Magnesium Sulfate and Cerebral Oxygen Saturation in Mild Traumatic Brain Injury: A Randomized, Double-Blind, Controlled Trial.

Perioperative cerebral hypoperfusion/ischemia is considered to play a pivotal role in the development of secondary traumatic brain injury (TBI). This prospective randomized, double-blind, controlled study investigated whether magnesium sulfate (MgSO4) infusion was associated with neuroprotection in maintaining regional cerebral oxygen saturation (rSO2) values in patients with mild TBI undergoing general anesthesia. Immediately after intubation, we randomly assigned patients with TBI to receive either intravenous MgSO4 (30 mg/kg for 10 min, followed by a continuous infusion of 15 mg/kg/h) or a placebo (saline) during surgery. We also implemented an intervention protocol for a sudden desaturation exceeding 20% of the initial baseline rSO2. The intraoperative rSO2 values were similar with respect to the median (left. 67% vs. 66%, respectively; p = 0.654), lowest, and highest rSO2 in both groups. The incidence (left 31.2% vs. 24.3%; p = 0.521) and duration (left 2.6% vs. 3.5%; p = 0.638) of cerebral desaturations (the relative decline in rSO2 < 80% of the baseline value) were also similar for both groups. Although the patients suffered serious traumatic injuries, all critical desaturation events were restored (100%) following stringent adherence to the intervention protocol. Intraoperative remifentanil consumption, postoperative pain intensity, and fentanyl consumption at 6 h were lower in the MgSO4 group (p = 0.024, 0.017, and 0.041, respectively) compared to the control group, whereas the satisfaction score was higher in the MgSO4 group (p = 0.007). The rSO2 did not respond to intraoperative MgSO4 in mild TBI. Nevertheless, MgSO4 helped the postoperative pain intensity, reduce the amount of intraoperative and postoperative analgesics administered, and heighten the satisfaction score.

Magnesium Sulfate Enables Patient Immobilization during Moderate Block and Ameliorates the Pain and Analgesic Requirements in Spine Surgery, Which Can Not Be Achieved with Opioid-Only Protocol: A Randomized Double-Blind Placebo-Controlled Study.

Spine surgery is painful despite the balanced techniques including intraoperative and postoperative opioids use. We investigated the effect of intraoperative magnesium sulfate (MgSO4) on acute pain intensity, analgesic consumption and intraoperative neurophysiological monitoring (IOM) during spine surgery. Seventy-two patients were randomly allocated to two groups: the Mg group or the control group. The pain intensity was significantly alleviated in the Mg group at 24 h (3.2 ± 1.7 vs. 4.4 ± 1.8, p = 0.009) and 48 h (3.0 ± 1.2 vs. 3.8 ± 1.6, p = 0.018) after surgery compared to the control group. Total opioid consumption was reduced by 30% in the Mg group during the same period (p = 0.024 and 0.038, respectively). Patients in the Mg group required less additional doses of rocuronium (0 vs. 6 doses, p = 0.025). Adequate IOM recordings were successfully obtained for all patients, and abnormal IOM results denoting warning criteria (amplitude decrement >50%) were similar. Total intravenous anesthesia with MgSO4 combined with opioid-based conventional pain control enables intraoperative patient immobilization without the need for additional neuromuscular blocking drugs and reduces pain intensity and analgesic requirements for 48 h after spine surgery, which is not achieved with only opioid-based protocol.

Immediate retrograde amnesia induced by midazolam: a prospective, nonrandomized cohort study.

BACKGROUND: Midazolam, a short-acting benzodiazepine, has sedative, anxiolytic, amnestic, and anticonvulsant effect. Given its advantages of rapid onset, short duration, and low toxicity, midazolam is optimal for any procedural sedation. Midazolam is known to cause anterograde amnesia; however, the possibility of retrograde amnesia has also been raised. This prospective cohort, nonrandomized study evaluated the presence and extent of retrograde amnesia induced by midazolam during cesarean delivery. METHODS: One-hundred parturients scheduled for elective cesarean delivery under spinal anesthesia were enrolled. As soon as giving birth, 6 picture cards were shown to the patients in one min intervals, and then midazolam (0.1 mg/kg) was given or not according to the patients' preference. This overall retrograde recall rate of six cards was the primary outcome of our study, which was asked by a blinded investigator. RESULTS: The overall retrograde card recall rate was lower in the midazolam group compared to the control group (77.0 ± 13.4 vs. 87.7 ± 3.9%, p <0.001), especially at one min before midazolam administration (58 vs. 88%, p <0.001). Decreased memory trend was observed as time progressed toward midazolam administration in the midazolam group (p = 0.035). More patients answered 'yes' to the factitious event in the midazolam group than in the control group (26% vs. 4%, p = 0.004). CONCLUSION: Intravenous midazolam could cause a brief-period retrograde amnesia in visual and event memory. Moreover, there were more spurious reports of intraoperative factitious events in the midazolam group, implying that episodic memories were also affected by midazolam.

Immediate retrograde amnesia induced by midazolam: A prospective, non-randomised cohort study.

BACKGROUND: Midazolam, a short-acting benzodiazepine, has sedative, anxiolytic, amnestic and anticonvulsant effects. Given its advantages of rapid onset, short duration and low toxicity, midazolam is optimal for any procedural sedation. Midazolam is known to cause anterograde amnesia; however, the possibility of retrograde amnesia has also been raised. This prospective cohort, non-randomised study evaluated the presence and extent of retrograde amnesia induced by midazolam during caesarean delivery. METHODS: One hundred parturients scheduled for elective caesarean delivery under spinal anaesthesia were enrolled. As soon as giving birth, six picture cards were shown to the patients in 1-min intervals, and then midazolam (0.1 mg/kg) was given or not according to the patients' preference. This overall retrograde recall rate of six cards was the primary outcome of our study, which was asked by a blinded investigator. RESULTS: The overall retrograde card recall rate was lower in the midazolam group compared with the control group (77.0 ± 13.4 vs. 87.7 ± 3.9%, P < .001), especially at 1 minute before midazolam administration (58% vs. 88%, P < .001). Decreased memory trend was observed as time progressed towards midazolam administration in the midazolam group (P = .035). More patients answered 'yes' to the factitious event in the midazolam group than in the control group (26% vs. 4%, P = .004). CONCLUSION: Intravenous midazolam could cause a brief-period retrograde amnesia in visual and event memory. Moreover, there were more spurious reports of intraoperative factitious events in the midazolam group, implying that episodic memories were also affected by midazolam.

Intraoperative Hypothermia Is Associated with Reduced Acute Kidney Injury After Spine Surgery Under General Anesthesia: A Retrospective Observational Study.

BACKGROUND: Although hypothermia is known to have protective effects against ischemic injuries, the effects of hypothermia on kidney injury have not yet been elucidated. Therefore, this study aimed to identify the association between intraoperative hypothermia and postoperative acute kidney injury (AKI) in patients who underwent spine surgery under general anesthesia. METHODS: In this retrospective observational study, we analyzed the medical records of adult patients who underwent elective spine surgery between January 2010 and March 2018. Patients were classified into the normothermia group (36.5 to 37.5°C), mild hypothermia group (35 to 36.5°C), and hypothermia group (<35°C) based on the mean intraoperative temperature, measured using an esophageal stethoscope. The association between mean intraoperative temperature and the incidence of postoperative AKI was analyzed using logistic regression analysis after inverse probability of treatment weighting (IPTW) adjustment. RESULTS: The analysis included 6520 patients, of whom 248 (3.8%) were diagnosed with AKI within POD 3. After applying IPTW adjustment, the incidence of postoperative AKI was 32% lower in the hypothermia group than in the normothermia group (odds ratio, 0.68; 95% confidence interval, 0.53-0.87; P=0.002), whereas the incidence of postoperative AKI in the mild hypothermia group was not significantly different from that in the normothermia (P=0.139) and hypothermia groups (P=0.075). CONCLUSIONS: This study showed that intraoperative hypothermia is associated with a reduction in the incidence of AKI following spine surgery under general anesthesia. Further, this association was evident in the group with hypothermia <35°C.

The Effect of Adjustment of Endotracheal Tube Cuff Pressure during Scarless Remote Access Endoscopic and Robotic Thyroidectomy on Laryngo-Pharyngeal Complications: Prospective Randomized and Controlled Trial.

Scarless remote access endoscopic and robotic thyroidectomy has been recently performed as a safe and feasible method. However, little is known about the laryngo-pharyngeal complications after surgery and the effect of adjusting the endotracheal tube cuff pressure during surgery on laryngo-pharyngeal complications. Patients were randomized into two groups: the control group (n = 52) and adjusted group (n = 52). The initial cuff pressure was set to 25 mmHg and then monitored without adjustment (control group) or with adjustment at approximately 25 mmHg (adjusted group) throughout surgery. The incidences and severity of postoperative sore throat (POST), hoarseness, dysphagia, and cough were recorded at 1, 6, 24, and 48 h after surgery. Cuff pressures of the control group changed significantly over time and were higher than those of the adjusted group. The incidence of POST was lower in the adjusted group at 24 h postoperatively (p = 0.035), and there was a significant difference in the severity of POST at 6 and 24 h postoperatively between the two groups. There were no differences in the incidence of hoarseness, dysphagia, and cough between the two groups, except dysphagia and cough at 6 h postoperatively. Therefore, intraoperative monitoring and adjustment of the cuff pressure can reduce the incidence of laryngo-pharyngeal complications.

Effects of Combined Remote Ischemic Pre-and Post-Conditioning on Neurologic Complications in Moyamoya Disease Patients Undergoing Superficial Temporal Artery-Middle Cerebral Artery Anastomosis.

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the most commonly used treatment for Moyamoya disease. During the perioperative period, however, these patients are vulnerable to ischemic injury or hyperperfusion syndrome. This study investigated the ability of combined remote ischemic pre-conditioning (RIPC) and remote ischemic post-conditioning (RIPostC) to reduce the occurrence of major neurologic complications in Moyamoya patients undergoing STA-MCA anastomosis. The 108 patients were randomly assigned to a RIPC with RIPostC group (n = 54) or a control group (n = 54). Patients in the RIPC with RIPostC group were treated with four cycles of 5-min ischemia and 5-min reperfusion before craniotomy and after STA-MCA anastomosis (RIPostC). The incidence of postoperative neurologic complications and the duration of hospital stay were determined. The overall incidence of neurologic complication was significantly higher in the control group than in the RIPC with RIPostC group (13 vs. 3, p = 0.013). The duration of hospital stay was significantly longer in the control group than in the RIPC with RIPostC group (17.8 (11.3) vs. 13.8 (5.9) days, p = 0.023). Combined remote ischemic pre- and post-conditioning can be effective in reducing neurologic complications and the duration of hospitalization in Moyamoya patients undergoing STA-MCA anastomosis.

Comparison of the effects of desflurane and total intravenous anesthesia on the optic nerve sheath diameter in robot assisted laparoscopic radical prostatectomy: A randomized controlled trial.

BACKGROUND: Optic nerve sheath diameter (ONSD) is a well-known surrogate marker for intracranial pressure during robot-assisted laparoscopic radical prostatectomies (RALP). ONSD during RALP is known to increase due to elevated intracranial pressure as a result of the steep Trendelenburg position and carbon dioxide pneumoperitoneum. We aimed to compare the effects of total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) on ONSD during RALP. METHODS: Patients scheduled for RALP were enrolled and randomly assigned to the TIVA (propofol and remifentanil) or DES (desflurane and remifentanil) group in this randomized trial. Ultrasonographic measurements of ONSD were conducted before administration of anesthesia (T0), 10 minutes after the Trendelenburg position (T1), 1 hour after the Trendelenburg position (T2), 2 hours after the Trendelenburg position (T3), 10 minutes after resuming the supine position (T4), and at the time of arrival in the post-anaesthetic care unit (T5). The primary outcome measure was the mean ONSD at T2 of the TIVA and DES group during RALP. RESULTS: A total of 56 patients were analysed in this study. The mean ONSD at T1, T2, T3, and T4 were significantly lower for patients in the TIVA group compared with those in the DES group (P = .023, .000, .000, and .003, respectively). CONCLUSION: The mean ONSD for patients in the TIVA group was significantly lower than that in the DES group during the RALP procedure. Our findings suggest that TIVA may be a more suitable anesthetic option for patients at risk of cerebral hypoperfusion.

Effects of palonosetron for prophylaxis of postoperative nausea and vomiting in high-risk patients undergoing total knee arthroplasty: A prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: The preemptive multimodal pain protocols used in total knee arthroplasty (TKA) often cause emesis postoperatively. We investigated whether palonosetron prophylaxis reduces postoperative nausea and vomiting (PONV) in high-risk patients after TKA. METHODS: We randomized 120 female patients undergoing TKA to receive either palonosetron (0.075 mg, intravenous) or no antiemetic prophylaxis (0.9% saline, control group). All patients were given spinal anesthesia, a continuous femoral nerve block, and fentanyl-based intravenous patient controlled analgesia. Patients undergoing staged bilateral TKA were assigned to one group for the first knee and the other group for the second knee. The overall incidence of PONV, the incidences of both nausea and vomiting, severity of nausea, complete response, requirement for rescue antiemetics, pain level, opioid consumption, and satisfaction scores were evaluated during three periods: 0-2, 2-24, and 24-48 h postoperatively. We also compared PONV and pain between the first and second TKA. RESULTS: The incidence of PONV during the first 48 h was lower in the palonosetron group compared with the controls (22 vs. 41%, p = 0.028), especially 2-24 h after surgery, as was the nausea and vomiting respectively. The severity of nausea was lower in the palonosetron group (p = 0.010). The complete response rate (93 vs. 73%, p = 0.016) and satisfaction score (84 ± 12 vs. 79 ± 15, p = 0.032) were higher in the palonosetron group during 2-24 h after surgery. Patients who underwent a second operation complained of more severe pain, and consumed more opioids than those of the first operation. There was no difference in the incidence of PONV between the first and second operations. CONCLUSIONS: Palonosetron prophylaxis reduced the incidence and severity of PONV in high-risk patients managed with multimodal pain protocol for 48 h, notably 2-24 h after TKA.

Comparison of ramosetron and ondansetron for the treatment of established postoperative nausea and vomiting after laparoscopic surgery: a prospective, randomized, double-blinded multicenter trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication after surgery, which increases physical and psychological discomfort and delays recovery. The aim of this study was to test the hypothesis that ramosetron is comparable to ondansetron for the treatment of established PONV after laparoscopic surgery using a prospective, randomized, double-blinded, noninferiority study. METHODS: Patients who had at least two risk factors of PONV and underwent laparoscopic surgery under general anesthesia were assessed for eligibility. Patients who developed PONV within the first 2 h after anesthesia received ondansetron (4 mg) or ramosetron (0.3 mg) intravenously in a randomized double-blind manner. Patients were then observed for 24 h after drug administration. The incidence of nausea and vomiting, severity of nausea, rescue antiemetic necessity, and adverse effects at 0-2 or 2-24 h after drug administration was evaluated. The primary endpoint was the rate of patients exhibiting a complete response, defined as no emesis and no further rescue antiemetic medication for 24 h after drug administration. RESULTS: Among the 583 patients, 210 (36.0%) developed PONV and were randomized to either the ondansetron (n=105) or ramosetron (n=105) group. Patient's characteristics were similar between the groups. The complete response rate was 44.1% in the ondansetron group and 52.9% in the ramosetron group after 24 h of initial antiemetic administration. The incidence of adverse events was not different between the groups. CONCLUSION: We found evidence to support the noninferiority of ramosetron (0.3 mg) compared to ondansetron (4 mg) for the treatment of established PONV in moderate to high-risk patients undergoing laparoscopic surgery.

The attenuation of neurological injury from the use of simvastatin after spinal cord ischemia-reperfusion injury in rats.

BACKGROUND: Spinal cord ischemic injury remains a serious complication of open surgical and endovascular aortic procedures. Simvastatin has been reported to be associated with neuroprotective effect after spinal cord ischemia-reperfusion (IR) injury. The aim of this study was to determine the therapeutic efficacy of starting simvastatin after spinal cord IR injury in a rat model. METHODS: In adult Sprague-Dawley rats, spinal cord ischemia was induced using a balloon-tipped catheter placed in the descending thoracic aorta. The animals were then randomly divided into 4 groups: group A (control); group B (0.5 mg/kg simvastatin); group C (1 mg/kg simvastatin); and group D (10 mg/kg simvastatin). Simvastatin was administered orally upon reperfusion for 5 days. Neurological function of the hind limbs was evaluated for 7 days after reperfusion and recorded using a motor deficit score (MDS) (0: normal, 5: complete paraplegia). The number of normal motor neurons within the anterior horns of the spinal cord was counted after final MDS evaluation. Then, the spinal cord was harvested for histopathological examination. RESULTS: Group D showed a significantly lower MDS than the other groups at post-reperfusion day 1 and this trend was sustained throughout the study period. Additionally, a greater number of normal motor neurons was observed in group D than in other groups (group D 21.2 [3.2] vs. group A: 15.8 [4.2]; group B 15.4 [3.4]; and group C 15.5 [3.7]; P = 0.002). CONCLUSIONS: The results of the current study suggest that 10 mg/kg can significantly improve neurologic outcome by attenuating neurologic injury and restoring normal motor neurons after spinal cord IR injury.

Higher Operating Table for Optimal Needle-Entry Angle and Less Discomfort During Spinal Anesthesia.

The aim of this study was to find the optimal table height to facilitate insertion of the spinal needle at a 90° angle and to reduce the anesthesiologist's discomfort. Sixty patients were randomly allocated according to landmarks on the anesthesiologist's body: umbilicus (group U), lowest rib margin (R), xiphoid process (X), and nipple (N). The coronal insertion angle between the patient's skin and the spinal needle was obtuse in groups U and R, and 90° in group X. We demonstrated that high operating tables at the xiphoid and nipple level facilitate more optimal needle entry angles while reducing the discomfort and joint flexion of anesthesiologists during spinal anesthesia.

Reproducible Motor Deficit Following Aortic Occlusion in a Rat Model Of Spinal Cord Ischemia.

Spinal cord ischemia is a fatal complication following thoracoabdominal aortic aneurysm surgery. Researchers can investigate the strategies for preventing and treating this complication using experimental models of spinal cord ischemia. The model described here demonstrates varying degrees of paraplegia that relate to the length of occlusion following thoracic aortic occlusion in a rat spinal cord ischemia model. A 2-Fr. balloon-tipped catheter was advanced through the femoral artery into the descending thoracic aorta until the catheter tip was placed at the left subclavian artery in anesthetized male Sprague-Dawley rats. Spinal cord ischemia was induced by inflating the catheter balloon. After a set period of occlusion (9, 10, or 11 min), the balloon was deflated. Neurologic assessment was performed using the motor deficit index at 24 h after surgery, and the spinal cord was harvested for histopathological examination. Rats that underwent 9 min of aortic occlusion showed mild and reversible motor impairment in the hind limb. Rats subjected to 10 min of aortic occlusion presented with moderate but reversible motor impairment. Rats subjected to 11 min of aortic occlusion displayed complete and persistent paralysis. The motor neurons in the spinal cord sections were more preserved in rats subjected to shorter duration of aortic occlusion. Researchers can achieve a reproducible hind limb motor deficit following thoracic aortic occlusion using this spinal cord ischemia model.

Magnesium sulphate improves pulmonary function after video-assisted thoracoscopic surgery: A randomised double-blind placebo-controlled study.

BACKGROUND: Reduced lung volumes are unavoidable after lung resection surgery. Magnesium sulphate (MgSO4) administration has been reported to reduce the requirement for neuromuscular blocking drugs and postoperative analgesics in surgical patients. OBJECTIVE: To investigate the effect of MgSO4 on pulmonary function after video-assisted thoracoscopic surgery (VATS). DESIGN: A randomised, double-blind, placebo-controlled trial. SETTING: A university tertiary care centre. PATIENTS: Sixty-six patients scheduled for pulmonary lobectomy or segmentectomy via VATS. INTERVENTION: Patients were allocated to one of two groups: the Mg (MgSO4 50 mg kg intravenously for 10 min, followed by a continuous infusion of 15 mg kg h during surgery) or the control (same volume of 0.9% saline). MAIN OUTCOME MEASURES: Pulmonary function tests [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate] were measured before surgery and at three time points after surgery (2, 24 and 48 h postoperatively) using a portable spirometer. Twelve months after surgery, pulmonary function test values were repeated at a regular outpatient follow-up visit. RESULTS: FEV1 at 24 (1.7 ±â€Š0.6 vs. 1.3 ±â€Š0.5 l, P = 0.033) and 48 h (1.7 ±â€Š0.6 vs. 1.4 ±â€Š0.5 l, P = 0.021) and FVC at 24 (2.0 ±â€Š0.8 vs. 1.6 ±â€Š0.6 l, P = 0.038) and 48 h (2.2 ±â€Š0.8 vs. 1.7 ±â€Š0.7 l, P = 0.008) after surgery were significantly greater in the Mg group. Patients in the Mg group required less rocuronium than those in the control group (64.2 ±â€Š19.9 vs. 74.9 ±â€Š20.3 mg, respectively; P = 0.041). Consumption of postoperative patient-controlled analgesia was also significantly less at 24 and 48 h after surgery in the Mg group (P = 0.022 and 0.015, respectively), although pain scores and rescue analgesics were comparable. Five patients in the control group were diagnosed with postoperative pneumonia using clinical and radiological criteria before discharge. FEV1 and FVC at 12 months after surgery were not different between the two groups. CONCLUSION: Intraoperative administration of MgSO4 improved pulmonary function and reduced the need for rocuronium and postoperative analgesics in patients who underwent VATS. TRIAL REGISTRATION: cris.nih.go.kr identifier: KCT0001410.

Simvastatin protects ischemic spinal cord injury from cell death and cytotoxicity through decreasing oxidative stress: in vitro primary cultured rat spinal cord model under oxygen and glucose deprivation-reoxygenation conditions.

BACKGROUND: Ischemia and the following reperfusion damage are critical mechanisms of spinal cord injury. Statins have been reported to decrease ischemia-reperfusion injury in many organs including the spinal cord. Anti-oxidative effect is one of the main protective mechanisms of statin against neuronal death and cytotoxicity. We hypothesized that statins' anti-oxidative property would yield neuroprotective effects on spinal cord ischemia-reperfusion injury METHODS: Primary cultured spinal cord motor neurons were isolated from Sprague-Dawley rat fetuses. Ischemia-reperfusion injury model was induced by 60 min of oxygen and glucose deprivation (OGD) and 24 h of reoxygenation. Healthy and OGD cells were treated with simvastatin at concentrations of 0.1, 1, and 10 µM for 24 h. Cell viability was assessed using water-soluble tetrazolium salt (WST)-8, cytotoxicity with LDH, and production of free radicals with DCFDA (2',7'-dichlorofluorescein diacetate). RESULTS: OGD reduced neuronal viability compared to normoxic control by 35.3%; however, 0.1-10 µM of simvastatin treatment following OGD improved cell survival. OGD increased LDH release up to 214%; however, simvastatin treatment attenuated its cytotoxicity at concentrations of 0.1-10 µM (p < 0.001 and p = 0.001). Simvastatin also reduced deteriorated morphological changes of motor neurons following OGD. Oxidative stress was reduced by simvastatin (0.1-10 µM) compared to untreated cells exposed to OGD (p < 0.001). CONCLUSIONS: Simvastatin effectively reduced spinal cord neuronal death and cytotoxicity against ischemia-reperfusion injury, probably via modification of oxidative stress.

Isoflurane decreases proliferation and differentiation, but none of the effects persist in human embryonic stem cell-derived neural progenitor cells.

PURPOSE: Volatile anesthetics are a potential risk for cognitive impairment in the developing brain. Isoflurane causes cell death, reduces neurogenesis, and changes neuronal differentiation. In this study, the effects of a single isoflurane exposure on the developing human brain were evaluated using human embryonic stem cell (hESC)-derived neural progenitor cells (NPCs). METHODS: Multipotent NPCs were derived from hESCs and randomly exposed to either 5 vol% isoflurane (4 h) or no isoflurane (control group). The cells were fixed after 1, 3, 5, and 7 days to evaluate differentiation using the ratio of ß-III tubulin to nestin. Neuronal cell survival and proliferation were assessed using the WST-1 and bromodeoxyuridine (BrdU) cell proliferation assays, respectively. To evaluate the mechanism of isoflurane neurotoxicity, we added TAT-Pep5, a p75 neurotrophic receptor (p75NTR) inhibitor, to each of the groups. RESULTS: Isoflurane had minimal or no effect on the cell survival of NPCs in vitro. Proliferation, assessed on the basis of BrdU incorporation, was inhibited in the isoflurane group on days 3 (p = 0.033) and 5 (p = 0.001). The ratios of ß-III tubulin to nestin in the isoflurane group on days 1 and 3 were significantly lower (p = 0.004 and p = 0.029, respectively) than those in the control group. Anti-proliferative and differentiation-reducing effect did not persist. TAT-Pep5 pretreatment significantly blocked the isoflurane-mediated decrease in the ß-III tubulin to nestin ratio (p = 0.012) on day 1. CONCLUSION: Exposing NPCs to isoflurane hampered proliferation and differentiation but not neuronal survival. Isoflurane may be a powerful neuronal modulator during the early developmental period, partly mediated by activation of p75NTR.

Postoperative cognitive changes after total knee arthroplasty under regional anesthesia.

BACKGROUND: The type of postoperative cognitive decline after surgery under spinal anesthesia is unknown. We investigated the type of postoperative cognitive decline after total knee arthroplasty (TKA). Neuropsychological testing was conducted and the changes in cerebrospinal fluid (CSF) biomarkers after surgery were evaluated. METHODS: Fifteen patients who required bilateral TKA at a 1-week interval under spinal anesthesia were included. Neuropsychological tests were performed twice, once the day before the first operation and just before the second operation (usually 1 week after the first test) to determine cognitive decline. Validated neuropsychological tests were used to examine 4 types of cognitive decline: memory, frontal-executive, language-semantic, and others. Concentrations of CSF amyloid peptide, tau protein, and S100B were measured twice during spinal anesthesia at a 1-week interval. The patients showed poor performance in frontal-executive function (forward digit span, semantic fluency, letter-phonemic fluency, and Stroop color reading) at the second compared to the first neuropsychological assessment. RESULTS: S100B concentration decreased significantly 1 week after the operation compared to the basal value (638 ±â€Š178 vs 509 ±â€Š167 pg/mL) (P = 0.019). Amyloid protein ß1-42, total tau, and phosphorylated tau concentrations tended to decrease but the changes were not significant. CONCLUSION: Our results suggest that frontal-executive function declined 1 week after TKA under spinal anesthesia. The CSF biomarker analysis indicated that TKA under regional anesthesia might not cause neuronal damage.

C-reactive protein is an independent predictor for 1-year mortality in elderly patients undergoing hip fracture surgery: A retrospective analysis.

Numerous factors are associated with mortality after hip fracture surgery in elderly patients. The aim of this study was to investigate whether preoperative C-reactive protein (CRP) was an independent risk factor for 1-year mortality after hip fracture surgery in the elderly. The electronic medical records of 772 elderly patients (age ≥ 65 years) undergoing hip fracture surgery from May 2003 to November 2011 were reviewed retrospectively. The patients comprised a high CRP group (>10.0 mg/dL) and low CRP group (≤10.0 mg/dL), based upon preoperative CRP levels. The overall 1-year mortality was 14.1%; the value was significantly higher in the high CRP group than in the low CRP group (31.8% vs 12.5%; P < 0.001). On binary logistic regression, body mass index (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.99; P = 0.025), history of malignancy (OR, 2.59; 95% CI, 1.47-4.57; P = 0.001), American Society of Anesthesiologists physical status (ASA PS) class 3-4 (OR, 1.96; 95% CI, 1.25-3.07; P = 0.003), preoperative albumin (OR, 0.39; 95% CI, 0.25-0.61; P < 0.001), preoperative CRP > 10.0 mg/dL (OR, 2.04; 95% CI, 1.09-3.80; P = 0.025), postoperative intensive care unit (ICU) admission (OR, 2.29; 95% CI, 1.15-4.59; P = 0.019), and creatinine on the second postoperative day (OR, 1.20; 95% CI, 1.00-1.45; P = 0.048) were independent predictors of 1-year mortality after hip surgery. Male gender and low preoperative hemoglobin were associated with in-hospital mortality, whereas delayed surgery and femoral neck fracture were related to the 6-month mortality. Low preoperative albumin and low body mass index predicted the 6-month and 1-year mortality. An increased preoperative CRP level, particularly >10.0 mg/dL, was associated with the 1-year mortality after hip fracture surgery in the elderly. In addition, a history of malignancy, high ASA PS score, and postoperative ICU admission were related to mortality after hip fracture.

Monitored anesthesia care in and outside the operating room.

Monitored anesthesia care (MAC) is an anesthesia technique combining local anesthesia with parenteral drugs for sedation and analgesia. The use of MAC is increasing for a variety of diagnostic and therapeutic procedures in and outside of the operating room due to the rapid postoperative recovery with the use of relatively small amounts of sedatives and analgesics compared to general anesthesia. The purposes of MAC are providing patients with safe sedation, comfort, pain control and satisfaction. Preoperative evaluation for patients with MAC is similar to those of general or regional anesthesia in that patients should be comprehensively assessed. Additionally, patient cooperation with comprehension of the procedure is an essential component during MAC. In addition to local anesthesia by operators or anesthesiologists, systemic sedatives and analgesics are administered to provide patients with comfort during procedures performed with MAC. The discretion and judgment of an experienced anesthesiologist are required for the safety and efficacy profiles because the airway of the patients is not secured. The infusion of sedatives and analgesics should be individualized during MAC. Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.

Perioperative complications of orthopedic surgery for lower extremity in patients with cerebral palsy.

Because complications are more common in patients with cerebral palsy (CP), surgeons and anesthesiologists must be aware of perioperative morbidity and be prepared to recognize and treat perioperative complications. This study aimed to determine the incidence of and risk factors for perioperative complications of orthopedic surgery on the lower extremities in patients with CP. We reviewed the medical records of consecutive CP patients undergoing orthopedic surgery. Medical history, anesthesia emergence time, intraoperative body temperature, heart rate, blood pressure, immediate postoperative complications, Gross Motor Function Classification System (GMFCS) level, Cormack-Lehane classification, and American Society of Anesthesiologists physical status classification were analyzed. A total of 868 patients was included. Mean age at first surgery was 11.8 (7.6) yr. The incidences of intraoperative hypothermia, absolute hypotension, and absolute bradycardia were 26.2%, 4.4%, and 20.0%, respectively. Twenty (2.3%) patients had major complications, and 35 (4.0%) patients had minor complications postoperatively. The incidences of intraoperative hypothermia, absolute hypotension, and major postoperative complications were significantly higher in patients at GMFCS levels IV and V compared with patients at GMFCS levels I to III (P<0.001). History of pneumonia was associated with intraoperative absolute hypotension and major postoperative complications (P<0.001). These results revealed that GMFCS level, patient age, hip reconstructive surgery, and history of pneumonia are associated with adverse effects on intraoperative body temperature, the cardiovascular system, and immediate postoperative complications.