Effect of an intravenous acetaminophen/ibuprofen fixed-dose combination on postoperative opioid consumption and pain after video-assisted thoracic surgery: a double-blind randomized controlled trial.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) often induces significant postoperative pain, potentially leading to chronic pain and decreased quality of life. This study aimed to evaluate the acetaminophen/ibuprofen combination effectiveness in reducing analgesic requirements and pain intensity in patients undergoing VATS. STUDY DESIGN: This is a double-blinded randomized controlled trial. METHODS: Adult patients scheduled for elective VATS for lung resection were randomized to receive either intravenous acetaminophen and ibuprofen (intervention group) or 100 mL normal saline (control group). Treatments were administered post-anesthesia induction and every 6 h for three cycles. The primary outcome was total analgesic consumption at 24 h postoperatively. Secondary outcomes were cumulative analgesic consumption at 2 and 48 h; analgesic-related side effects at 2, 24, and 48 h; quality of recovery at 24 h and 48 h postoperatively; pain intensity at rest and during coughing; and rescue analgesics use. Chronic postsurgical pain (CPSP) was assessed through telephone interviews 3 months postoperatively. RESULTS: The study included 96 participants. The intervention group showed significantly lower analgesic consumption at 24 h and 48 h postoperatively (24 h: median difference: - 100 µg equivalent intravenous fentanyl [95% confidence interval (CI) - 200 to - 5 µg], P = 0.037; 48 h: median difference: - 140 µg [95% CI - 320 to - 20 µg], P = 0.035). Compared to the controls, the intervention group exhibited a significantly lower quality of recovery 24 h post-surgery, with no significant difference at 48 h. All pain scores except for coughing at 48 h post-surgery were significantly lower in the intervention group compared to the controls. No significant differences were observed between the groups in postoperative nausea and vomiting occurrence, hospital stay length, and CPSP. CONCLUSION: Perioperative administration of acetaminophen/ibuprofen significantly decreased analgesic needs in patients undergoing VATS, providing an effective postoperative pain management strategy, and potentially minimizing the need for stronger analgesics.

Effect of a repeated verbal reminder of orientation on emergence agitation after general anaesthesia for minimally invasive abdominal surgery: a randomised controlled trial.

BACKGROUND: An orientation strategy providing repeated verbal reminders of time, place, and person has been widely used for the non-pharmacological management of delirium. We hypothesised that using this strategy could reduce emergence agitation and improve recovery profiles. METHODS: This prospective observer-blinded RCT included male and female patients aged 18-70 yr undergoing minimally invasive abdominal surgery. During emergence from general anaesthesia, subjects in the orientation group (n=57) were provided a repeated reminder, including orientation: '(Patient's name), you are now recovering from general anaesthesia after surgery at Seoul National University Hospital, open your eyes!' via noise-cancelling headphones, whereas those in the control group (n=57) only heard their name: '(Patient's name), open your eyes!'. The primary outcome was the incidence of emergence agitation (Riker sedation agitation scale [SAS] ≥5). The incidence of dangerous agitation (SAS=7), maximal SAS score in the operating room, and recovery profile until 24 h postoperatively were evaluated as secondary outcomes. RESULTS: The incidence of emergence agitation in the operating room was significantly lower in the orientation group than in the control group (16/57 [28.1%] vs 38/57 [66.7%]; relative risk [95% confidence interval], 0.5 [0.3-0.7]; P<0.001). The incidence of dangerous agitation (0 [0.0%] vs 10 [17.5%], P=0.001) and the median maximal SAS score (4 [4-5] vs 5 [4-6], P<0.001) were also lower in the orientation group. Secondary outcomes, other than agitation-related variables, were comparable between the two groups. CONCLUSIONS: Repeated verbal stimulation of orientation may serve as a simple and easily applicable strategy to reduce emergence agitation after general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT05105178.

Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial.

BACKGROUND: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. METHODS: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. RESULTS: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, sd]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; -2.1 [-2.4 to -1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference -2.3%; 95% CI, -8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [sd], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O-1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group. CONCLUSIONS: In lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation. CLINICAL TRIAL REGISTRATION: NCT04260451.

Ultrasound-guided versus conventional lung recruitment manoeuvres in laparoscopic gynaecological surgery: A randomised controlled trial.

BACKGROUND: Pneumoperitoneum and steep Trendelenburg position promote the formation of pulmonary atelectasis during laparoscopic gynaecological surgery. OBJECTIVE: To determine whether lung ultrasound-guided alveolar recruitment manoeuvres could reduce peri-operative atelectasis compared with conventional recruitment manoeuvres during laparoscopic gynaecological surgery. DESIGN: Randomised controlled trial. SETTING: Tertiary hospital, Republic of Korea, from August 2018 to January 2019. PATIENTS: Adult patients scheduled for laparoscopic gynaecological surgery under general anaesthesia. INTERVENTION: Forty patients were randomised to receive either ultrasound-guided recruitment manoeuvres (manual inflation until no visibly collapsed area was seen with lung ultrasonography; intervention group) or conventional recruitment manoeuvres (single manual inflation with 30 cmH2O pressure; control group). Recruitment manoeuvres were performed 5 min after induction and at the end of surgery in both groups. All patients received volume-controlled ventilation with a tidal volume of 8 ml kg-1 and a positive end-expiratory pressure of 5 cmH2O. MAIN OUTCOME MEASURES: The primary outcome was the lung ultrasound score at the end of surgery; a higher score indicates worse lung aeration. RESULTS: Lung ultrasound scores at the end of surgery were significantly lower in the intervention group compared with control group (median [IQR], 7.5 [6.5 to 8.5] versus 9.5 [8.5 to 13.5]; difference, -2 [95% CI, -4.5 to -1]; P = 0.008). The intergroup difference persisted in the postanaesthesia care unit (7 [5 to 8.8] versus 10 [7.3 to 12.8]; difference, -3 [95% CI, -5.5 to -1.5]; P = 0.005). The incidence of atelectasis was lower in the intervention group compared with control group at the end of surgery (35 versus 80%; P = 0.010) but was comparable in the postanaesthesia care unit (40 versus 55%; P = 0.527). CONCLUSIONS: The use of ultrasound-guided recruitment manoeuvres improves peri-operative lung aeration; these effects may persist in the postanaesthesia care unit. However, the long-term effects of ultrasound-guided recruitment manoeuvres on clinical outcomes should be the subject of future trials. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03607240).

Efficacy of intra-operative administration of iron isomaltoside for preventing postoperative anaemia after total knee arthroplasty: A randomised controlled trial.

BACKGROUND: Postoperative anaemia is common after total knee arthroplasty (TKA). Emerging evidence shows the beneficial effects of peri-operative iron supplementation in patients at risk of postoperative anaemia. OBJECTIVE: To evaluate the efficacy of intra-operative administration of iron isomaltoside for the prevention of postoperative anaemia in patients undergoing TKA. DESIGN: Randomised, controlled, double-blind, parallel-group study. SETTING: A tertiary care teaching hospital; between 29 March 2018 and 16 April 2019. PATIENTS: Eighty-nine patients scheduled for unilateral TKA were included. INTERVENTION: Iron isomaltoside or placebo were administered intravenously over 30 min during surgical wound closure. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of anaemia at 30 days after TKA: anaemia was defined as haemoglobin less than 12 g dl-1 for female and less than 13 g dl-1 for male. RESULTS: In total, 89 patients were included in the final analysis (44 in the treatment group; 45 in the control group). The administered dose of iron isomaltoside in the treatment group was 1136 ±â€Š225 mg. The incidence of anaemia at 30 days after TKA was significantly lower in the treatment group (34.1%, 15/44) than that in the control group (62.2%, 28/45): relative risk 0.55 (95% confidence interval, 0.34 to 0.88), P = 0.008. Haemoglobin concentration, serum ferritin concentrations, and transferrin saturation were also significantly higher in the treatment group at 30 days after TKA. CONCLUSION: The intra-operative administration of iron isomaltoside effectively prevents postoperative anaemia in patients undergoing TKA, and thus it can be included in patient blood management protocols for reducing postoperative anaemia in these population. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03470649.

Relationship between blood pressure stability and mortality in cardiac surgery patients: retrospective cohort study.

Performance measurement variables can be applied in clinical practice to evaluate hemodynamic instability. This study aimed to evaluate the relationship between the performance measurement of mean arterial pressure during cardiac surgery using cardiopulmonary bypass and postoperative mortality. A retrospective cohort study of patients who underwent cardiac surgery requiring cardiopulmonary bypass between 2013 and 2016 was conducted. The median performance error (MDPE) and median absolute performance error (MDAPE) were calculated using the preoperative mean arterial pressure as a reference, and intraoperative mean arterial pressures as measured values. Multivariable logistic regression analyses were performed using performance measurement variables to predict 30-day mortality. Overall survival according to performance measurement variables was evaluated using Cox proportional hazard models and Kaplan-Meier survival curves were generated to compare survival probability. Among 1203 patients, 110 (9.1%) died after surgery, and the 30-day mortality rate was 2.3% (28/1203). After adjusting for confounders, MDPE and MDAPE were significant mean arterial pressure derived predictors of 30-day mortality and overall survival. Intraoperative hypotension measured by performance measurement variables was independently associated with 30-day and overall mortality after cardiac surgery requiring cardiopulmonary bypass. Kaplan-Meier survival curves showed lower survival probability in patients with higher MDAPE during the pre- and post- cardiopulmonary bypass periods (P < 0.001 by log-rank test). Intraoperative hypotension measured by performance measurement variables was independently associated with 30-day and overall mortality after cardiac surgery requiring CPB. We propose that performance measurement variables are useful for quantifying the degree of intraoperative hypotension and predicting survival following cardiac surgery.Trial registration: ClinicalTrials.gov, identifier: NCT03785132.

The impact of total intravenous anesthesia versus inhalation anesthesia on acute kidney injury after major abdominal surgery: a propensity score analysis.

PURPOSE: The effect of anesthetic types on postoperative acute kidney injury (AKI) remains unclear particularly in patients undergoing non-cardiac surgery. The purpose of this retrospective study was to compare total intravenous anesthesia (TIVA) and inhalation anesthesia in terms of the risk of AKI after open major abdominal surgery (MAS). METHODS: Adult patients who underwent open MAS (gastrectomy, hepatectomy, colectomy, or pancreatectomy) at our institute from 2016 to 2018 were included. Using the multivariable logistic regression, the risk of postoperative AKI was compared among patients who underwent TIVA (TIVA group) and inhalation anesthesia (inhalation group) both in the total cohort and in the propensity score-matched cohort. Additional multivariable logistic regression analysis was performed with inverse probability of treatment weighting (IPTW) using the propensity score. RESULTS: In total, 3616 patients were analyzed. The incidence of postoperative AKI was 5.0% (77/1546) and 7.8% (161/2070) in the TIVA and inhalation groups, respectively. The risk of AKI was significantly higher in the inhalation group [adjusted odds ratio (aOR) 1.72; 95% confidence interval (CI) 1.27-2.35; P = 0.002] than the TIVA group. In the matched cohort (n = 1518 in each group), the inhalation group also had a higher risk of AKI (aOR 1.66; 95% CI 1.20-2.31; P = 0.002). The multivariable logistic regression with IPTW showed similar results (aOR 1.59; 95% CI 1.30-1.95; P < 0.001). CONCLUSIONS: The risk of AKI after open MAS differed significantly according to the anesthetic used. Patients receiving inhalation anesthesia may have a greater risk of postoperative AKI than those undergoing TIVA.

Validation and clinical utility of the Korean version of the Quality of Recovery-15 with enhanced recovery after surgery: a prospective observational cohort study.

BACKGROUND: The 15-item Quality of Recovery (QoR-15) scale is a validated patient-reported outcome questionnaire that measures the quality of postoperative recovery. This study aimed to validate a translated Korean version of QoR-15 (QoR-15K) in a broad range of surgical patients. METHODS: After Korean translation of the original English version of the QoR-15, we performed psychometric validation of the QoR-15K to evaluate the quality of recovery after surgery. The validity, reliability, responsiveness, and clinical feasibility of the QoR-15K were evaluated. A subgroup analysis in patients with video-assisted lung resection was performed. RESULTS: Among 193 patients, 188 (97.4%) completed the QoR-15K after surgery. We found good convergent validity between the postoperative QoR-15K and the global QoR visual analogue scale (ρ=0.61, P<0.001). The negative correlation between the QoR-15K score and the extent of surgery (ρ=-0.33, P<0.001), the duration of surgery (ρ=-0.33, P<0.001), and the severity of postoperative pain (ρ=-0.40, P<0.001) supported construct validity. The postoperative QoR-15K showed good internal consistency (Cronbach α=0.90), split-half reliability (0.81), and test-retest reliability (0.95; 95% confidence interval [CI], 0.94-0.96). The QoR-15K score decreased from 140 (preoperative, inter-quartile range [IQR] 128-146) to 100 (postoperative day 1, IQR 75-122), median difference -36.5 (95% CI, -41 to -32.5; P<0.0001). The QoR-15K indicated excellent responsiveness with Cliff's effect size -0.78 (95% CI, -0.84 to -0.71). Subgroup analysis yielded similar results. CONCLUSIONS: The QoR-15K is valid and has excellent reliability, a high degree of responsiveness, and clinical feasibility as a metric of quality of recovery in Korean surgical population. CLINICAL TRIAL REGISTRATION: NCT04169087.

Ultrasound-Assisted Versus Landmark-Guided Spinal Anesthesia in Patients With Abnormal Spinal Anatomy: A Randomized Controlled Trial.

BACKGROUND: Spinal anesthesia using a surface landmark-guided technique can be challenging in patients with anatomical alterations of the lumbar spine; however, it is unclear whether using ultrasonography can decrease the technical difficulties in these populations. We assessed whether an ultrasound-assisted technique could reduce the number of needle passes required for block success compared with the landmark-guided technique in patients with abnormal spinal anatomy. METHODS: Forty-four patients with abnormal spinal anatomy including documented lumbar scoliosis and previous spinal surgery were randomized to receive either surface landmark-guided or preprocedural ultrasound-assisted spinal anesthesia. All spinal procedures were performed by 1 of 3 experienced anesthesiologists. The primary outcome was the number of needle passes required for successful dural puncture. Secondary outcomes included the success rate on the first pass, total procedure time, periprocedural pain scores, and the incidences of radicular pain, paresthesia, and bloody tap during the neuraxial procedure. Intergroup difference in the primary outcome was assessed for significance using Mann-Whitney U test. RESULTS: The median (interquartile range [IQR; range]) number of needle passes was significantly lower in the ultrasound group than in the landmark group (ultrasound 1.5 [1-3 {1-5}]; landmark 6 [2-9.3 {1-15}]; P < .001). First-pass success was achieved in 11 (50.0%) and 2 (9.1%) patients in the ultrasound and landmark groups, respectively (P = .007). The total procedure time, defined as the sum of the time for identifying landmarks and performing spinal anesthesia, did not differ significantly between the 2 groups (ultrasound 141 seconds [115-181 seconds {101-336 seconds}]; landmark 146 seconds [90-295 seconds {53-404 seconds}]; P = .888). The ultrasound group showed lower periprocedural pain scores compared with the landmark group (ultrasound 3.5 [1-5 {0-7}]; landmark 5.5 [3-8 {0-9}]; P = .012). The incidences of complications during the procedure showed no significant differences between the 2 groups. CONCLUSIONS: For anesthesiologists with experience in neuraxial ultrasonography, the use of ultrasound significantly reduces the technical difficulties of spinal anesthesia in patients with abnormal spinal anatomy compared with the landmark-guided technique. Our results can lead to practical suggestions that encourage the use of neuraxial ultrasonography for spinal anesthesia in such patients.

Hydroxyethyl Starch 6% 130/0.4 in a Balanced Electrolyte Solution and Renal Function After Nephrectomy.

BACKGROUND: Although previous studies have reported nephrotoxicity associated with hydroxyethyl starch (HES), the long-term effect of HES on renal function after nephrectomy has rarely been reported. We evaluated the association between intraoperative HES administration and short- and long-term renal function after nephrectomy. METHODS: We retrospectively reviewed 1106 patients who underwent partial or radical nephrectomy. The patients were divided into 2 groups: patients who received (HES group) or did not receive 6% HES 130/0.4 intraoperatively (non-HES group). The primary outcome was new-onset chronic kidney disease (CKD) stage 3a (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m) or higher or all-cause mortality during 60 months after surgery. Propensity score matching was performed to address baseline differences between the 2 groups. Renal survival determined by stage 3a and stage 5 CKD (eGFR <15 mL/min/1.73 m) or all-cause mortality were compared up to 60 months before and after matching. We compared postoperative acute kidney injury (AKI) and CKD upstaging in the matched cohort as secondary outcomes. Ordinal logistic regression and Cox proportional hazards regression analyses using inverse probability of treatment weighting were performed for postoperative AKI and our primary outcome, respectively. A subgroup analysis of partial nephrectomy was performed. RESULTS: Thirty percent of patients received HES intraoperatively. Balanced solution and 0.9% normal saline was administered during surgery in both groups. Renal survival was not significantly different between groups after matching (log-rank test P = .377 for our primary outcome, and P = .981 for stage 5 or all-cause mortality, respectively). In the matched cohort (HES group: n = 280, non-HES group: n = 280), the incidence of AKI or CKD upstaging at 1 year was not significantly different (AKI: n = 94, 33.6% in HES group versus n = 90, 32.1% in non-HES group; CKD upstaging: n = 132, 47.1% in HES group versus n = 122, 43.6% in non-HES group; odds ratio [OR], 1.16; 95% confidence interval [CI], 0.83-1.61; P = .396). Intraoperative HES administration was not associated with postoperative renal outcomes (AKI: OR, 0.97; 95% CI, 0.81-1.16; P = .723; CKD stage 3a or higher or all-cause mortality: hazard ratio, 1.01; 95% CI, 0.89-1.14; P = .920). Subgroup analysis yielded similar results. CONCLUSIONS: Intraoperative 6% HES 130/0.4 administration was not significantly associated with short- and long-term renal function or renal survival up to 5 years in patients undergoing partial or radical nephrectomy. However, wide CI including large harm effect precludes firm conclusion and inadequate assessment of safety cannot be ruled out by our results.

Lung ultrasound score to determine the effect of fraction inspired oxygen during alveolar recruitment on absorption atelectasis in laparoscopic surgery: a randomized controlled trial.

BACKGROUND: Although the intraoperative alveolar recruitment maneuver (RM) efficiently treats atelectasis, the effect of FIO2 on atelectasis during RM is uncertain. We hypothesized that a high FIO2 (1.0) during RM would lead to a higher degree of postoperative atelectasis without benefiting oxygenation when compared to low FIO2 (0.4). METHODS: In this randomized controlled trial, patients undergoing elective laparoscopic surgery in the Trendelenburg position were allocated to low- (FIO2 0.4, n = 44) and high-FIO2 (FIO2 1.0, n = 46) groups. RM was performed 1-min post tracheal intubation and post changes in supine and Trendelenburg positions during surgery. We set the intraoperative FIO2 at 0.4 for both groups and calculated the modified lung ultrasound score (LUSS) to assess lung aeration after anesthesia induction and at surgery completion. The primary outcome was modified LUSS at the end of the surgery. The secondary outcomes were the intra- and postoperative PaO2 to FIO2 ratio and postoperative pulmonary complications. RESULTS: The modified LUSS before capnoperitoneum and RM (P = 0.747) were similar in both groups. However, the postoperative modified LUSS was significantly lower in the low FIO2 group (median difference 5.0, 95% CI 3.0-7.0, P < 0.001). Postoperatively, substantial atelectasis was more common in the high-FIO2 group (relative risk 1.77, 95% CI 1.27-2.47, P < 0.001). Intra- and postoperative PaO2 to FIO2 were similar with no postoperative pulmonary complications. Atelectasis occurred more frequently when RM was performed with high than with low FIO2; oxygenation was not benefitted by a high-FIO2. CONCLUSIONS: In patients undergoing laparoscopic surgery in the Trendelenburg position, absorption atelectasis occurred more frequently with high rather than low FIO2. No oxygenation benefit was observed in the high-FIO2 group. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03943433 . Registered 7 May 2019.

The cumulative duration of bispectral index less than 40 concurrent with hypotension is associated with 90-day postoperative mortality: a retrospective study.

BACKGROUND: The relationship between intraoperative low bispectral index (BIS) values and poor clinical outcomes has been controversial. Intraoperative hypotension is associated with postoperative complication. The purpose of this study was to investigate the influence of intraoperative low BIS values and hypotension on postoperative mortality in patients undergoing major abdominal surgery. METHODS: This retrospective study analyzed 1862 cases of general anesthesia. We collected the cumulative time of BIS values below 20 and 40 as well as electroencephalographic suppression and documented the incidences in which these states were maintained for at least 5 min. Durations of intraoperative mean arterial pressures (MAP) less than 50 mmHg were also recorded. Multivariable logistic regression was used to evaluate the association between suspected risk factors and postoperative mortality. RESULTS: Ninety-day mortality and 180-day mortality were 1.5 and 3.2% respectively. The cumulative time in minutes for BIS values falling below 40 coupled with MAP falling below 50 mmHg was associated with 90-day mortality (odds ratio, 1.26; 95% confidence interval, 1.04-1.53; P = .019). We found no association between BIS related values and 180-day mortality. CONCLUSIONS: The cumulative duration of BIS values less than 40 concurrent with MAP less than 50 mmHg was associated with 90-day postoperative mortality, not 180-day postoperative mortality.

Effect of combining a recruitment maneuver with protective ventilation on inflammatory responses in video-assisted thoracoscopic lobectomy: a randomized controlled trial.

BACKGROUND: We hypothesized that the addition of a recruitment maneuver to protective ventilation (PVRM) would result in lower pulmonary and systemic inflammatory responses than traditional ventilation or protective ventilation (PV) alone in patients undergoing lung surgery. METHODS: Sixty patients who underwent scheduled thoracoscopic lobectomy were randomly assigned to three groups: traditional ventilation, PV, or PVRM. Ventilations were performed using a tidal volume of 10 mL/kg for the traditional ventilation group and either 8 mL/kg (two-lung) or 6 mL/kg (one-lung, OLV) with a positive end-expiratory pressure of 5 cm H2O for the PV and PVRM groups. The RM was performed 10 min after the start of OLV. Fiberoptic bronchoalveolar lavage (BAL) was performed twice in dependent and non-dependent lungs: before the start and immediately after the end of OLV. Blood samples were collected at the same time points. The levels of cytokines, including TNF-α, IL-1ß, IL-6, IL-8, and IL-10, were measured. RESULTS: After OLV, the level of TNF-α in the BAL fluid of dependent lungs was significantly higher in the PV than in the PVRM group (P = 0.049), whereas IL-1ß, IL-6, IL-8, and IL-10 levels were not significantly different among the groups. In non-dependent lung BAL fluid, no cytokines were significantly different among the groups. After OLV, IL-10 serum levels were significantly higher in the traditional ventilation than in the PVRM group (P = 0.027). CONCLUSIONS: Lower inflammatory responses in the ventilated lung and serum were observed with PVRM than with traditional ventilation or PV alone. Larger multi-center clinical trials are warranted to confirm the effects of different ventilatory strategies on postoperative outcomes.

Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients With Normal Airways.

BACKGROUND: During induction of general anesthesia, it is common practice to delay neuromuscular blockade until the ability to deliver mask ventilation has been confirmed. However, the benefits of this approach have never been scientifically validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the efficiency of mask ventilation and the time to tracheal intubation in patients with normal airways. METHODS: Patients (n = 114) were randomized to receive IV rocuronium either before (early rocuronium group, n = 58) or after (late rocuronium group, n = 56) checking mask ventilation. Expiratory tidal volumes (VTs) were measured at 10, 20, 30, 40, 50, and 60 seconds after apnea during mask ventilation. We graded the ease of mask ventilation and measured the time from apnea to tracheal intubation. The primary outcome was the average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea. The main secondary outcome was the time from apnea to tracheal intubation. STATA was used for statistical analysis. RESULTS: The average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea was larger in the early rocuronium group than in the late rocuronium group (552 mL breath [165 mL breath] vs 393 mL breath [165 mL breath], mean difference, 160 mL breath; 95% CI, 98-221 mL breath; P < .001, unpaired t test). Because the interaction between time and group was significant in mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea (P < .001, linear mixed effects model), pairwise comparisons were performed at the 6 time points. The differences in VTs between the groups were significant at 10, 20, 30, 40, and 50 seconds after apnea (P < .001 each, contrast statements in STATA). The time from apnea to tracheal intubation was shorter in the early rocuronium group than in the late rocuronium group (116 seconds [42 seconds] vs 195 seconds [41 seconds]; mean difference, -79 seconds; 95% CI, -96 to -64 seconds, P < .001). CONCLUSIONS: The early administration of rocuronium before checking mask ventilation resulted in a larger mask VT and earlier tracheal intubation than the late administration of rocuronium after checking mask ventilation in patients with normal airways.

The effect of neck extension on success rate of blind intubation through Ambu® AuraGain™ laryngeal mask: a randomized clinical trial.

PURPOSE: Although the use of fibreoptic guidance is recommended for tracheal intubation through supraglottic airway devices, it can also be performed in a blind manner. Based on the previous finding that a fibreoptic view of the vocal cords was better in the extended neck position than in the neutral position, we hypothesized that neck extension can better facilitate blind intubation through the Ambu® AuraGain™ laryngeal mask than the neutral position. METHODS: Patients undergoing general anesthesia were randomly assigned to the extension group or the neutral group. After induction of anesthesia, the AuraGain™ was placed in the oropharynx, followed by blind intubation through the AuraGain™ in the assigned neck position within a maximum of two attempts. The primary outcome was successful blind intubation through the AuraGain™ in the first attempt. RESULTS: Of 168 adult patients screened, 124 patients were enrolled and 121 patients were included in the final analysis (extension group, n = 59; neutral group, n = 62). The incidence of successful blind intubation on the first attempt was significantly higher in the extension group than in the neutral group (68% vs. 47%, respectively; relative risk [RR], 1.45; 95% confidence interval [CI], 1.05 to 1.99; P = 0.02). The overall incidence of successful blind intubation was also significantly higher in the extension group than in the neutral group (71% vs 50%, respectively; RR, 1.42; 95% CI, 1.06 to 1.92; P = 0.02). The time required for successful blind intubation and the incidence of hoarseness, cough, or sore throat at 24 hr after extubation did not differ between groups. CONCLUSION: Neck extension can be used to facilitate blind intubation through the Ambu® AuraGain™ laryngeal mask. Considering the relatively high failure rate, blind intubation via the AuraGain™ should be used as an alternative, not as a first-line choice. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03408431); registered 24 January 2018.

Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly: A randomised controlled trial.

BACKGROUND: Neuraxial ultrasound might improve the efficacy of spinal anaesthesia but this has not been tested for the paramedian approach in the elderly. OBJECTIVE: The current study aims to assess whether the ultrasound-assisted paramedian technique can decrease the number of needle passes required for success compared with the landmark-guided paramedian technique in the elderly. DESIGN: Randomised controlled study. SETTING: Single-institution, tertiary-level hospital in Seoul, Republic of Korea from October 2017 to January 2018. PATIENTS: Eighty patients aged at least 60 years undergoing orthopaedic surgery. INTERVENTION: All received paramedian spinal anaesthesia by either the landmark-guided or preprocedural ultrasound-assisted technique. MAIN OUTCOME MEASURES: The number of needle passes required for successful dural puncture. RESULTS: The number of needle passes (median [interquartile range]) was significantly lower (1.0 [1.0 to 2.0] vs. 4.5 [2.0 to 7.0]) and the success rate at first pass significantly higher at 65.0 vs. 17.5% in the ultrasound compared with the landmark group (both P < 0.001). The ultrasound-assisted technique required a longer time for establishing landmarks (117.5 s [85.5 to 150.7 s] vs. 17.5 s [14.0 to 23.0 s]) and for total procedure (181.5 s [133.5 to 212.5 s] vs. 92.5 s [62.5 to 176.5 s]) but a shorter time for administering spinal anaesthesia (39.5 s [31.5 to 71.3 s] vs. 77.0 s [45.8 to 136.5 s]; all, P < 0.001) than the palpation-guided technique. The ultrasound group showed lower periprocedural pain scores (3 [2 to 4] vs. 4 [4 to 6]; P = 0.009) and discomfort scores (2 [0 to 3] vs. 5 [2 to 6]; P = 0.003) than the landmark group. CONCLUSION: Compared with the landmark-guided paramedian technique, the ultrasound-assisted paramedian technique decreases the number of needle manipulations and periprocedural pain and discomfort scores in the elderly. Our results suggest that neuraxial ultrasonography facilitates the performance of spinal anaesthesia in the elderly. TRIAL REGISTRATION: NCT03316352.

Comparative effectiveness of interventions for managing postoperative catheter-related bladder discomfort: a systematic review and network meta-analysis.

BACKGROUND: Although many drugs or interventions have been studied to manage catheter-related bladder discomfort (CRBD), their comparative effectiveness is unknown. We attempted to assess the comparative effectiveness of the strategies to manage CRBD in patients undergoing urologic surgery including amikacin, solifenacin, darifenacin, butylscopolamine, dexmedetomidine, gabapentin, glycopyrrolate, ketamine, oxybutynin, resiniferatoxin, tolterodine, tramadol, caudal block, dorsal penile nerve block, lidocaine-prilocaine cream. METHODS: We performed an arm-based network meta-analysis including 29 trials with 2841 participants. Goodness of model fit was evaluated by deviance information criteria (DIC). The incidence of CRBD at 0, 1, and 6 h after surgery and the incidence of moderate to severe CRBD at 0, 1, and 6 h after surgery were compared. RESULTS: Random effect model was selected according to DIC. Most of the drugs significantly decreased the incidence of CRBD except amikacin, tramadol at 0 and 1 h after surgery. Dexmedetomidine, solifenacin, caudal block, dorsal penile nerve block, resiniferatoxin, and gabapentin 1200 mg p.o. significantly decreased the incidence of CRBD at 6 h after surgery (gabapentin 1200: Odds ratio [OR] 0.02; SUCRA 95.6). Dexmedetomidine and tolterodine significantly decreased the incidence of moderate to severe CRBD at 0, 1, and 6 h after surgery (tolterodine at 6 h: OR 0.05; SUCRA 73.7). CONCLUSIONS: Gabapentin was ranked best regarding the overall incidence of CRBD, while tolterodine was ranked best in reducing the severity of CRBD. However, a firm conclusion cannot be made from our analysis due to small-study number and heterogeneity regarding study setting and outcome measurement.

Association Between Elevated Echocardiographic Index of Left Ventricular Filling Pressure and Acute Kidney Injury After Off-Pump Coronary Artery Surgery.

BACKGROUND: The ratio of the early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an echocardiographic index of mean left ventricular (LV) filling pressure. We investigated the association between the preoperative E/e' ratio and postoperative acute kidney injury (AKI) during off-pump coronary artery bypass surgery (OPCAB).Methods and Results:We reviewed 585 patients who underwent OPCAB and with preserved LV ejection fraction determined by preoperative echocardiography. AKI was determined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression analysis was performed. E/e' was also analyzed as 3 categories (E/e' <8, 8≤E/e'≤15, and E/e' >15) and as a continuous variable. A propensity score analysis was used to match the patients with E/e' >15 and E/e' ≤15. A preoperative E/e' >15 was an independent predictor for AKI (odds ratio 3.01, 95% confidence interval 1.40-6.17). E/e' >15 was also an independent predictor for AKI when E/e' was analyzed with 3 categories or as a continuous variable. In the matched sample, the incidence of AKI and 1-year mortality was significantly higher in patients with E/e' >15. CONCLUSIONS: Among patients undergoing OPCAB with preserved LV systolic function, a preoperative E/e' ratio >15 was an independent predictor of postoperative AKI. Measurement of the preoperative E/e' ratio may help to assess the risk of postoperative AKI.

Computed Tomographic Window Setting for Bronchial Measurement to Guide Double-Lumen Tube Size.

OBJECTIVES: The bronchial diameter measured on computed tomography (CT) can be used to guide double-lumen tube (DLT) sizes objectively. The bronchus is known to be measured most accurately in the so-called bronchial CT window. The authors investigated whether using the bronchial window results in the selection of more appropriately sized DLTs than using the other windows. DESIGN: CT image analysis and prospective randomized study. SETTING: Tertiary hospital. PARTICIPANTS: Adults receiving left-sided DLTs. INTERVENTIONS: The authors simulated selection of DLT sizes based on the left bronchial diameters measured in the lung (width 1,500 Hounsfield unit [HU] and level -700 HU), bronchial (1,000 HU and -450 HU), and mediastinal (400 HU and 25 HU) CT windows. Furthermore, patients were randomly assigned to undergo imaging with either the bronchial or mediastinal window to guide DLT sizes. Using the underwater seal technique, the authors assessed whether the DLT was appropriately sized, undersized, or oversized for the patient. MAIN MEASUREMENTS AND RESULTS: On 130 CT images, the bronchial diameter (9.9 ± 1.2 mm v 10.5 ± 1.3 mm v 11.7 ± 1.3 mm) and the selected DLT size were different in the lung, bronchial, and mediastinal windows, respectively (p < 0.001). In 13 patients (17%), the bronchial diameter measured in the lung window suggested too small DLTs (28 Fr) for adults. In the prospective study, oversized tubes were chosen less frequently in the bronchial window than in the mediastinal window (6/110 v 23/111; risk ratio 0.38; 95% CI 0.19-0.79; p = 0.003). No tubes were undersized after measurements in these two windows. CONCLUSIONS: The bronchial measurement in the bronchial window guided more appropriately sized DLTs compared with the lung or mediastinal windows.

Neutrophil, Lymphocyte, and Platelet Counts and Acute Kidney Injury After Cardiovascular Surgery.

OBJECTIVE: Postoperative low platelet count and perioperative high neutrophil/lymphocyte (N/L) ratio are associated with acute kidney injury (AKI) and mortality after cardiac surgery. The authors investigated whether (1) their combination neutrophil/lymphocyte × platelet (N/LP) ratio is an independent predictor of AKI and postoperative mortality and (2) whether the N/LP ratio increases predictive ability compared with the N/L ratio or platelet nadir. DESIGN: This was a retrospective and observational study. SETTING: Single large university hospital. PARTICIPANTS: The study comprised 1,099 adult patients who underwent cardiovascular surgeries with cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Baseline clinical parameters including platelet counts, the N/L ratio, and the N/LP ratio measured before surgery, immediately after surgery, and on postoperative days 1 and 2 were obtained. Multivariable analysis revealed that the maximal N/LP ratio was an independent predictor of AKI and 5-year mortality. Propensity score matching was performed between the high and low preoperative N/LP ratio groups. Significant differences in the mortality rate and incidence of AKI also were found in the matched cohort. The area under the receiver operating characteristic curve (AUC) of the maximal N/LP ratio as a continuous variable was significantly higher than the AUC of the maximal N/L ratio or nadir platelet as continuous variables (maximal N/LP ratio: 0.62 v N/L ratio: 0.59; p = 0.026 v platelet nadir: 0.57; p = 0.003). The AUC of multivariable risk prediction with the maximal N/LP ratio (0.77) was significantly higher than the AUC without the N/LP ratio (0.70; p < 0.0001). CONCLUSIONS: High N/LP ratios were associated with postoperative AKI and 5-year mortality. The N/LP ratio may assist with the the prediction of AKI and mortality in high-risk cardiovascular surgery.