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Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639 .).

clinicaltrials.gov Identifier: NCT01082874.

Electroencephalographic (EEG) monitoring to indicate brain state during anesthesia has become widely available. It remains unclear whether EEG-guided anesthesia influences perioperative outcomes. The sixth Perioperative Quality Initiative (POQI-6) brought together an international team of multidisciplinary experts from anesthesiology, biomedical engineering, neurology, and surgery to review the current literature and to develop consensus recommendations on the utility of EEG monitoring during anesthesia. We retrieved a total of 1023 articles addressing the use of EEG monitoring during anesthesia and conducted meta-analyses from 15 trials to determine the effect of EEG-guided anesthesia on the rate of unintentional awareness, postoperative delirium, neurocognitive disorder, and long-term mortality after surgery. After considering current evidence, the working group recommends that EEG monitoring should be considered as part of the vital organ monitors to guide anesthetic management. In addition, we encourage anesthesiologists to be knowledgeable in basic EEG interpretation, such as raw waveform, spectrogram, and processed indices, when using these devices. Current evidence suggests that EEG-guided anesthesia reduces the rate of awareness during total intravenous anesthesia and has similar efficacy in preventing awareness as compared with end-tidal anesthetic gas monitoring. There is, however, insufficient evidence to recommend the use of EEG monitoring for preventing postoperative delirium, neurocognitive disorder, or postoperative mortality.

A lthough patient survival and freedom from disability are important outcomes after surgery, it is unclear how postoperative disability should be measured. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS) was developed to measure disability cross-culturally, in the aged, and for diseaserelated states, and has been used to assess disability after trauma, stroke, spinal cord injury, and in various chronic diseases. However, it has not been specifically evaluated in a surgical setting. The current study evaluates WHODAS in a diverse surgical cohort with varying degrees of comorbid medical disease, disability, and health. In addition, it attempts to characterize disabilityfree survival after surgery.This multicenter prospective observational cohort study of more than 500 patients took place in 5 hospitals in Australia and Hong Kong. The authors examined the psychometric qualities of WHODAS, as well as assessed its clinical acceptability, validity, reliability, and responsiveness up to 12 months after surgery. Validity of WHODAS was tested by comparison to the 40-item quality of recovery score (QoR-40 score measuring the quality of recovery), EQ-SD scale (measuring quality of life), the Katz Index of Independence in Activities of Daily Living scale (Katz ADL scale, measuring physical functioning), and the modified Brief Pain Inventory Short Form (mBPI-SF, measuring daily pain). Patients were instructed to complete each of the above health status questionnaires, then were followed up with self-assessment questionnaires and by telephone at 30 days and 3, 6, and 12 months after surgery.WHODAS demonstrated good clinical acceptability, discriminative validity, reliability, scaling properties, and responsiveness to change. It showed moderate correlation with the Katz ADL scale and the QoR-40 score at all time points. WHODAS showed good correlation with the mBPI-SF pain scores and strong correlation with mean pain interference scores, which increased over time at day 30 and at 3, 6, and 12 months. Disability-free survival was 72%, 74%, 80%, and 76% at day 30 and at 3, 6, and 12 months, respectively. These results indicate that both postoperative disability/disability-free survival is an ideal study end point and that WHODAS is a valid and reliable instrument for the measure of disability in a surgical population.

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Background: The effect of choice of anesthesia on clinical outcome for endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) remains unclear.Methods: We conducted a pilot trial of 43 patients with acute anterior circulation ischemic stroke having EVT. Patients were randomly allocated to receive general anesthesia or conscious sedation. We documented the rate of recruitment and rate of conversion from conscious sedation to general anesthesia. In addition, we recorded the change in National Institute of Health stroke scale (NIHSS) on day 7, the rate of successful reperfusion and measured neurological function by certified researchers using modified Rankin Score (mRS 0 to 2) at 90 days. Results:The recruitment rate was 31.4% and majority of patients were excluded because of delay in hospital presentation and posterior circulation stroke. The rate of conversion from conscious sedation to general anesthesia was 18.2%. This was primarily related to excessive sedation and uncontrolled movement. Change in NIHSS score, rate of successful reperfusion and functional recovery were similar between groups.Conclusions: It was feasible to randomize AIS patients receiving either general anesthesia or conscious sedation for EVT.

SummaryIn a prospective, double-blind, randomised controlled trial, we compared the efficacy of patientcontrolled analgesia using remifentanil (25-30 lg per bolus) with intramuscular pethidine (50-75 mg) for labour analgesia in 69 parturients. Parturients receiving patient-controlled analgesia reported less pain than those receiving intramuscular pethidine throughout the study period (p < 0.001), with maximal reduction in visual analogue pain score at 2 h after commencement of analgesia (mean (SD) 20 (17) in the patient-controlled analgesia group and 36 (22) in the intramuscular pethidine group. The median (95% CI) time to the first request for rescue analgesics was significantly longer with patient-controlled analgesia (8.0 (6.8-9.2) h) compared with intramuscular pethidine (4.9 (3.8-5.4) h, p < 0.001). Maternal satisfaction scores were also higher with remifentanil compared with intramuscular pethidine (p = 0.001). There was no report of sedation, aponea or oxygen desaturation in either group, and Apgar scores were similar between groups. We conclude that patient-controlled analgesia with remifentanil provides better labour analgesia and maternal satisfaction than intramuscular pethidine. At this dose, maternal and fetal side effects were uncommon.