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BACKGROUND AND PURPOSE: The adverse effects of general anesthesia in stroke thrombectomy have been attributed to intraprocedural hypotension, yet optimal hemodynamic targets remain elusive. Identifying hemodynamic thresholds from patients without exposure to general anesthesia may help separate the effect of hypotension from the effect of anesthesia in thrombectomy outcomes. Therefore, we investigated which hemodynamic parameters and targets best correlate with outcome in patients treated under sedation with monitored anesthesia care. MATERIALS AND METHODS: We performed a retrospective analysis of a prospectively collected data base of patients with anterior circulation stroke who were successfully reperfused (modified TICI ≥ 2b) under monitored anesthesia care sedation from 2010 to 2015. Receiver operating characteristic curves were generated for the lowest mean arterial pressure before reperfusion, both as absolute values and relative changes from baseline. Cutoffs were tested in binary logistic regression models of poor outcome (90-day mRS > 2). RESULTS: Two-hundred fifty-six of 714 patients met the inclusion criteria. In a multivariable model, a ≥10% mean arterial pressure decrease from baseline had an OR for poor outcome of 4.38 (95% CI, 1.53-12.56; P < .01). Other models revealed that any mean pressure of <85 mm Hg before reperfusion had an OR for poor outcome of 2.22 (95% CI, 1.09-4.55; P = .03) and that every 10-mm Hg drop in mean arterial pressure below 100 mm Hg had an OR of 1.28 (95% CI, 1.01-1.62; P = .04). CONCLUSIONS: A ≥10% mean arterial pressure drop from baseline is a strong risk factor for poor outcome in a homogeneous population of patients with stroke undergoing thrombectomy under sedation. This threshold could guide hemodynamic management of patients during sedation and general anesthesia.

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BACKGROUND: Occurrence of explicit memory (i.e., conscious recall) has been reported especially after surgical procedures in which anesthesia is considered to be "light." In addition, previous research has shown that implicit memory (e.g., improved memory test performance in absence of conscious recall) decreases with increasing hypnotic state. The current study investigated explicit and implicit memory during emergency cesarean sections with consistently light levels of hypnotic state. METHOD: Words were presented via headphones, and the bispectral index was recorded throughout surgery. Memory for the presented words was tested after recovery with a word-stem completion test. Using both parts of the process dissociation procedure allowed separation of explicit and implicit memory. In the "inclusion" part of the process dissociation procedure, patients are asked to complete word stems, if possible, with the corresponding words recalled from the intraoperative presentation. In the "exclusion" part, patients are instructed to avoid the words presented intraoperatively and to use other words instead. In the absence of recall, patients are asked to use the first word that comes to mind. RESULTS: The mean bispectral index during word presentation was 76.3 (+/-3.0). On average, the 24 patients were able to make correct inclusion-exclusion decisions: In the inclusion part, hit rates (i.e., the probability of responding with a word presented during surgery) were higher than base rates (0.37 vs. 0.31), whereas in the exclusion part hit rates were lower (0.23 vs. 0.28). Importantly, the patients made these inclusion-exclusion decisions without being able to consciously recall the words presented during surgery. CONCLUSIONS: This study shows that if words are presented at relatively light levels of anesthesia, patients are able to control their inclusion-exclusion decisions. This weak form of explicit memory can occur in the absence of conscious recall.

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We wished to determine whether immunosuppression and/or acceleration of human immunodeficiency virus (HIV)-associated disease is related to the mode of anesthesia in the HIV infected parturient. Ninety-six known HIV-infected asymptomatic parturients who delivered between January 1990 and January 1992 at Grady Memorial Hospital were reviewed for pre-delivery health status, mode of anesthesia and peripartum/post-partum complications. Statistics used chi2 analysis. There were 36 regional anesthetics (28 epidural, 8 spinal), 11 general anesthetics, 22 local anesthesia/intravenous sedation and 27 patients who did not receive anesthesia. There were no differences in the 24-48 h and 4-6 week complication rates. None of the women studied developed neurologic sequelae for 2 years after anesthesia. Thirty-one of the 96 women had CD4/CD8 T-cell lymphocyte data at second trimester and 24-48 h post partum which showed no worsening of maternal immune status in women receiving regional anesthesia, local anesthesia/intravenous sedation or no anesthesia. We believe that both regional and general anesthesia can be performed safely on the asymptomatic HIV-infected parturient. The choice of anesthesia should be based on the usual obstetric and clinical considerations.

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PURPOSE: This case report describes a radiologically proven subdural catheter placed in a term parturient, which consistently performed as an epidural catheter for both labour analgesia as well as surgical anaesthesia. CLINICAL FEATURES: The patient was a 26-yr-old, 52.7 kg. 140 cm healthy woman with a 39 wk intrauterine pregnancy. At initiation of epidural blockade, and for many hours throughout labour, an appropriate volume and concentration of local anaesthetic achieved an appropriate analgesic sensory level (10 ml bupivacaine 0.25%, bilateral T10 sensory level). However, for Caesarean section, while an appropriate volume and concentration of local anaesthetic achieved an appropriate surgical anaesthetic sensory level (15 ml bupivacaine 0.5%, bilateral T4 sensory level), there was no demonstrable motor blockade (0 on the Bromage scale). The Caesarean section was performed without incident, and without the need for supplemental intravenous opioids or anxiolytics. CONCLUSION: We report the case to question the commonly held beliefs of subdural catheter presentation. We questioned the catheter position, and proved its subdural placement, only after larger volumes of higher concentration local anaesthetic did not achieve expected goals. It is possible that a high percentage of epidural catheters may be subdural, unbeknownst to the practitioner.

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A double-blinded randomized prospective study was performed to determine whether alkalinization of lidocaine decreases the pain of intradermal injection and if a larger intravenous catheter (16 gauge) causes more discomfort on insertion than a smaller (20 gauge) catheter when intradermal anesthesia has been used. In a random manner, 100 patients received skin wheals with commercially prepared lidocaine or lidocaine with the addition of sodium bicarbonate before the insertion of a 16- or 20-gauge intravenous catheter. Visual analogue pain scores were obtained after the skin wheal was placed and after the intravenous catheter was inserted. There was no statistically significant difference in pain scores between the two local anesthetic solutions. However, the catheter insertions pain scores were slightly, but statistically significantly larger in the 16-gauge group regardless of local anesthetic solution used. The addition of sodium bicarbonate to commercially prepared lidocaine does not decrease the pain associated with an intradermal skin wheal. There is a slight increase in patient discomfort upon insertion of a large-bore intravenous catheter, even with the prior use of local anesthetic.

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