0.15 μg / kg / min) showed less epileptiform discharges during anaesthesia induction (P = 0.008). 43.5% of all children developed emergence delirium. The occurrence of interictal discharge patterns was positive correlated with the occurrence of emergence delirium (delirium group with 48% than in the non-delirium group with 14% (P = 0.004)). 52% of the children showed a burst suppression phase in the EEG intraoperatively. The 6 occurrence and length of these patterns were not related to the development of emergence delirium. Conclusion: We were able to show that anaesthesia induction with propofol leads to epileptiform discharges, which occur significantly less frequently than with inhalativ anaesthesia with sevoflurane. The significantly lower occurrence of epileptiform discharges with a higher dose of remifentanyl allows the assumption that an opioid administration has a protective effect during the induction of anaesthesia. Deep anaesthesia, in which a burst suppression pattern can be observed, does not lead to a more frequent occurrence of postoperative delirium in the recovery room. However, the occurrence of interictal discharges is positively correlated with the development of emergence delirium in young children

Molecular enhancement of fracture healing - Is there a role for Bone Morphogenetic Protein-2, parathyroid hormone, statins, or sclerostin-antibodies?

Enhancement of fracture healing has been a hot topic over the last two decades. This narrative review article is aimed to provide an update on current clinical use and evidence on four clinically available agents in the treatment of fracture healing: bone morphogenetic proteins-2 (BMP-2), parathyroid hormone, statins and sclerostin-antibodies. After first promising results from animal and clinical studies in the early 20 0 0s, BMP-2 was studied mainly in open tibia shaft fractures treated with intramedullary nailing. There are conflicting results from different randomized clinical trials (RCTs) regarding fracture healing time and complications compared to BMP-2 free control treatment in open tibia fractures, as BMP-2 could not show significant differences in patients treated with reamed nails compared to BMP-2 free control treatment with reamed nailing only. Given that fact, its official use was limited in Europe to open tibia shaft fractures treated with unreamed tibial nailing by the European Medical Agency (EMA). Another more recent RCT failed to show equivalence of BMP-2 together with allograft versus autograft for the treatment of tibia fractures with critical size defects. Recombinant human parathyroid hormone has proven anabolic effects on bone metabolism and is commonly used in treatment of severe osteoporosis. Different animal trials suggested an enhancement effect in fracture healing by PTH. In several clinical trials, PTH seems to have a stimulative effect for lower limb fractures. Statins, commonly used in treatment of dyslipidemia, could also enhance fracture healing in animal trials, especially when they were applied locally at the fracture site. For statins, there is only one RCT that failed to show significant effects for the oral administration of statins in undisplaced distal radius fractures. The role of sclerostin in fracture healing has more and more been understood. Application of sclerostin antibodies has been shown to be beneficial for fracture healing in animal trials. However, no RCTs on the effect of sclerostin antibodies on fracture healing have been performed yet. In conclusion, the "magic bullet" for molecular enhancement of fracture healing has not been identified yet, at least not with its optimal dosage and delivery method. (c) 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/

Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases

Purpose To investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures. Methods Data were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019–2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality. Results Among 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23–9.58), acute renal failure (OR = 3.20, 95% CI: 2.26–4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64–2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56–0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16–0.71) were identified as potential protective factors (both p < 0.05). Conclusion Comprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors

Can necrotic bone be objectively identified in chronic fracture related infections? — First clinical experience with an intraoperative fluorescence imaging technique

Introduction: Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope (R)) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients. Methods: Ten consecutive patients with chronic fracture related infections of the lower extremity were included into this prospectively performed case series. All patients had to be treated surgically for fracture related infections requiring bony debridement. An intraoperative illumination method (VELscope (R)) was used to intraoperatively differentiate between viable and necrotic bone. Tissue samples from the identified viable and necrotic bone areas were histopathologically examined and compared to intraoperative findings. Results: In all included patients, the intraoperative illumination was deemed helpful to differentiate between necrotic and viable bone tissues during bony debridement. The histopathological examination of the samples showed good correlation of the intraoperative illumination findings with histopathological signs of necrosis for areas deemed dead and histopathological signs of intact bone for areas deemed vital during illumination. Conclusion: The fluorescence-assisted, intraoperative detection of necrotic and viable bone using the VELscope (R) is an easy-to-use procedure that can help surgeons to optimize intraoperative bone resection in chronic fracture related infections by unmasking viable from necrotic bone tissue. This may help to improve resection techniques and eventually treatment outcome in patients in the future. (C) 2020 Elsevier Ltd. All rights reserved