Electroencephalographic spectrogram-guided total intravenous anesthesia using dexmedetomidine and propofol prevents unnecessary anesthetic dosing during craniotomy: a propensity score-matched analysis.

BACKGROUND: The bispectral index (BIS) may be unreliable to gauge anesthetic depth when dexmedetomidine is administered. By comparison, the electroencephalogram (EEG) spectrogram enables the visualization of the brain response during anesthesia and may prevent unnecessary anesthetic consumption. METHODS: This retrospective study included 140 adult patients undergoing elective craniotomy who received total intravenous anesthesia using a combination of propofol and dexmedetomidine infusions. Patients were equally matched to the spectrogram group (maintaining the robust EEG alpha power during surgery) or the index group (maintaining the BIS score between 40 and 60 during surgery) based on the propensity score of age and surgical type. The primary outcome was the propofol dose. Secondary outcome was the postoperative neurological profile. RESULTS: Patients in the spectrogram group received significantly less propofol (1585 ± 581 vs. 2314 ± 810 mg, P < 0.001). Fewer patients in the spectrogram group exhibited delayed emergence (1.4% vs. 11.4%, P = 0.033). The postoperative delirium profile was similar between the groups (profile P = 0.227). Patients in the spectrogram group exhibited better in-hospital Barthel's index scores changes (admission state: 83.6 ± 27.6 vs. 91.6 ± 17.1; discharge state: 86.4 ± 24.3 vs. 85.1 ± 21.5; group-time interaction P = 0.008). However, the incidence of postoperative neurological complications was similar between the groups. CONCLUSIONS: EEG spectrogram-guided anesthesia prevents unnecessary anesthetic consumption during elective craniotomy. This may also prevent delayed emergence and improve postoperative Barthel index scores.

Development of the Chronic Pain Cognition Scale: A Culture-Sensitive Pain Measurement in Chinese.

Purpose: People with pain problems are highly vulnerable to cultural disparities, and it is imperative to reduce these inequalities. This cross-sectional study aimed to develop a culturally sensitive Chronic Pain Cognition Scale (CPCS) for Chinese-/Chinese dialect-speaking populations and investigate its psychometric properties. Patients and Methods: Adult patients with chronic low back pain or chronic neck pain who visited pain clinics at a medical center in northern Taiwan were enrolled. Participants completed the demographic, intensity of pain, and two other related sensations, "Sng ()" and "Ma ()", often reported in Chinese-speaking populations, CPCS, Chronic Pain Acceptance Questionnaire-8, and Pain Self-Efficacy Questionnaire. Results: 200 patients were included. Patients' mean age was 64.84 ± 14.33, 126 (63.0%) were female, and 83 (41.5%) had 13+ years of education. The average duration of pain was 77.25 ± 97.46 months, the intensity of pain was 6.04 ± 2.50, Ma was 3.43 ± 3.24, and Sng was 4.54 ± 3.14. The CPCS comprised four factors: pain impact (how pain impact one's life), losing face (how one being disrespected due to pain), helplessness, and avoidance, with good structural validity and adequate reliability (Cronbach α, 0.60-0.81) and satisfactory criterion-related validity. Moreover, losing face, an essential concept in Chinese relationalism, was significantly related to pain, Sng, and Ma (r = 0.19, 0.15 and 0.16), but not to pain acceptance or self-efficacy, indicating a culturally specific element in pain measurement. Conclusion: The CPCS has good psychometric properties and is suitable for evaluating chronic pain in the clinical setting, and might be generalizable to other Chinese-/Chinese dialect-speaking populations.

Validation of Chinese version of a global anesthetic recovery questionnaire: A multicenter observational trial on ObsQoR-11.

BACKGROUND: The obstetric quality of recovery (ObsQoR-11) is considered one of the best patient-reported outcome measures of post-cesarean recovery. However, it has been neither validated in Chinese nor evaluated at >24 h after delivery. METHODS: Parturients from three hospitals (n = 279) completed the Chinese ObsQoR-11 at 24 h (T1) and 96 h (T2) after elective cesarean delivery. Convergent validity was assessed by correlation of Chinese ObsQoR-11 with a 100-mm numerical rating scale (NRS) of general health status; discriminant validity of good recovery (NRS ≥ 70-mm); and construct validity by correlation with influential factors to post-cesarean recovery. The reliability and responsiveness were also assessed. RESULTS: The Chinese ObsQoR-11 correlated moderately with the NRS [T1: r = 0.38 (95% confidence interval: 0.28-0.48), p < 0.0001; T2: r = 0.43 (95% confidence interval: 0.32-0.52), p < 0.0001] and discriminated between good and poor recovery [T1: mean (SD) score: 64 (20) vs 49 (17), p < 0.0001; T2: median (IQR) score: 81 (66-94) vs. 61 (53-72); p = 0.0002]; weakly correlated with gestational age, successful breastfeeding, and operation time. It was reliable (internal consistency: 0.75 (T1) and 0.82 (T2); split-half: 0.77 (T1) and 0.85 (T2); test-retest intraclass correlation coefficient r > 0.6 for each item) and responsive (Cohen effect size: 0.88; standardized response mean: 0.81). CONCLUSION: The Chinese ObsQoR-11may be used for assessing recovery at 24 h and 96 h after cesarean delivery. However, its' cutoff value for good recovery may be lower than that of other versions.

Subcellular Distribution of BALF2 and the Role of Rab1 in the Formation of Epstein-Barr Virus Cytoplasmic Assembly Compartment and Virion Release.

Epstein-Barr virus (EBV) replicates its genome in the nucleus and undergoes tegumentation and envelopment in the cytoplasm. We are interested in how the single-stranded DNA binding protein BALF2, which executes its function and distributes predominantly in the nucleus, is packaged into the tegument of virions. At the mid-stage of virus replication in epithelial TW01-EBV cells, a small pool of BALF2 colocalizes with tegument protein BBLF1, BGLF4 protein kinase, and the cis-Golgi marker GM130 at the perinuclear viral assembly compartment (AC). A possible nuclear localization signal (NLS) between amino acids 1100 and 1128 (C29), which contains positive charged amino acid 1113RRKRR1117, is able to promote yellow fluorescent protein (YFP)-LacZ into the nucleus. In addition, BALF2 interacts with the nucleocapsid-associated protein BVRF1, suggesting that BALF2 may be transported into the cytoplasm with nucleocapsids in a nuclear egress complex (NEC)-dependent manner. A group of proteins involved in intracellular transport were identified to interact with BALF2 in a proteomic analysis. Among them, the small GTPase Rab1A functioning in bi-directional trafficking at the ER-Golgi interface is also a tegument component. In reactivated TW01-EBV cells, BALF2 colocalizes with Rab1A in the cytoplasmic AC. Expression of dominant-negative GFP-Rab1A(N124I) diminished the accumulation of BALF2 in the AC, coupling with attenuation of gp350/220 glycosylation. Virion release was significantly downregulated by expressing dominant-negative GFP-Rab1A(N124I). Overall, the subcellular distribution of BALF2 is regulated through its complex interaction with various proteins. Rab1 activity is required for proper gp350/220 glycosylation and the maturation of EBV. IMPORTANCE Upon EBV lytic reactivation, the virus-encoded DNA replication machinery functions in the nucleus, while the newly synthesized DNA is encapsidated and transported to the cytoplasm for final virus assembly. The single-stranded DNA binding protein BALF2 executing functions within the nucleus was also identified in the tegument layer of mature virions. Here, we studied the functional domain of BALF2 that contributes to the nuclear targeting and used a proteomic approach to identify novel BALF2-interacting cellular proteins that may contribute to virion morphogenesis. The GTPase Rab1, a master regulator of anterograde and retrograde endoplasmic reticulum (ER)-Golgi trafficking, colocalizes with BALF2 in the juxtanuclear concave region at the midstage of EBV reactivation. Rab1 activity is required for BALF2 targeting to the cytoplasmic assembly compartment (AC) and for gp350/220 targeting to cis-Golgi for proper glycosylation and virion release. Our study hints that EBV hijacks the bi-directional ER-Golgi trafficking machinery to complete virus assembly.

Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial.

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter-incision incongruent for cesarean delivery. METHODS: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. RESULTS: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). CONCLUSIONS: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Influence of scalp block on oncological outcomes of high-grade glioma in adult patients with and without isocitrate dehydrogenase-1 mutation.

High-grade gliomas are notorious for a high recurrence rate even after curative resection surgery. Studies regarding the influence of scalp block on high-grade gliomas have been inconclusive, possibly because the condition's most important genetic mutation profile, namely the isocitrate dehydrogenase 1 (IDH1) mutation, had not been analyzed. Therefore, we conducted a single-center study including patients with high-grade glioma who underwent tumor resection between January 2014 and December 2019. Kaplan-Meier survival analysis revealed that scalp block was associated with longer progression-free survival (PFS; 15.17 vs. 10.77 months, p = 0.0018), as was the IDH1 mutation (37.37 vs. 10.90 months, p = 0.0149). Multivariate Cox regression analysis revealed that scalp block (hazard ratio: 0.436, 95% confidence interval: 0.236-0.807, p = 0.0082), gross total resection (hazard ratio: 0.405, 95% confidence interval: 0.227-0.721, p = 0.0021), and IDH1 mutation (hazard ratio: 0.304, 95% confidence interval: 0.118-0.784, p = 0.0138) were associated with better PFS. Our results demonstrate that application of scalp block, regardless of IDH1 profile, is an independent factor associated with longer PFS for patients with high-grade glioma.

Comparison of inhaled nitric oxide with aerosolized prostacyclin or analogues for the postoperative management of pulmonary hypertension: a systematic review and meta-analysis.

Background: This study aims to compare the effectiveness of inhaled prostacyclin or its analoguesversus nitric oxide (NO) in treating pulmonary hypertension (PH) after cardiac or pulmonary surgery remains unclear.Methods: PubMed, Cochrane, and Embase databases were searched for literature published prior to December 2019 using the following keywords: inhaled, nitric oxide, prostacyclin, iloprost, treprostinil, epoprostenol, Tyvaso, flolan, and pulmonary hypertension. Randomized controlled trials and multiple-armed prospective studies that evaluated inhaled NO versus prostacyclin (or analogues) in patients for perioperative and/or postoperative PH after either cardiac or pulmonary surgery were included. Retrospective studies, reviews, letters, comments, editorials, and case reports were excluded.Results: Seven studies with a total of 195 patients were included. No difference in the improvement of mean pulmonary arterial pressure (pooled difference in mean change= -0.10, 95% CI: -3.98 to 3.78, p = .959) or pulmonary vascular resistance (pooled standardized difference in mean change= -0.27, 95% CI: -0.60 to 0.05, p = .099) were found between the two treatments. Similarly, no difference was found in other outcomes between the two treatments or subgroup analysis.Conclusions: Inhaled prostacyclin (or analogues) was comparable to inhaled NO in treating PH after cardiac or pulmonary surgery.Key messagesThis study compared the efficacy of inhaled prostacyclin or its analogues versus inhaled NO to treat PH after surgery. The two types of agent exhibited similar efficacy in managing MPAP, PVR, heart rate, and cardiac output was observed.Inhaled prostacyclin may serve as an alternative treatment option for PH after cardiac or pulmonary surgery.

Is robotic hepatectomy cost-effective? In view of patient-reported outcomes.

BACKGROUND: Robotic hepatectomy has been accepted as an alternative for patients needing surgery. However, few reports addressed the patient-reported outcomes and long-term quality of life (QoL) of patients having undergone robotic liver surgery. METHODS: This study presented the QoL and cost-effectiveness associated with robotic and open hepatectomy by performing a comparative survey using two standardized questionnaires (Short Form-36 and Gastrointestinal Quality of Life Index). RESULTS: One hundred patients completed the study. The robotic group tended to experienced longer operation time but shorter length of hospital stay compared to open group. Moreover, the robotic group had faster return to daily activities, less need of patient-controlled anesthesia, and less wound-related complaints in long-term follow-up. The robotic group incurred higher peri-operative expenses; however, the cost of inpatient care was lower. CONCLUSIONS: Our study suggested that robotic hepatectomy provided good post-operative QoL and recovery of daily activity. However, efforts for lowering the financial burden of medical care by reducing the cost of robotic surgery is necessary for further application.

Leading Comorbidity associated with 30-day post-anesthetic mortality in geriatric surgical patients in Taiwan: a retrospective study from the health insurance data.

BACKGROUND: Elderly patients with aged physical status and increased underlying disease suffered from more postoperative complication and mortality. We design this retrospective cohort study to investigate the relationship between existing comorbidity of elder patients and 30 day post-anesthetic mortality by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) from Health Insurance Database. METHODS: Patients aged above 65 years old who received anesthesia between 2000 and 2010 were included from 1 million Longitudinal Health Insurance Database in (LHID) 2005 in Taiwan. We use age, sex, type of surgery to calculate propensity score and match death group and survival one with 1:4 ratio (death: survival = 1401: 5823). Multivariate logistic model with stepwise variable selection was employed to investigate the factors affecting death 30 days after anesthesia. RESULTS: Thirty seven comorbidities can independently predict the post-anesthetic mortality. In our study, the leading comorbidities predict post-anesthetic mortality is chronic renal disease (OR = 2.806), acute myocardial infarction (OR = 4.58), and intracranial hemorrhage (OR = 3.758). CONCLUSIONS: In this study, we present the leading comorbidity contributing to the postoperative mortality in elderly patients in Taiwan from National Health Insurance Database. Chronic renal failure is the leading contributing comorbidity of 30 days mortality after anesthesia in Taiwan which can be explained by the great number of hemodialysis and prolong life span under National Taiwan Health Insurance. Large scale database can offer enormous information which can help to improve quality of medical care.

Long-term outcomes of totally implantable venous access devices.

PURPOSE: Identifying risk factors for premature totally implantable venous access device (TIVAD) catheter removal is crucial; however, because of the diversity of study methodologies, there is no consensus on such factors. The objective of the present study was to identify such risk factors by applying a cohort design study with a long-term follow-up period. METHODS: For this cohort study, we selected cancer patients who had newly implanted TIVADs between July 2008 and December 2008. The follow-up period lasted until September 2012. Univariate analysis was performed for age, gender, cancer type, TIVAD brand, puncture site, sidedness of puncture, and catheter tip position. The hazard ratio (HR) of potential risk factors was calculated using the Cox proportional hazards regression model, and Kaplan-Meier curves were applied for catheter survival analysis. RESULTS: Our study consisted of 240 people, with 5 people lost to follow-up. The cumulative premature catheter removal rate of all TIVADs was 9.8%, with the most common reason for premature removal being port-associated blood stream infection (PABSI), which proved to be highest in patients with hematology cancer (27.8%) and upper gastrointestinal cancer (19.4%). Suboptimal tip position (HR 5.13, 95% confidence interval 1.73-15.21) was also a risk factor for premature removal, and it was correlated with symptomatic TIVAD occlusion (p = 0.0004). CONCLUSIONS: PABSI was the most common reason for premature catheter removal, with a varied incidence rate between different cancer types. Suboptimal tip position was also a risk factor. Confirming the final tip position after implantation is crucial. Infection control is important for TIVAD care, especially in high-risk cancer patients.

Robotic Versus Open Hepatectomy for Hepatocellular Carcinoma: A Matched Comparison.

BACKGROUND: Robotic hepatectomy has been suggested to be a safe and effective approach for liver disease; however, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma (HCC) are limited. Accordingly, we performed a matched comparison of surgical and oncological outcomes between robotic and open hepatectomy. METHODS: Between January 2012 and October 2015, a total of 183 patients underwent robotic hepatectomy and 275 patients underwent open hepatectomy by the same surgical team in our center. Eighty-one newly diagnosed HCC cases in each group were compared under propensity score matching (PSM) in a 1:1 ratio. RESULTS: With robotic hepatectomy, the conversion rate was 1.6 % and the complication rate was 4.4 %. On PSM, the groups had a comparable percentage of major liver resections (41.9 vs. 39.5 %) and liver cirrhosis (45.7 vs. 46.9 %). Compared with the open group, the robotic group required longer operation times (343 vs. 220 min), shorter hospital stays (7.5 vs. 10.1 days), and lower dosages of postoperative patient-controlled analgesia (350 vs. 554 ng/kg). The 3-year disease-free survival of the robotic group was comparable with that of the open group (72.2 % vs. 58.0 %; p = 0.062), as was the 3-year overall survival (92.6 vs. 93.7 %; p = 0.431). CONCLUSIONS: This is the first oncological study comparing robotic liver resection for HCC with open resection. Robotic hepatectomy can be applied for challenging major resections in patients with cirrhotic liver disease with less postoperative pain and shorter hospital stays without compromising oncological outcomes.

Mirtazapine, in orodispersible form, for patients with preoperative psychological distress: A pilot study.

BACKGROUND: Perioperative psychological distress is associated with preoperative anxiety, depression, and postoperative pain. Mirtazapine is effective as an antidepressant, anxiolytic agent, and sleep enhancer. Moreover, mirtazapine can be made as orodispersible tablets with a fast onset for patients in nil per os status. This study is to determine whether mirtazapine can help psychologically distressed patients reduce perioperative anxiety, depression, and postoperative pain. MATERIALS AND METHODS: Patients with preoperative psychological distress, undergoing major abdominal surgery, were inquired and assigned to two groups according to their own choice. In the treatment group, patients could choose to take orodispersible mirtazapine 30 mg at each night from Preoperative Day 0 to Postoperative Day 3. There was no other intervention in the nontreatment group. Hospital Anxiety and Depression Scale (HADS), Athens Insomnia Scale (AIS), and pain scores were accessed on the day before operation (Day 0), and on the 1(st) day (Day 2) and 3(rd) day (Day 4) after operation. We compared the HADS, AIS, and pain scores, and morphine consumptions between the two groups on a daily basis. Marginal regression models were fitted to our correlated longitudinal data alone with the generalized estimating equations method to estimate the population average effects of time-varying mirtazapine usage on the mean values of HADS, AIS, and pain scores, and daily morphine consumptions. RESULTS: From September 2007 to December 2008, 86 patients agreed to be enrolled and 79 of them completed the study. Propensity scores and multivariate analysis showed that mirtazapine reduced HADS scores of patients in 2 days. Trial results indicated that mirtazapine lowered the AIS day index and tended to decrease night index as well. Mirtazapine may reduce patients' morphine consumption, but this effect was not statistically significant (p = 0.2). CONCLUSION: Mirtazapine helps reduce anxiety, depression, and insomnia scores for patients with perioperative psychological distress.

Metastatic breast cancer with right ventricular erosion.

Cancer that has metastasized to the heart and pericardium has a dismal outcome. Individualized treatment to preserve the quality of life and reduce surgical mortality is important. We describe a 57-year old woman who had a recurrence of breast cancer 23 years after the initial complete treatment. Cardiac metastasis with poor anterior chest wall healing led to right ventricular rupture, which caused hypovolaemic shock. The right ventricular wall defect was repaired with a percutaneous patch and a myocutaneous flap without cardiopulmonary bypass. The patient was discharged home after intensive wound care. Our patient shows that even with complete initial treatment, clinicians should be alert for the recurrence of breast cancer.

Fast Track ultrasound protocol to detect acute complications after totally implantable venous access device placement.

BACKGROUND: The role of ultrasound examination in detection of postprocedure complications from totally implantable venous access devices (TIVAD) placement is still uncertain. In a cohort of 665 cancer outpatients, we assessed a quick ultrasound examination protocol in early detection of mechanical complications of catheterization. METHODS: Immediately after TIVAD placement, an ultrasound examination and chest radiography were performed to detect hemothorax, pneumothorax, and catheter malposition. The two methods were compared. RESULTS: Of the 668 catheters inserted, 628 were placed into axillary veins and 40 into internal jugular veins. The ultrasound examination took 2.5 ± 1.1 min. No hemothorax was detected, and neither pneumothorax nor catheter malposition was evident among the 40 internal jugular vein cannulations. Ultrasound and chest radiography examinations of the 628 axillary vein cannulations detected five and four instances of pneumothorax, respectively. Ultrasound detected all six catheter malpositions into the internal jugular vein. However, ultrasound failed to detect two out of three malpositions in the contralateral brachiocephalic vein and one kinking inside the superior vena cava. Without revision surgery, the operating time was 34.1 ± 15.6 min. With revision surgery, the operating time was shorter when ultrasound detected catheter malposition than when chest radiography was used (96.8 ± 12.9 vs. 188.8 ± 10.3 min, p < 0.001). CONCLUSIONS: Postprocedure ultrasound examination is a quick and sensitive method to detect TIVAD-related pneumothorax. It also precisely detects catheter malposition to internal jugular vein thus reduces time needed for revision surgery while chest radiography remains necessary to confirm catheter final position.

Evaluation of tracheal intubation: A retrospective study of skill acquisition by medical students in the operating theater.

BACKGROUND/PURPOSE: Tracheal intubation is a critical life-saving invasive procedure. Medical students generally obtain the skill of performing tracheal intubation in the operating theater during their anesthesiology rotation. In this study, we sought to characterize medical students' skill acquisition of tracheal intubation. METHODS: We retrospectively reviewed the logbooks of 94 medical students who had completed a 3-4 week rotation in our department between January 2011 and June 2012. RESULTS: Ninety-four students performed 934 tracheal intubations. The success rate of intubation was 76.7%. After adjustment for age, body mass index, Mallampati class and grade, American Society of Anesthesiology (ASA) scores, and surgical category, the odds ratio of successful tracheal intubation improved with cumulative practice [odds ratio (OR) = 1.05 for each additional intubation performed; 95% confidence interval (CI) 1.00-1.09]. By contrast, the success rate decreased significantly with increasing scores of Mallampati class (OR = 0.32 for each increase in class; 95% CI 0.23-0.24) and grade (OR = 0.57 for each increase in grade; 95% CI 0.39-0.84). The main reason for intubation failure (57%) was poor visualization of vocal cords, due to suboptimal placement of the position of the laryngoscope. The satisfaction and confidence of students regarding the ability of performing tracheal intubation increased with each additional procedure, but decreased significantly after multiple unsuccessful attempts and the occurrence of any complication. CONCLUSION: Medical students acquired the ability of tracheal intubation and overcame major challenges through cumulative clinical practice of the procedure.

Injury Location and Mechanism for Complex Regional Pain Syndrome: A Nationwide Population-Based Case-Control Study in Taiwan.

BACKGROUND: Few studies have investigated the relationship between injury location, mechanism and their association with complex regional pain syndrome (CRPS). We conducted a nationwide database survey to explore this issue. METHODS: This was a population-based case-control study. Five hundred and eighty-nine patients with at least one ambulatory visit or admission with a principal diagnosis of CRPS from 2004 to 2009 were selected. For each CRPS patient, ten age- and sex-matched non-CRPS subjects were randomly selected. The odds ratios (PLoS One. 2013;8:e57205) and 95% confidence intervals (95% CIs) of risk factors for CRPS were derived from multivariate logistic regression models. RESULTS: Injury was a risk factor for CRPS (OR, 2.96; 95% CI, 2.18 to 4.02) independent of age and sex. In adjusted models, open wound on the upper limbs (OR 1.25, 95% CI 1.02 to 1.54) conferred higher CRPS risk. Injury mechanisms including nerve and spinal cord injury (OR 2.42, 95% CI 1.44 to 4.08), muscle and joint sprain and strain (OR 1.69, 95% CI 1.40 to 2.03), superficial injury (OR 1.23, 95% CI 1.00 to 1.51), and contusion (OR 1.44, 95% CI 1.20 to 1.74), but not fracture, increased the risk of CRPS. CONCLUSION: Injury in the extremities rather than the trunk is an important risk factor for CRPS. Certain injury mechanisms confer higher risk of CRPS. This nationwide study demonstrated that injury increased CRPS nearly threefold. Open wound, sprain and strain, superficial injury, contusion, and nerve and spinal cord injury are main injury mechanisms. Injury in the extremities confers a higher risk of CRPS.

Transcatheter aortic valve implantation: Anesthetic experience of retrograde transfemoral approach with CoreValve ReValving System.

OBJECTIVES: Valvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure. METHODS: We included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded. RESULTS: The mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5-10 µg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality. CONCLUSION: TAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.

The admission systemic inflammatory response syndrome predicts outcome in patients undergoing emergency surgery.

OBJECTIVE: To investigate the incidence of systemic inflammatory response syndrome (SIRS) on emergency department admission and the prognostic significance of SIRS in patients undergoing emergency surgery. METHODS: This is a retrospective study of 889 adults who were admitted as emergency cases and were operated on within 24 hours of admission. Data on patient demography, clinical information including comorbidities, categories of surgery, American Society of Anesthesiologists physical status, SIRS score, postoperative outcomes including duration of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay, and mortality were collected. RESULTS: SIRS occurred in 43% of the patients and was associated with a significantly worse outcome in terms of duration of ventilator use (10.5 ± 15.4 vs. 3.5 ± 4.4 days, p < 0.001), ICU stay (11.2 ± 13.6 vs. 5.0 ± 5.4 days, p < 0.001), hospital length of stay (19.4 ± 22.4 vs. 7.1 ± 7.6 days, p < 0.001) and mortality (12.7% vs. 0.4%, p < 0.001). After adjusting for covariates (including age, gender, American Society of Anesthesiologists physical status, comorbid conditions, and surgery categories), SIRS was independently associated with higher mortality (adjusted odd ratio, 21.5; 95% confidence interval (CI), 4.9-93.2), longer ventilator duration (adjusted coefficient, 7.8; 95% CI, 3.2-12.5), longer ICU stay (adjusted coefficient, 6.2; 95% CI, 2.6-9.8) and longer hospital stay (adjusted coefficient, 9.7; 95% CI, 7.5-11.9). CONCLUSION: The presence of SIRS at admission in patients receiving emergency surgery predicted worse outcomes and higher mortality rates.

Compatibility and stability of binary mixtures of ketorolac tromethamine and tramadol hydrochloride injection concentrate and diluted infusion solution.

OBJECTIVE: Ketorolac added to tramadol as an injection mixture convenient for clinical use has been shown to be an effective balanced analgesic regimen in alleviating moderate-to-severe pain. However, analytical confirmation of the compatibility and stability of this combination is not available. This study examined the compatibility and stability of this combination. METHODS: Two different mixtures containing ketorolac tromethamine and tramadol hydrochloride were examined: ketorolac (10 mg/mL) and tramadol (33.3 mg/mL) prepared as injection concentrate in ampoule mingled together in the ratio of one ampoule to one ampoule; diluted ketorolac (2 mg/mL) and tramadol (20 mg/mL) prepared in saline infusion solution, with or without pH adjustment. The mixtures were visually inspected for precipitation and color change. Quantitative chemical analysis was performed on days 0, 1, 3 and 7 by high-performance liquid chromatography. RESULTS: When stored at room temperature under ambient light, the ketorolac (10 mg/mL)-tramadol (33.3 mg/mL) injection concentrate and ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution, without pH adjustment and adjusted to pH 5-8, were physico-chemically stable, and neither visible precipitation nor loss of concentration was found. With the ketorolac (2 mg/mL)-tramadol (20 mg/mL) solution adjusted to pH 9, however, precipitation occurred immediately, resulting in a significant loss of tramadol. CONCLUSION: This study suggests that a ready-to-use ketorolac-tramadol mixture, either undiluted or diluted in physiological saline solution, can be prepared, with a shelf life of at least 7 days when stored at room temperature under ambient light.