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Background High-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient’s trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway. Methods Twenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray. Results Two cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75). Conclusion Our pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.

Multimodal, non-opioid based analgesia has become the cornerstone of ERAS protocols for effective analgesia after spinal surgery. Opioid side effects, dependence and legislation restricting long term opioid use has led to a resurgence in interest in opioid sparing techniques. The increasing array of multimodal opioid sparing analgesics available for spinal surgery targeting novel receptors, transmitters, and altering epigenetics can help provide an optimal perioperative experience with less opioid side effects and long-term dependence. Epigenetic mechanisms of pain may enhance or suppress gene expression, without altering the genome itself. Such mechanisms are complex, dynamic and responsive to environment. Alterations that occur can affect the pathophysiology of pain management at a DNA level, modifying perceived pain relief. In this review, we provide a brief overview of epigenetics of pain, systemic local anesthetics and neuraxial techniques that continue to remain useful for spinal surgery, neuropathic agents, as well as other common and less common target receptors for a truly multimodal approach to perioperative pain management.

Introduction: Chest compression and ventilation during CPR may increase risk of regurgitation and aspiration. Pulmonary aspiration is a clinically relevant endpoint as it is associated with significant mortality. There is limited data comparing the impact of continuous and interrupted chest compression during CPR on risk of regurgitation and aspiration. Thus, we aim to obtain a preliminary estimate of incidences of regurgitation and aspiration of continuous versus interrupted chest compression using a cadaver model. Hypothesis: Interrupted chest compression, compared with continuous chest compression during CPR, is associated with a lower risk of regurgitation and aspiration. Methods: In a cross-over design, 10 cadavers (BMI<45 kg/m 2 ) with no airway pathologies were studied. Cadavers were suctioned for pre-existing stomach contents, applied the Lucas CPR board (Physio Control, Redmond, WA) and a King LTS-D supraglottic device was placed. Stomach content was simulated by methylene-blue and barium sulfate for the first and second interventions, respectively. Cadavers were randomized to receive CPR starting with either 1) Continuous compressions (rate of 100/min), while ventilating at rate of 10/min or 2) Interrupted compressions, while ventilating at a rate of 30:2. Each CPR session lasted 14 minutes. Stomach was properly suctioned prior to the next intervention to avoid cross-over contamination. Regurgitation and/or aspiration was assessed by bronchoscopy (methylene blue) and radiography (barium sulfate). Results: The incidence of regurgitation was 100% for continuous chest compression, while that of interrupted chest compression was 70%. The incidence of aspiration of continuous chest compression was 50% while that of interrupted chest compression was 30%. Conclusions: In conclusion, interrupted chest compression was associated with 20% less incidence of aspiration compared to continuous compression during CPR in our cadaver model. Our study is limited by its small size and use of cadavers, but nonetheless estimated incidences of pulmonary aspiration by CPR method to provide insight for future studies.

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