Two new supraglottic airway devices, the LMA Supreme™ (LMA) and the i-gel™, offer potential benefits when inserted by inexperienced operators. This study compared the insertion success rate and ventilation profile between the LMA Supreme and the i-gel when inserted by operators without previous airway management expertise. Following a short lecture and manikin training, airway novices were randomly allocated to insert either the LMA Supreme or the i-gel into 80 patients undergoing breast surgery. The primary outcome was first-time success rate, and secondary outcomes were overall success rate, insertion time, airway leak pressure, tidal volume during pressure controlled ventilation at 17 cmH₂O, and adverse events. First-time insertion success rate was significantly higher for the LMA Supreme than the i-gel (30/39 (77%) vs 22/41 (54%); p = 0.029). Significantly more placement failures occurred with the i-gel (6 vs 0, p = 0.025). Mean (SD) leak pressure (29 (8) vs 23 (11) cmH₂O, p = 0.007) and expired tidal volume (PCV 17 cmH₂O) (785 (198) vs 654 (91), p = 0.001) were significantly greater with the LMA Supreme than with the i-gel, respectively. More patients complained of pharyngolaryngeal pain with the LMA Supreme than with the i-gel (17/39 (44%) vs 8/41 (20%); p = 0.053). We found better first time success rate, fewer failures, and a better seal with the LMA Supreme compared with the i-gel, indicating that the LMA Supreme may be preferable for emergency airway use by novices.

The SHAM (Serious Harm and Morbidity) scale was developed to categorise the severity of potential complications of placebo control interventions in the context of local anaesthesia research. A convenience sample of 43 anaesthetists used the SHAM scale to grade ten published randomised controlled trials investigating local anaesthesia nerve blocks. The Fleiss κ statistic assessed agreement between these anaesthetists and probability of random agreement (Pr(e)) when using the SHAM scale; a κ > 0 shows concordance between assessors above random agreement. Overall κ was 0.50 (95% CI 0.49–0.51, p < 0.001), Pr(e) = 0.21. There was moderate agreement between assessors in determining whether studies were low-risk (SHAM score 0–2) or high-risk (SHAM score 3–4) (κ 0.60 (95% CI 0.58–0.62), Pr(e) = 0.51). Compared with anaesthetists given clinical examples of interventions when applying the SHAM score, anaesthetists who were not given examples showed significantly less inter-individual agreement (κ 0.76 (95% CI 0.72–0.81), Pr(e) = 0.5 vs 0.45 (95% CI 0.41–0.49), Pr(e) = 0.52, p < 0.0001). These results suggest that the SHAM score can be successfully used to grade the severity of potential complications of placebo-controlled interventions in local anaesthesia research and represent a first step towards the score’s validation.

Aspirin has been found to improve outcomes in an animal model of transfusion-related acute lung injury. We examined the association of aspirin use before admission to the intensive care unit and the development of transfusion-related acute lung injury in critically ill patients. We performed a post-hoc analysis of a nested case-control study that had been undertaken in a tertiary referral hospital. Transfusion-related acute lung injury cases were matched with controls (transfused patients not developing lung injury). Of these 218 patients, 66 used aspirin (30%). Use of aspirin did not alter the risk of transfusion-related acute lung injury after transfusion of platelets (OR 1.06, CI 0.59–1.91, p = 0.85), plasma (OR 1.06, 95% CI 0.59–1.92, p = 0.84), or red blood cells (OR 1.09, 95% CI 0.61–1.94, p = 0.77). Adjustment for confounding variables using propensity scoring also did not affect the risk of acquiring transfusion-related acute lung injury (p = 0.66). In conclusion, aspirin did not protect against transfusion-related lung injury in this cohort of critically ill patients.

The surgical pleth index has been shown to correlate with surrogate variables of nociception during general anaesthesia, and it has been suggested to be of use as a depth of anaesthesia monitor. However, little is known about confounding factors. As the main determining variables are based on both central and peripheral autonomic regulatory mechanisms, we hypothesised that changing a patient`s posture may produce a marked effect. We studied the effects of posture change in 45 patients who were randomly assigned to receive general (n = 15) or spinal anaesthesia with (n = 15) or without sedation (n = 15), as well as 15 awake volunteers. Mean (SD) values of the surgical pleth index after adoption of the lithotomy position were reduced from 57 (22) to 21 (6) under general anaesthesia, 63 (15) to 31 (9) under spinal anaesthesia alone, and 52 (14) to 22 (8) under spinal anaesthesia with sedation (all p < 0.01). In healthy volunteers, the surgical pleth index increased from 37 (13) to 57 (11) (p < 0.01) after 30° head-up tilt and was reduced from 35 (11) to 25 (11) after head-down tilt (p < 0.05). Change in posture has a marked effect on the surgical pleth index which lasts for at least 45 min, and this must be considered when interpreting the displayed values.

Intubation with a double-lumen tube is important for achieving one-lung ventilation and facilitating thoracic surgery. The GlideScope^® videolaryngoscope (Verathon Inc., Bothell, WA, USA) is designed to assist tracheal intubation for patients with a difficult airway. We wished to compare the GlideScope and direct laryngoscopy for double-lumen tube intubation. Sixty adult patients requiring a double-lumen tube for thoracic surgery and predicted uncomplicated laryngoscopy were randomly assigned to a direct Macintosh laryngoscopy group (n = 30) or a GlideScope group (n = 30). The mean (SD) duration of intubation was longer in the Macintosh group (62.5 (29.7) s) than in the GlideScope group (45.6 (10.7) s; p = 0.007). There was no difference in the success of the first attempt at intubation (26/30 (87%) and 30/30 (100%) for Macintosh and GlideScope groups, respectively; p = 0.112). The incidence of sore throat and hoarseness was higher in the Macintosh group (18 (60%) and 14 (47%), respectively) than in the GlideScope group (6 (20%) and 4 (13%), respectively; p = 0.003 and 0.004). We conclude that double-lumen tube intubation in patients with predicted normal laryngoscopy is easier using the GlideScope videolaryngoscope than the Macintosh laryngoscope.

The tube of the laryngeal mask airway is frequently protected by foil during ablative laser procedures. The pilot balloon, however, is often left exposed. The effect of firing seven different cutaneous lasers at the pilot balloon of a disposable laryngeal mask airway was examined to assess its susceptibility to accidental laser strikes. The time taken for each laser to penetrate the pilot balloon was calculated from an average of five laser strikes. The carbon dioxide and erbium YAG lasers punctured the pilot balloon in a mean (SD) of 0.07 (0.02) s and 0.7 (0.1) s, respectively, with the neodymium YAG laser the next quickest to puncture at 3.3 (1.0) s. All other lasers punctured the pilot balloon in less than 15 s. These data suggest that protection of the pilot balloon of the LMA is necessary when using carbon dioxide and erbium YAG lasers.

The i-gel^TM and LMA Supreme^TM are extraglottic airway devices with non-inflatable and inflatable cuffs, respectively. We hypothesised that directly measured mucosal pressures would differ between these devices in anesthetised paralysed patients. Thirty patients were randomly allocated to receive one of these two devices. Four pressure sensors were attached to all airway devices used to measure mucosal pressure at the base of the tongue, the distal oropharynx, the hypopharynx and the pyriform fossa. At these four places, median (IQR [range]) i-gel mucosal pressures were 8.0 (2.7–10.7 [0–26.7]), 5.0 (2.7–7 [1.0–37.3]), 9.3 (2.7–13.3 [0–22.7] and 8.0 (2.7–10.7 [0–25.3]) cmH₂O, respectively, and for the LMA Supreme, these were 5.0 (0.5–8.0 [0–33]), 4.0 (1.3–9.3 [0–24]), 10.7 (4–17.3 [0–26.7]) and 8.0 (0–10.7 [0–36]) cmH₂O, respectively. Mucosal pressures were low and similar for both devices. The LMA Supreme mucosal pressures were higher in the hypopharynx than in the distal oropharynx (p = 0.04) and base of the tongue (p = 0.011). There were no pressure differences between the locations for the i-gel.

The GlideScope^® videolaryngoscope is widely utilised in the management of the difficult airway. However, complications such as mucosal injury, palatal and tonsillar perforations have been reported with its use. The Shikani optical stylet has shown promise in aiding difficult intubations. This randomised controlled trial evaluates the Shikani optical stylet as an alternative to the GlideScope videolaryngoscope in patients undergoing anaesthesia, with a simulated difficult airway. Sixty patients were randomised to undergo tracheal intubation with either the GlideScope videolaryngoscope (n = 30) or the Shikani optical stylet (n = 30). All patients had rigid cervical collars applied to simulate a difficult airway. Tracheal intubation was successful in all patients, with first attempt success rates of 97% (29/30) the GlideScope group compared with 93% (28/30) in the Shikani group compared with 93% (28/30) in the Shikani group (p = 0.5). The mean (SD) time to intubation was 64 (37) s when using the GlideScope and 58 (26) s in the Shikani group (p = 0.48). A higher incidence of airway mucosal injury was noted in patients intubated with the GlideScope videolaryngoscope, compared with the Shikani optical stylet (5 vs 0, respectively, p = 0.05). This trial suggests that the Shikani optical stylet is a viable alternative to the GlideScope videolaryngoscope in the management of the difficult airway.

Peripheral pulse oximetry has become a core monitoring modality in most fields of medicine. Pulse oximeters are used ubiquitously in operating theatres, hospital wards, outpatient clinics and general practice surgeries. This study used a portable spectrometer (Lightman^®, The Electrode Co. Ltd., Monmouthshire, UK) to measure the emission spectra of the two light emitting diodes within the pulse oximeter sensor and to determine the accuracy of 847 pulse oximeters currently in use in 29 NHS hospitals in the UK. The standard manufacturing claim of accuracy for pulse oximeters is ± 2–3% over the range of 70–100% S_pO₂. Eighty-nine sensors (10.5%) were found to have a functional error of their electrical circuitry that could cause inaccuracy of measurement. Of the remaining 758 sensors, 169 (22.3%) were found to have emission spectra different from the manufacturers’ specification that would cause an inaccuracy in saturation estimation of > 4% in the range of 70–100% saturation. This study has demonstrated that a significant proportion of pulse oximeter sensors may be inaccurate.

Although brain natriuretic peptide has been shown to be superior to the revised cardiac risk index for risk stratification of vascular surgical patients, it remains unknown whether it is superior to alternative dynamic risk predictors, such as other pre-operative biomarkers (C-reactive protein and troponins) or myocardial ischaemia monitoring. The aim of this prospective observational study was to determine the relative clinical utility of these risk predictors for the prediction of postoperative cardiac events in elective vascular surgical patients. Only pre-operative troponin elevation (OR 56.8, 95% CI 6.5–496.0, p < 0.001) and brain natriuretic peptide above the optimal discriminatory point (OR 6.0, 95% CI 2.7–12.9, p < 0.001) were independently associated with cardiac events. Both brain natriuretic peptide and troponin risk stratification significantly improved overall net reclassification (74.6% (95% CI 51.6%–97.5%) and 38.5% (95% CI 22.4–54.6%, respectively)); however, troponin stratification decreased the correct classification of patients with cardiac complications (−59%, p < 0.001). Pre-operative brain natriuretic peptide evaluation was the only clinically useful predictor of postoperative cardiac complications.

The newly introduced Nexfin^® device allows analysis of the blood pressure trace produced by a non-invasive finger cuff. We compared the cardiac output derived from the Nexfin and PiCCO, using transcardiopulmonary thermodilution, during cardiac surgery. Forty patients with preserved left ventricular function undergoing elective coronary artery bypass graft surgery were studied after induction of general anaesthesia and until discharge to the intensive care unit. There was a significant correlation between Nexfin and PiCCO before (r² = 0.81, p < 0.001) and after (r² = 0.56, p < 0.001) cardiopulmonary bypass. Bland–Altman analysis demonstrated the mean bias of Nexfin to be −0.1 (95% limits of agreement −0.6 to +0.5, percentage error 23%) and −0.1 (−0.8 to +0.6, 26%) l.min⁻¹.m⁻², before and after cardiopulmonary bypass, respectively. After a passive leg-raise was performed, there was also good correlation between the two methods, both before (r² = 0.72, p < 0.001) and after (r² = 0.76, p < 0.001) cardiopulmonary bypass. We conclude that the Nexfin is a reliable method of measuring cardiac output during and after cardiac surgery.

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

A caudal epidural injection was performed on a middle-aged woman for pain in her right foot. Although the procedure was uncomplicated and a good epidurogram was obtained, the patient went on to develop an orthostatic headache with generalised weakness and syncopal episodes that were treated successfully by epidural blood patching. We describe the aetiology, presentation and treatment of spontaneous intracranial hypotension and review the similarities with our patient’s clinical presentation. We hypothesise as to how our intervention may have resulted in a dural tear.

Ametop^® gel (4% tetracaine) is used to provide topical anaesthesia for venous cannulation. Rapydan^® patch (7% lidocaine and 7% tetracaine) has been developed to provide topical anaesthesia by a different mechanism, that of heat assisted delivery. We compared the topical anaesthetic effect of these agents for venous cannulation. One hundred healthy adults undergoing day-case surgery were randomly assigned to receive either Rapydan (n = 50) or Ametop (n = 50) before venous cannulation. Pain on insertion was scored on a visual analogue scale between 0 and 100 (where 100 = unbearable pain). Median(IQR[range]) pain scores were not different between groups with 11 (5–20 [0–72]) for Rapydan and 10 (5–24 [0–95]) for Ametop (p = 0.63). Adequate topical anaesthesia was achieved in over 90% of patients in both groups. Rapydan produces topical anaesthesia comparable with Ametop for venous cannulation.

Remifentanil patient-controlled analgesia is well established in many centres and provides satisfactory pain relief for many women in labour. We describe a patient using remifentanil patient-controlled analgesia who suffered a respiratory arrest requiring a brief period of ventilation. In our institution, remifentanil patient-controlled analgesia has been offered to women in labour since 2009. Up to this point, we had not observed any critical incidents in over 130 patients using this mode of analgesia in our labour suite.

I report the case of a 57-year-old patient admitted to the intensive care unit with severe community-acquired pneumonia, complicated by prolonged mechanical ventilation of the lungs and intractable cardiac failure. He underwent percutaneous coronary angioplasty of the right coronary artery, but this did not improve his clinical condition. He was subsequently found to be suffering from mitral valve prolapse, that was felt to be the cause of recurrent episodes of severe pulmonary oedema. As open surgery was felt to be not feasible, the patient underwent percutaneous repair of his mitral valve using the MitraClip® device, and, after months of ventilatory support, was then weaned from the ventilator in a matter of days. While the procedure itself and the technology employed are still under evaluation, I conclude that the technique of percutaneous mitral valve repair may be considered for similar patients for whom open repair is contraindicated.

The Airtraq^™ optical laryngoscope became available in paediatric sizes in the UK in May 2008. We conducted a randomised, controlled trial comparing the Airtraq with conventional laryngoscopy during routine anaesthesia in children. We hypothesised that the Airtraq laryngoscope would perform as well as conventional laryngoscopy. Sixty patients (20 infants and 40 children) were recruited. The mean (SD) intubation time using the Airtraq was longer than conventional laryngoscopy overall (47.3 (32.6) vs 26.3 (11.5) s; p = 0.002), though the difference was only significant for children (p = 0.003) and not for infants (p = 0.29). The Airtraq provided a better view of the larynx compared with conventional laryngoscopy (in infants (percentage of glottic opening scores 100 (95–100 [90–100]) vs 77 (50–90 [40–100]), respectively; p = 0.001; visual analogue scores for field of view 9.2 (9.2–9.5 [8.2–10.0]) vs 6.8 (5.1–8.0 [4.7–10.0]), respectively; p = 0.001). In children, the Airtraq provided a similar view of the larynx (percentage of glottic opening scores 100 (100–100 [40–100]) vs 100 (90–100 [50–100]), respectively; visual analogue scores for field of view 9.2 (8.6–10.0 [7.0–10.0]) vs 9.2 (8.6–10.0 [5.6–10.0]), respectively; both p > 0.05), compared with conventional laryngoscopy.

Awake videolaryngoscopy may be useful for the tracheal intubation of the morbidly obese. This prospective, observational study enrolled 50 patients undergoing bariatric surgery. After sedation and topical anaesthesia of the airway, awake tracheal intubation was attempted, assisted by videolaryngoscopy, and terminated if there was severe gagging, coughing, or inadequate laryngeal view. After three attempts the procedure was considered a failure. Twenty-seven intubations were successful on the first attempt, fifteen on the second, six on the third and two were not successful, giving a success rate of 96% (95% CI 86–100%). In one failure, inserting the tracheal tube caused severe gagging in spite of an adequate view of the larynx, and the trachea was intubated with the videolaryngoscope after induction of anaesthesia. The second failure was due to gagging, with subsequent tracheal intubation successful using fibreoptic bronchoscopy. When managing the morbidly obese airway, awake tracheal intubation using videolaryngoscopy may be considered.

The aim of the present study was to determine the precision of the PiCCO^® system for post-cardiac arrest patients who underwent therapeutic hypothermia. The precision of the measurements for cardiac output, global end-diastolic volume, extravascular lung water and the pulmonary vascular permeability index was assessed using the least significant change; this was regarded as precise when less than 15%. A total of 462 measurement sets were prospectively performed on 88 patients following successful resuscitation after cardiac arrest. Using the mean value of three injections for a measurement, the least significant change for the cardiac output, global end-diastolic volume, extravascular lung water and pulmonary vascular permeability index measurements were found to be 7.8%, 8.5%, 7.8% and 12.1%, respectively. No significant differences between hypothermia (n = 150) and non-hypothermia (n = 312) were found. The PiCCO-derived variables were found to be precise for post-cardiac arrest patients even under conditions of varying body temperature.

Forced-air warming exhaust may disrupt operating theatre airflows via formation of convection currents, which depends upon differences in exhaust and operating room air temperatures. We investigated whether the floor-to-ceiling temperatures around a draped manikin in a laminar-flow theatre differed when using three types of warming devices: a forced-air warming blanket (Bair Hugger™); an over-body conductive blanket (Hot Dog™); and an under-body resistive mattress (Inditherm™). With forced-air warming, mean (SD) temperatures were significantly elevated over the surgical site vs those measured with the conductive blanket (+2.73 (0.7) °C; p < 0.001) or resistive mattress (+3.63 (0.7) °C; p < 0.001). Air temperature differences were insignificant between devices at floor (p = 0.339), knee (p = 0.799) and head height levels (p = 0.573). We conclude that forced-air warming generates convection current activity in the vicinity of the surgical site. The clinical concern is that these currents may disrupt ventilation airflows intended to clear airborne contaminants from the surgical site.

There are conflicting results with regard to the use of catheter-based techniques for continuous paravertebral block. Local anaesthetic spread within the paravertebral space is limited and the clinical effect is often variable. Discrepancies between needle tip position and final catheter position can also be problematic. The aim of this proof-of-concept study was to assess the reliability of placing a newly developed coiled catheter in human cadavers. Sixty Tuohy needles and coiled catheters were placed under ultrasound guidance, three on each side of the thoracic vertebral column in 10 human cadavers. Computed tomography was used to assess needle tip and catheter tip locations. No catheter was misplaced into the epidural, pleural or prevertebral spaces. The mean (SD) distance between catheter tips and needle tips was 8.2 (4.9) mm. The median (IQR [range]) caudo-cephalad spread of contrast dye injectate through a subset of 20 catheters was 4 (4–5[3–8]) thoracic segments. All catheters were removed without incident. Precise paravertebral catheter placement can be achieved using ultrasound-guided placement of a coiled catheter.

Many anaesthetic agents affect intra-ocular pressure, yet little is known about nitrous oxide and intra-ocular pressure. This study assessed the effect of nitrous oxide on intra-ocular pressure in 20 healthy adult volunteers. The intra-ocular pressure was measured at baseline, while breathing a 70:30 mix of nitrous oxide and oxygen for 12 min, and then while breathing room air for 15 min. A linear mixed effects model was used to assess change in intra-ocular pressure over time. There was no significant difference in intra-ocular pressure between baseline and during or after nitrous oxide inhalation. Several differences in intra-ocular pressure were noted between internal time-points: pressure increased by 2.4 mmHg between 3 and 6 min of breathing nitrous oxide (p = 0.01); it increased by 1.4 mmHg between 3 and 9 min of breathing nitrous oxide (p = 0.046); and it decreased by 2.2 mmHg between 6 min of breathing nitrous oxide and 15 min of breathing room air (p = 0.035). This study indicates that nitrous oxide inhalation does not significantly change intra-ocular pressure from baseline values in a population of healthy adults.

The aim of this study was to evaluate the efficacy of the Intubating Laryngeal Mask Airway™ (ILMA) and Laryngeal Mask Airway CTrach™ (LMA CTrach) in facilitating tracheal intubation in morbidly obese patients. Eighty patients (body mass index > 40kg.m⁻²) were randomly allocated to the ILMA or the LMA CTrach. The median (IQR [range]) total time taken for tracheal intubation was shorter with the ILMA than with the LMA CTrach (78 (63–105 [40–265]) s vs 128 (98–221 [60–423]) s, respectively; p < 0.001). Significantly more manoeuvres were applied for the satisfactory ventilation and viewing of the glottis with the LMA CTrach (25% vs 55% with the ILMA; p = 0.006). During the postoperative period, there was more sore throat with the LMA CTrach (p < 0.02). We conclude that the ILMA results in shorter intubation times with fewer manoeuvres and sore throat compared with the LMA CTrach in the morbidly obese.

The availability of sugammadex as a selective encapsulating agent for rocuronium has led to speculation that it may be useful in mitigating rocuronium-induced anaphylaxis. Off-label use of sugammadex for this indication has already been documented in case reports although there are theoretical objections to the likelihood of an allergen-binding agent's being able to attenuate the immunological cascade of anaphylaxis. Using a cutaneous model of anaphylaxis in rocuronium-sensitised patients, we were unable to demonstrate that sugammadex was effective in attenuating the type-1 hypersensitivity reaction after it has been triggered by rocuronium, but we were able to demonstrate that these patients are anergic to sugammadex-bound rocuronium. These findings demonstrate that a cyclodextrin can bind an allergen and exclude it from interacting with the immune system, and may potentially lead to novel applications in other allergic diseases. However, there is no evidence that sugammadex should be used for the treatment of rocuronium-induced anaphylaxis, and clinical management should follow established protocols.

We compared the ability of automated non-invasive intermittent oscillometric blood pressure monitoring with a new device, CNAP^TM (continuous non-invasive arterial pressure) to provide a new blood pressure reading in each 1-min interval between spinal anaesthesia and delivery during caesarean section. We also compared the accuracy of continuous non-invasive arterial pressure readings with non-invasive blood pressure measurements before spinal anaesthesia. Fifty-nine women participated. The non-invasive and continuous non-invasive monitors displayed new blood pressure readings in a mean of 82% (11%) and 83% (13%) (p = 0.97) of the one-minute intervals between spinal anaesthesia and delivery, respectively. Continuous non-invasive arterial pressure was more likely to fail on two or more consecutive minutes (p = 0.001). From the pre-spinal readings, the mean bias, defined as non-invasive – continuous non-invasive arterial pressure, and limits of agreement (±2SD mean bias) for systolic, diastolic and mean blood pressure respectively were +1.3 (±26.0), −2.9 (±21.8) and +2.6 (±20.4) mmHg. The new monitor has disadvantages compared with conventional non-invasive intermittent blood pressure monitoring.

Postoperative cognitive dysfunction is receiving increasing attention, particularly as it mainly affects the (growing) elderly population. Until recently, cognitive deficits after cardiac surgery were thought to be caused by physiological disturbances associated with the cardiopulmonary bypass technique. Although the technique of ‘off-pump’ coronary revascularisation may potentially be associated with improved outcome, long-term follow-up studies have failed to demonstrate a significant reduction in the incidence of postoperative cognitive dysfunction. The focus of research is thus shifting from cardiopulmonary bypass to other factors common to both techniques, such as surgery, anaesthesia and patient-related predisposing factors. Priming of the immune system by ageing and atherosclerosis may result in an exaggerated systemic and cerebral inflammatory response to cardiac surgery and anaesthesia, causing neuronal loss or dysfunction resulting in cognitive dysfunction. We briefly discuss the evidence for cardiopulmonary bypass-related neuronal injuries in adult cardiac surgery patients, and review the evidence that immune priming is a key factor in the pathogenesis of cognitive dysfunction after cardiac surgery.