BIS-guided anaesthesia can reduce the risk of intraoperative awareness in surgical patients at high risk for awareness in comparison to using clinical signs as a guide for anaesthetic depth. BIS-guided anaesthesia and ETAG-guided anaesthesia may be equivalent in protection against intraoperative awareness but the evidence for this is inconclusive. In addition, anaesthesia guided by BIS kept within the recommended range improves anaesthetic delivery and postoperative recovery from relatively deep anaesthesia.

There is moderate-quality evidence that optimized anaesthesia guided by processed EEG indices could reduce the risk of postoperative delirium in patients aged 60 years or over undergoing non-cardiac surgical and non-neurosurgical procedures. We found moderate-quality evidence that postoperative cognitive dysfunction at three months could be reduced in these patients. The effect on POCD at one week and over one year after surgery is uncertain. There are no data available for patients under 60 years. Further blinded randomized controlled trials are needed to elucidate strategies for the amelioration of postoperative delirium and postoperative cognitive dysfunction, and their consequences such as dementia (including Alzheimer's disease (AD)) in both non-elderly (below 60 years) and elderly (60 years or over) adult patients. The one study awaiting classification and five ongoing studies may alter the conclusions of the review once assessed.

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Background and Goal of Study:The use of hypotonic intravenous fluids has been associated with more than 50 international case reports of death or neurological injury in children. In 2003 the Royal College of Anaesthetists warned of the risk of iatrogenic hyponatraemia and water overload developing after the use of sodium chloride 0.18% with glucose 4% in children. A followup survey found less than half of consultant anaesthetists had been aware of this warning. 1 Our audit looked at whether anaesthetists' fluid prescriptions intraoperatively and postoperatively reflected these concerns in our department. Materials and Methods:The audit examined the fluid administration in paediatric operations over a 4 month period. Data collected included the age and weight of the child, the volume, rate and type of fluid prescribed intraoperatively and postoperatively, whether there was any estimate of blood or fluid loss, and whether capillary blood sugar was recorded.We also recorded the current locations of sodium chloride 0.18% with glucose 4%. Results and Discussions: Over the 4 month period, 35 patients received intraoperative fluids: none had a capillary blood sugar recorded and only 1 had an estimate of blood or fluid loss. 31 were given isotonic solutions, at volumes between 3-34 ml/kg. 4 were given hypotonic solutions (2 at 10-20 ml/kg, 2 at greater volumes).Only 17 patients were prescribed postoperative fluids: 13 were given isotonic solutions, of which only 4 were prescribed according to the Holliday and Segar formula. 2 The majority were prescribed at greater rates. 4 were given hypotonic fluids, 1 at the predicted rate, 2 at a greater rate and 1 at almost half the calculated rate. 2 Sodium chloride 0.18% with glucose 4% solution was freely available in all clinical areas. Conclusion(s):There is no restriction in the availability of sodium chloride 0.18% with glucose 4% solution. The majority of paediatric patients are given isotonic fluid intraoperatively. However, despite the concerns about hyponatraemia, post-operatively the majority are being prescribed either hypotonic or excessive rates of fluid.

Lidocaine has been used for spinal anesthesia since 1948, seemingly without causing concern. However, during the last 10 years, a number of reports have appeared implicating lidocaine as a possible cause of neurologic complications after spinal anesthesia. Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities--transient neurologic symptoms (TNS). In this study, we sought to compare the frequency of 1) TNS and 2) neurologic complications after spinal anesthesia with lidocaine with that after other local anesthetics. Published trials were identified by computerized searches of The Cochrane Library, MEDLINE, LILAC, and EMBASE and by checking the reference lists of trials and review articles. The search identified 14 trials reporting 1347 patients, 117 of whom developed TNS. None of these patients showed signs of neurologic complications. The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine), i.e., 4.35 (95% confidence interval, 1.98-9.54). There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day.

Ischemia and reperfusion (I/R) injury induced by tourniquet (TQ) application leads to the release of both oxygen free radicals and inflammatory cytokines. The skeletal muscle I/R may contribute to local skeletal muscle and remote organ damage affecting outcomes after total knee arthroplasty (TKA). The aim of the study is to summarize the current findings associated with I/R injury following TKA using a thigh TQ, which include cellular alterations and protective therapeutic interventions. The PubMed database was searched using the keywords “ischemia reperfusion injury,” “oxidative stress,” “tourniquet,” and “knee arthroplasty.” The search was limited to research articles published in the English language. Twenty-eight clinical studies were included in this qualitative review. Skeletal muscle I/R reduces protein synthesis, increases protein degradation, and upregulates genes in cell stress pathways. The I/R of the lower extremity elevates local and systemic oxidative stress as well as inflammatory reactions and impairs renal function. Propofol reduces oxidative injury in this I/R model. Ischemic preconditioning (IPC) and vitamin C may prevent oxygen free radical production. However, a high dose of N-acetylcysteine possibly induces kidney injury. In summary, TQ-related I/R during TKA leads to muscle protein metabolism alteration, endothelial dysfunction, oxidative stress, inflammatory response, and renal function disturbance. Propofol, IPC, and vitamin C show protective effects on oxidative and inflammatory markers. However, a relationship between biochemical parameters and postoperative clinical outcomes has not been validated.

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