Risk factors associated with hypotensive bradycardic events during open shoulder surgery in the beach chair position.

BACKGROUND: Shoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs. METHODS: We retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at Samsung Medical Center. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine. RESULTS: Symptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs (odds ratio [OR]: 3.240, 95% CI: 2.003, 5.242, P < 0.001; OR: 1.060 for each 1-year increase, 95% CI: 1.044, 1.076, P < 0.001, respectively). Receiver operating curve analysis revealed that a threshold of 62 years of age had a moderate degree of accuracy for predicting symptomatic HBEs (area under curve: 0.764, 95% CI: 0.720, 0.804, P < 0.001). CONCLUSIONS: Considering the increasing risk of neurocognitive complications with aging, proactive hemodynamic management is needed, especially for elderly patients undergoing shoulder surgery in the beach chair position using ISB.

Severe lumbar radiculopathy with epidural venous plexus engorgement in a morbidly obese pediatric patient: A case report.

INTRODUCTION: Engorgement of the epidural venous plexus (EVP) is a rare cause of nerve root impingement. Dilated epidural veins cause compression of the thecal sac and spinal nerve roots, leading to lumbar radiculopathy. PATIENT CONCERNS: Here we describe a case of severe lumbar radiculopathy in a 15-year-old morbidly obese boy. DIAGNOSIS: Enhanced lumbar magnetic resonance imaging revealed left sided L1-L2 disc protrusion and engorgement of the lumbar EVP, resulting in narrowing of the thecal sac in the entire lumbar spine. There was no evidence of an intra-abdominal mass, thrombosis of the inferior vena cava, or vascular malformation. INTERVENTIONS: A caudal epidural block was administered under fluoroscopic guidance. The patient reported a 30% reduction in pain intensity for just 1 day. OUTCOMES: The patient has been followed up for 2 years. He continues to take medication, including morphine sulfate 15 mg, gabapentin 300 mg, and oxycodone 20 mg per day. He is on a diet with exercise for weight reduction. CONCLUSION: An engorged EVP should be considered in the differential diagnosis of radiculopathy in morbidly obese patients.

Clinical effect of the proximity of epidural blood patch injection to the leakage site in spontaneous intracranial hypotension.

BACKGROUND: Epidural blood patch (EBP) has been shown to be an effective treatment option for spontaneous intracranial hypotension (SIH). We investigated whether response to the EBP was related to the distance of the injection site from the leakage site in patients with SIH. METHODS: We reviewed patients with SIH who underwent EBP at a single hospital. Patients were assigned to group R (response after EBP) or group N (no response after EBP). We then analyzed the demographics, clinical characteristics, leakage site, leakage length, EBP injection level and distance from leakage site, and injected EBP volume. RESULTS: Sixty-two patients were included in the analysis. The overall response rate to EBP was 59.7% (37 patients). The leakage length and injection distance from the leakage site did not differ between the two groups. Age, gender, body mass index, leakage site, and EBP volume did not differ significantly between the two groups. CONCLUSION: The clinical effect of EBP in SIH was not affected by leakage length or injection distance to leakage site. Further large studies must be conducted to investigate the efficacy of targeted EBP for SIH.

Impact of surgical approach on postoperative delirium in elderly patients undergoing gastrectomy: laparoscopic versus open approaches.

BACKGROUND: Postoperative delirium is a frequent complication in elderly patients undergoing major abdominal surgery and is associated with a poor outcome. We compared postoperative delirium in elderly patients following laparoscopic gastrectomy (LG) versus open gastrectomy (OG). METHODS: In total, 130 patients aged ≥ 65 years with gastric cancer undergoing LG and OG were enrolled prospectively. Postoperative delirium and cognitive status were assessed daily using the Confusion Assessment Method (CAM) and Mini-Mental Status Examination (MMSE), respectively, for 3 days postoperatively. For CAM-positive patients, delirium severity was then assessed using the Delirium Index (DI). RESULTS: In total, 123 subjects (LG, n = 60; OG, n = 63) were included in the analysis. In both groups, the overall incidences of postoperative delirium were similar: 31.6% (19/60) in the LG group and 41.2% (26/63) in the OG group. When considering only those with delirium, the severity, expressed as the highest DI score, was similar between the groups. A decline in cognitive function (reduction in MMSE ≥ 2 points from baseline) during 3 days postoperatively was observed in 23 patients in the LG group (38.3%) and 27 patients in the OG group (42.9%) (P = 0.744). In both groups, postoperative cognitive decline was significantly associated with postoperative delirium (P < 0.001). CONCLUSIONS: We found that, compared with traditional open gastrectomy, laparoscopic gastrectomy did not reduce either postoperative delirium or cognitive decline in elderly patients with gastric cancer.

Effect of pre-warmed intravenous fluids on perioperative hypothermia and shivering after ambulatory surgery under monitored anesthesia care.

PURPOSE: The aim of this study was to evaluate the effects of pre-warmed (approximately 41 °C) intravenous fluids (IV) on perioperative hypothermia and postoperative shivering in female patients undergoing short, ambulatory urological surgery under monitored anesthesia care (MAC). METHODS: Patients between the ages of 35 and 80 years were randomly assigned to either the pre-warmed (n = 27) or the room temperature (n = 26) group. According to group allocation, either pre-warmed IV fluids that had been stored in a warming cabinet for at least 8 h or room temperature IV fluids were administered intraoperatively up to approximately 600-700 ml, including a bolus infusion of 10 ml/kg within 20 min. Perioperative core temperatures at the tympanic membrane, postoperative shivering, subjective thermal comfort, and the use of forced-air warming interventions in the post-anesthesia care unit (PACU) were recorded. RESULTS: Mean core temperatures were significantly higher in the pre-warmed group than they were in the room temperature group after 10 ml/kg preload fluid was administered, at the end of the operation, and on admission to the PACU (p = 0.004, p = 0.02, and p = 0.008, respectively). The incidence of hypothermia (<36 °C) was significantly lower in the pre-warmed group (n = 4) than in the room temperature group (n = 11, p = 0.035) upon PACU admission. The postoperative shivering incidence was also significantly lower in the pre-warmed group (n = 2) than in the room temperature group (n = 8, p = 0.039). CONCLUSIONS: Infusion of pre-warmed IV fluid improved the postoperative recovery profile by decreasing hypothermia and shivering in female patients undergoing short, ambulatory urological surgery under MAC.