Evaluating the Efficacy of the Erector Spinae Plane Block as a Supplementary Approach to Cardiac Anesthesia during Off-Pump Coronary Bypass Graft Surgery via Median Sternotomy: A Randomized Clinical Trial.

Background: Pain control after off-pump coronary artery bypass graft (OPCAB) facilitates mobilization and improves outcomes. The efficacy of the erector spinae plane block (ESPB) after cardiac surgery remains controversial. Methods: We aimed to investigate the analgesic effects of ESPB after OPCAB. Precisely 56 patients receiving OPCAB were randomly divided into ESPB and control groups. The primary outcome was visual analog scale (VAS) pain scores at 6, 12, 24, and 48 h postoperatively. Secondary outcomes were the dose of rescue analgesics in terms of oral morphine milligram equivalents, the dose of antiemetics, the length of intubation time, and the length of stay in the intensive care unit (ICU). Results: The VAS scores were similar at all time points in both groups. The incidence of severe pain (VAS score > 7) was significantly lower in the ESPB group (50% vs. 15.4%; p = 0.008). The dose of rescue analgesics was also lower in the ESPB group (19.04 ± 18.76, 9.83 ± 12.84, p = 0.044) compared with the control group. The other secondary outcomes did not differ significantly between the two groups. Conclusions: ESPB provides analgesic efficacy by reducing the incidence of severe pain and opioid use after OPCAB.

Incidence of intraoperative hypotension in older patients undergoing total intravenous anesthesia by remimazolam versus propofol: A randomized controlled trial.

BACKGROUND: An increase in the frequency of surgeries among older individuals is observed in some countries. Hypotension is common and exaggerated in older patients and can lead to increased morbidity and mortality. Total intravenous anesthesia is commonly administered with propofol, while remimazolam has been suggested as an alternative to propofol because of advantages such as a more stable hemodynamic profile and less respiratory suppression. We conducted a single-blind, parallel-group randomized controlled trial to compare the incidence of intraoperative hypotension between patients administered with remimazolam and propofol. METHODS: A total of 132 patients, aged between 65 to 80 years and undergoing laparoscopic cholecystectomy or transurethral resection of bladder tumors were randomly assigned to the propofol or remimazolam group with a permuted block system while being blinded to the hypnotic agent. Remifentanil was administered via target-controlled infusion in both groups, with an initial effect-site concentration of 3.0 ng/mL and titration range of 1.5 to 4.0 ng/mL intraoperatively. The primary outcome of this study was the overall incidence of hypotension during general anesthesia. RESULTS: Patients in the propofol group experienced higher intraoperative hypotension than those in the remimazolam group (59.7% vs 33.3%, P = .006). Multivariate logistic regression analysis showed that remimazolam administration was associated with reduced hypotension (adjusted odds ratio, 0.34; 95% CI, 0.16-0.73). Secondary outcomes such as recovery time, delirium, and postoperative nausea and vomiting were comparable in both groups. CONCLUSION: Total intravenous anesthesia with remimazolam was associated with less intraoperative hypotension than propofol in older patients, with a comparable recovery profile.

Massive pulmonary embolism after caesarean section managed with surgical thrombectomy bridged with extracorporeal membrane oxygenation: A case report.

INTRODUCTION: Pulmonary embolism (PE) is a rare but fatal complication in postpartum women. Mortality is as high as 65% in massive PE, in which systemic hypotension persists or circulatory collapse occurs. This case report describes a patient who underwent a caesarean section complicated by massive PE. The patient was managed with early surgical embolectomy and bridged with extracorporeal membrane oxygenation (ECMO). PRESENTATION OF CASE: A 36 years old postpartum patient with an unremarkable medical history had sudden cardiac arrest due to PE on the day after a caesarean section. The patient recovered spontaneous cardiac rhythm after cardiopulmonary resuscitation; however, hypoxia and shock persisted. Cardiac arrest and spontaneous circulation recovery were repeated twice per hour. Veno-arterial (VA) ECMO rapidly improved the patient's condition. Surgical embolectomy was conducted 6 h after the initial collapse by the experienced cardiovascular surgeon. The patient's condition improved rapidly, and was weaned from ECMO on postoperative day three. The patient recovered normal heart function and no pulmonary hypertension was observed on follow-up echocardiography performed 15 months later. DISCUSSION: Timely intervention is important in the management of PE because of its rapid progression. VA ECMO is a useful bridge therapy to prevent derangement and severe organ failure. Surgical embolectomy is appropriate following the use of ECMO in postpartum patients because of the risk of major haemorrhagic complications or intracranial haemorrhage. CONCLUSION: In patients who have undergone caesarean section complicated by massive PE, surgical embolectomy is preferred because of the risk of haemorrhagic complications and their relatively young age.

Post-induction hypotension with remimazolam versus propofol in patients routinely administered angiotensin axis blockades: a randomized control trial.

BACKGROUND: Certain routine medication could result in post-induction hypotension (PIH), such as angiotensin axis blockades, which are frequently administered as a first-line therapy against hypertension. Remimazolam is reportedly associated with lesser intraoperative hypotension than propofol. This study compared the overall incidence of PIH following remimazolam or propofol administration in patients managed by angiotensin axis blockades. METHODS: This single-blind, parallel-group, randomized control trial was conducted in a tertiary university hospital in South Korea. Patients undergoing surgery with general anesthesia were considered for enrollment if the inclusion criteria were met: administration of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 19 to 65 years old, American Society of Anesthesiologists physical status classification ≤ III, and no involvement in other clinical trials. The primary outcome was the overall incidence of PIH, defined as a mean blood pressure (MBP) < 65 mmHg or decrease by ≥ 30% of the baseline MBP. The time points of measurement were baseline, just before the initial intubation attempt, and 1, 5, 10, and 15 min following intubation. The heart rate, systolic and diastolic blood pressures, and bispectral index were also recorded. Groups P and R included patients administered propofol and remimazolam, respectively, as an induction agent. RESULTS: A total of 81 patients were analyzed, of the 82 randomized patients. PIH was less frequent in group R than group P (62.5% versus 82.9%; t value 4.27, P = 0.04, adjusted odds ratio = 0.32 [95% confidence interval 0.10-0.99]). The decrease in the MBP from baseline was 9.6 mmHg lesser in group R than in group P before the initial intubation attempt (95% confidence interval 3.3-15.9). A similar trend was observed for systolic and diastolic blood pressures. No severe adverse events were observed in either group. CONCLUSION: Remimazolam results in less frequent PIH than propofol in patients undergoing routine administration of angiotensin axis blockades. TRIAL REGISTRATION: This trial was retrospectively registered on Clinical Research Information Service (CRIS), Republic of Korea (KCT0007488). Registration date: 30/06/2022.

Temporal and spatial distribution of microplastic in the sediment of the Han River, South Korea.

Sediments are sinks for microplastics (MPs) in freshwater environments. It is, therefore, necessary to investigate the occurrence and fate of accumulated MPs in the sediments, which pose a risk to aquatic organisms. We conducted the first comprehensive investigation of MPs in riverine sediment in South Korea to examine the temporal and spatial distribution of MPs in the sediment at the two main branches and downstream of the Han River. The average abundance of MPs over all sites was 0.494 ± 0.280 particles/g. Spatially, the MP abundance at three sites in the North Han River (0.546 ± 0.217 particles/g) was higher than those in the South Han River (0.383 ± 0.145 particles/g) and downstream of the Han River (0.417 ± 0.114 particles/g). The abundances of MPs before dams at two upstream sites were significantly higher than that at other sites because of the slow river flow velocity attributed to the artificial structure. The abundance of MPs after the mosoon season (October, 0.600 ± 0.357 particles/g) was higher than that before the mosoon season (April, 0.389 ± 0.099 particles/g). The most common polymer types observed were polyethylene (>38%) and polypropylene (>24%). Irrespective of the location and season, greater than 93% of MPs identified were fragments, and the remaining were fibers. The concentrations of TOC, TN, and TP in the sediment were positively correlated with MP abundance. MP abundance was also positively correlated with clay and silt fractions of the sediment; however, it was negatively correlated with sand fraction. This study provides a basis for the management of MP pollution by offering findings related to critical factors influencing MP abundance in sediment.

New insights into the occurrence and removal of 36 pesticides in pesticide wastewater treatment plants in Korea.

This study investigates the occurrence of 36 pesticides-including 33 that were monitored from 2007 to 2019 in Korean rivers-in wastewaters from pesticide manufacturing facilities (PMFs) and in 13 pesticide wastewater treatment plants (PWWTPs). Furthermore, an approach for the effective removal of these pesticides from pesticide wastewater (PW) is proposed. Among the 36 pesticides investigated, 32 were found to be present in the PMF wastewater and PWWTP influents (at concentrations ≤466.8 mg/L). In addition, 24 of the 36 pesticides were detected in PWWTP effluents, indicating that effluents are discharged without the complete removal of many pesticides. Moreover, the PWWTP effluent influences the presence of pesticides in river (confidence interval: ≥ 95%; p < 0.05). Although the chemical oxidation-activated sludge process is frequently recommended for the treatment of PWs, the findings from the current study indicate that an activated sludge-activated carbon adsorption process is more suitable for PW treatment due to its superior removal efficiency, treatment stability, and economic feasibility. Consequently, its application for the treatment of PWs can markedly decrease the levels of pesticides discharged into rivers.

The Analgesic Efficacy of the Single Erector Spinae Plane Block with Intercostal Nerve Block Is Not Inferior to That of the Thoracic Paravertebral Block with Intercostal Nerve Block in Video-Assisted Thoracic Surgery.

This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain (0-10, where 10 = worst imaginable pain) in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction (1-5, where 5 = extremely satisfied) and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups (PACU: 2.0 (1.8, 5.3) vs. 2.0 (2.0, 4.0), p = 0.970; 24 h: 2.0 (0.8, 3.0) vs. 2.0 (1.0, 3.5), p = 0.993; 48 h: 1.0 (0.0, 3.5) vs. 1.0 (0.0, 5.0), p = 0.985). The upper limit of the 95% CI for the differences (PACU: 1.428, 24 h: 1.052, 48 h: 1.176) was within the predefined noninferiority margin of 2. Total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, p = 0.767) and satisfaction scores (3.5 (3.0, 4.0) vs. 4.0 (3.0, 5.0), p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.

Occurrence and characteristics of microplastics in fish of the Han River, South Korea: Factors affecting microplastic abundance in fish.

This study examined the abundance of microplastics (MPs) in 106 fish from 22 species inhabiting three sites of the Han River, South Korea. In total, 1753 MPs from 106 fish samples were identified with an average abundance of 15.60 ± 13.45 MPs per individual fish (MPs indiv-1) in the North Han River, 16.35 ± 12.32 MPs indiv-1 in the South Han River, and 20.14 ± 10.01 MPs indiv-1 in downstream of the Han River, indicating that the fish in the downstream of the Han River was the most contaminated by MPs. The dominant size of MPs detected in fish ranged between 0.1 and 0.2 mm, and the most common polymer types found in fish were polypropylene (PP) (≥40%) and polyethylene (PE) (≥23%), followed by polytetrafluoroethylene (PTFE) (≥16%) at all sampling locations. A significant correlation was observed between the log-transformed number of MPs with log-transformed fish length (p < 0.01) and with log-transformed fish weight (p < 0.01). The Kruskal-Wallis test disclosed a significant difference in the number of MPs among the feeding habits (p < 0.01), indicating that omnivorous and insectivorous fish contained more MPs than carnivorous and herbivorous fish. In addition, fish habitat result showed that pelagic fish contained a higher level of MPs than demersal fish, but no significant differences in the number of MPs among fish habitats were observed (p > 0.05).

Novel techniques to determine dilution ratios of raw wastewater and wastewater treatment plant effluent in the 5-day biochemical oxygen demand test.

The current 5-day biochemical oxygen demand (BOD5) test methods lack detailed information on sample dilution, which typically leads to an incorrect dilution ratio of samples and failed BOD5 testing. This study proposed an improved dilution technique that effectively determines the dilution ratios for raw wastewater and wastewater treatment plants (WWTPs) effluent. The numbers of raw wastewater and WWTPs effluent samples used in the BOD5 tests were 201 and 61, respectively. The experimental results demonstrated that both the raw wastewater and WWTPs effluent varied in BOD5 values with the sample dilution ratio, and these changes were more noticeable when the dissolved oxygen consumption ratio (DOCR) was less than 20% or when the dilution ratio was large. Assuming that the BOD5 value over the DOCR range of 40%-70% was true, the optimal DOCR range was 40%-90% for the raw wastewater and 40%-70% and 80%-90% for the WWTPs effluent, where the relative error of BOD5 values in these DOCR ranges was less than 10% depending on the dilution ratio. The correlation between the sample dilution ratio and the BOD5 value over the optimal DOCR range was considerably higher than that over the entire DOCR range. This was combined with the correlation equation between BOD5 and chemical oxygen demand to propose an equation that could determine more accurate sample dilution ratios for raw wastewater and WWTPs effluent compared to the conventional sample dilution methods for the BOD5 test.

Dynamic Indices Fail to Predict Fluid Responsiveness in Patients Undergoing One-Lung Ventilation for Thoracoscopic Surgery.

Thoracic surgery using CO2 insufflation maintains closed-chest one-lung ventilation (OLV) that may provide the necessary heart-lung interaction for the dynamic indices to predict fluid responsiveness. We studied whether pulse pressure variation (PPV) and stroke volume variation (SVV) can predict fluid responsiveness during thoracoscopic surgery. Forty patients were enrolled in the study. OLV was performed with a tidal volume of 6 mL/kg at a positive end-expiratory pressure of 5 cm H2O, while CO2 was insufflated to the contralateral side at 8 mm Hg. Patients whose stroke volume index (SVI) increased ≥15% after fluid challenge (7 mL/kg) were defined as fluid responders. The predictive ability of PPV and SVV on fluid responsiveness was investigated using the area under the receiver-operator characteristic curve (AUROC), which was also assessed according to the right or left lateral decubitus position considering the intrathoracic location of the right-sided superior vena cava. AUROCs of PPV and SVV for predicting fluid responsiveness were 0.65 (95% confidence interval 0.47-0.83, p = 0.113) and 0.64 (95% confidence interval 0.45-0.82, p = 0.147), respectively. The AUROCs of indices did not exhibit any statistical significance according to position. Dynamic indices of preload cannot predict fluid responsiveness during one-lung ventilation with CO2 gas insufflation.

The efficacy of intramuscular ephedrine in preventing hemodynamic perturbations in patients with spinal anesthesia and dexmedetomidine sedation.

Dexmedetomidine is used for sedation during spinal anesthesia. The sympatholytic effect of dexmedetomidine may exacerbate hypotension and bradycardia with spinal anesthesia. This study investigated the effects of prophylactic intramuscular injection of ephedrine in preventing hypotension and bradycardia occurring through combined use of spinal anesthesia and dexmedetomidine. One hundred sixteen patients scheduled for lower extremity orthopedic surgery were randomized into two groups receiving either ephedrine 20 mg intramuscularly or equivalent amount of 0.9% NaCl, both with dexmedetomidine and spinal anesthesia. The primary endpoint was the incidence of hemodynamic perturbations (hypotension or bradycardia event). The secondary endpoint was a rescue doses of ephedrine and atropine. The incidence of hemodynamic perturbations was significantly lower in the ephedrine group compared with to the saline group (26.3% versus 55.9%, p = 0.001). The rescue doses of atropine (0.09 ± 0.21 versus 0.28 ± 0.41, p = 0.001) and ephedrine (1.04 ± 2.89 versus 2.03 ± 3.25, p = 0.007) were also significantly lower in the ephedrine group. There was no differences in number of patients with hypertensive (7.0% versus 11.9%, p = 0.375) or tachycardia (1.8% versus 3.4% p = 0.581) episodes. The use of ephedrine intramuscular injections may be a safe and efficacious option in preventing hemodynamic perturbations in patients who received spinal anesthesia and sedation using dexmedetomidine.

Development of water quality criteria for arsenic to protect aquatic life based on species sensitivity distribution.

Arsenic is a hazardous environmental pollutant widely distributed globally. Arsenic toxicity is well known and it is regulated by many countries in terms of managing water quality and protecting aquatic organisms. Unfortunately, water quality criterion (WQC) to protect aquatic organisms has not been introduced in Korea yet. Thus, it is of great importance and necessity to introduce WQC to protect aquatic organisms from arsenic, as WQC play a significant role in protecting aquatic ecosystems from pollutants. Therefore, the purpose of this study is to derive arsenic water quality criterion for aquatic life in Korea. Arsenic acute toxicity tests were performed with 10 Korean native aquatic species, which belong to 7 different taxonomic groups. Based on the results of acute toxicity test and additional toxicity data from literature, the species sensitivity distribution (SSD) method was used in ecological risk assessment. The arsenic concentration of 95% protection level for aquatic life was 0.229 mg L-1 in this study. An assessment factor 3 and a background concentration 0.0004 mg L-1 were applied to the concentration value in consideration of the uncertainty of the data and the amount of arsenic natural generation. Consequently, the WQC value derived for arsenic was found to be 0.077 mg L-1. These results will serve as reference values to establish water quality criterion for the protection of aquatic life in Korea.

Anesthetic Efficacy of Dexmedetomidine versus Midazolam When Combined with Remifentanil for Percutaneous Transluminal Angioplasty in Patients with Peripheral Artery Disease.

Anesthesia for percutaneous transluminal angioplasty (PTA) involves a high-risk population having a broad spectrum of pain character and intensity. This study delved the anesthetic efficacy of dexmedetomidine versus midazolam, when used with remifentanil. Seventy patients scheduled for femoropopliteal PTA were randomized into two groups receiving either intermittent midazolam boluses (0.03⁻0.05 mg/kg) (MR group) or dexmedetomidine 0.2⁻0.7 µg/kg/h after a loading dose of 1.0 µg/kg for 10 min (DR group), both with remifentanil. The primary endpoint was the patients' satisfaction (1⁻5, 5; extremely satisfied). Secondary endpoints included postprocedural pain scores (0⁻10, 10; worst imaginable pain) and adverse events. The satisfaction level of patients was significantly greater in the DR group compared with the MR group (4.0 [3.0, 5.0] versus 4.0 [2.0, 5.0] p = 0.021). The number of patients having a postprocedural pain score of at least 3 was significantly greater in the MR group compared with the DR group (10 [29%] versus 2 [6%], p = 0.013). The number of patients with hypotensive episodes was higher in the DR group (5 [14.7%] versus 0, p = 0.025), which could all be restored with ephedrine. The use of dexmedetomidine in conjunction with remifentanil may be a safe option that provides excellent patient satisfaction while potentially attenuating postprocedural pain.

Significance of Perianal Lesion in Pediatric Crohn Disease.

PURPOSE: Despite the increasing incidence of pediatric Crohn disease (CD) in Korea, data on the characteristics of perianal lesions are scarce. Therefore, we aimed to investigate the characteristics of pediatric CD with accompanying perianal lesions in Korea. METHODS: We retrospectively reviewed the medical records of children (age ≤18 years) with confirmed CD at Gachon University Gil Medical Center between 2000 and 2014. Patients were classified into two groups based on the presence or absence of any perianal lesions including skin tags. Additional analysis was performed according to the presence or absence of perianal perforating lesions. RESULTS: Among the 69 CD children (mean age, 15.4 years) include in the analysis, 54 (78.3%) had a perianal lesion and 29 (42.0%) had a perianal perforating lesion. The median duration of chief complaints was longer in pediatric CD with any accompanying perianal lesions (5.40 months vs. 1.89 months, p=0.02), while there was no difference between pediatric CD with and without perianal perforating lesions (5.48 months vs. 4.02 months, p=0.18). Perianal symptoms preceded gastrointestinal symptoms in 13 of 29 (44.8%) patients with perianal perforating lesions. CONCLUSIONS: CD should be suspected in children with perianal lesions, even in circumstances when gastrointestinal symptoms are absent.

Characteristics of Upper Gastrointestinal Tract Involvement in Korean Pediatric Crohn's Disease: A Multicenter Study.

PURPOSE: Crohn's disease (CD) can involve any site of the gastrointestinal tract (GIT). However, the characteristics of upper GIT involvement in CD are unclear, especially in the Eastern pediatric population. This study aimed to estimate the prevalence of upper GIT involvement and identify the clinical features of Korean children with CD. METHODS: This was a retrospective multicenter cohort study that included 52 pediatric patients with CD who underwent esophagogastroduodenoscopy and biopsy. The clinical symptoms and endoscopic and histologic features of the upper GIT were identified according to the presence or absence of upper gastrointestinal symptoms. RESULTS: Among the 52 patients, upper GIT involvement was noted in 50.0% (26/52). The mean age at CD diagnosis was 14.1±2.1 years. Gastric ulcer was the most common lesion (19.2%) found on upper GIT endoscopy, followed by duodenal ulcers (15.4%). Chronic inflammation was the most common histopathologic feature (75.0%), followed by gastric erosion (17.3%). Granuloma was found in 9.6% of patients. Helicobacter pylori infection was identified in 5.8% of patients. Endoscopic and histologic findings were not significantly different, but the mean values of erythrocyte sedimentation rate (60.7±27.1 vs. 43.0±27.6 mm/h, p=0.037) and C-reactive protein (16.5±28.2 vs. 6.62±13.4 mg/dL, p=0.014) were significantly different between patients with and without upper gastrointestinal CD symptoms. CONCLUSION: Upper GIT involvement was relatively common in pediatric patients with CD irrespective of upper gastrointestinal symptoms, and H. pylori infection was relatively uncommon. The results of this study should aid the establishment of regional guidelines for upper GIT examination.

Suspected Anaphylactic Reaction Prior to Induction of Anesthesia.

Although uncommon, anaphylactic reactions during surgery are very dangerous and can result in serious morbidity. Various anesthetics can trigger anaphylactic reactions, and incidents with cephalosporin antibiotics are on the rise. In the case presented, an 84-year-old woman scheduled for calcaneus fracture surgery, was injected with cefbuperazone as a prophylactic antibiotic. On the way to the operating room, before induction of anesthesia, the patient lost consciousness and showed signs of hypoxemia, and anaphylactic reaction, which included hypotension, bronchospasm, and rash. Five hours after immediate intubation and fluid resuscitation, the patient was extubated and transferred to the general ward. Eight weeks later, the skin prick test confirmed a positive reaction to cefbuperazone.

Difficult Intubation in Pediatric Patient with a Large Lymphangioma at the Tongue Base.

Lymphangioma is a congenital malformation of lymphatic system and often involves the oral cavity. When lymphangioma is located on the mouth floor and enlarges, it can compress the airway and make intubation difficult. The GlideScope(®) video laryngoscope is sometimes used in routine intubation, but is most commonly used in difficult or failed intubation. We report a pediatric patient with a difficult intubation due to a large tongue base mass. The airway was compromised due to limited intraoral space, large mass at the tongue base, and glottis distortion. Oral approach was not successful with the Macintosh laryngoscope. In this case, a rigid stylet was made to match the GlideScope(®) curve and the endo-tracheal tube was inserted through the glottis under GlideScope(®) guidance. We believe that, even in pediatric patients, a rigid stylet is necessary when intubation at a sharp posterior angulation to the trachea is difficult during GlideScope(®) approach.