Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium.

OBJECTIVES: To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). DESIGN: A single-center retrospective observational study. SETTING: University teaching hospital. PARTICIPANTS: A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]). CONCLUSIONS: A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.

Impact of Milrinone Administration in Adult Cardiac Surgery Patients: Updated Meta-Analysis.

OBJECTIVE: To determine the effects of milrinone on short-term mortality in cardiac surgery patients with focus on the presence or absence of heterogeneity of the effect. DESIGN: A systematic review and meta-analysis. SETTING AND PARTICIPANTS: Five hundred thirty-seven adult cardiac surgery patients from 12 RCTs. INTERVENTIONS: Milrinone administration. MEASUREMENTS AND MAIN RESULTS: The authors conducted a systematic Medline and Pubmed search to assess the effect of milrinone on short-term mortality in adult cardiac surgery patients. Subanalysis was performed according to the timing for commencement of milrinone administration and the type of comparators. The primary outcome was any short-term mortality. Overall analysis showed no difference in mortality rates in patients who received milrinone and patients who received comparators (odds ratio = 1.25, 95% CI 0.45-3.51, p = 0.67). In subanalysis for the timing to commence milrinone administration and the type of comparators, odds ratio for mortality varied from 0.19 (placebo as control drug, start of administration after cardiopulmonary bypass) to 2.58 (levosimendan as control drug, start of administration after cardiopulmonary bypass). CONCLUSIONS: Among RCTs to assess the effect of milrinone administration in adult cardiac surgery patients, there are wide variations of the odds ratios of administration of milrinone for short-term mortality according to the comparators and the timing of administration. This fact may suggest that a simple pooling meta-analysis is not applicable for assessing the risk and benefit of milrinone administration in an adult cardiac surgery cohort.

Ultrasound-guided continuous thoracic paravertebral block provides comparable analgesia and fewer episodes of hypotension than continuous epidural block after lung surgery.

PURPOSE: Both paravertebral block (PVB) and thoracic epidural block (TEB) are recommended for postoperative pain relief after lung surgery. The addition of fentanyl to the anesthetic solution became popular for TEB because of the stronger effects; however, there have been few comparable trials about the addition of fentanyl to PVB. The purpose of this study was thus to compare postoperative analgesia, side effects, and complications between ultrasound-guided PVB (USG-PVB) and TEB with the addition of fentanyl to ropivacaine after lung surgery. METHODS: We examined 90 consecutive patients (age 18-75 years) scheduled for video-assisted thoracic surgery (VATS). In both groups, all blocks (four blocks in USG-PVB and one block in TEB) and one catheter insertion were performed preoperatively. Continuous postoperative infusion (0.1% ropivacaine plus fentanyl at 0.4 mg/day) was undertaken for 36 h in both groups. The recorded data included the verbal rating scale (VRS) for pain, blood pressure, side effects, complications for 2 days, and overall satisfaction score. RESULTS: There was no difference in the frequency of taking supplemental analgesics (twice or more frequently), or in VRS. Hypotension occurred significantly more frequently in TEB (n = 7/33) than in PVB (n = 1/36) (P = 0.02); on the other hand, the incidences of PONV and pruritus, as well as overall satisfaction score, were similar. There were no complications in both groups; however, the catheters migrated intrathoracically in four patients in PVB. CONCLUSION: USG-PVB achieved similar pain relief and lowered the incidence of hypotension compared with TEB. We conclude that both blocks with the same concentration of ropivacaine and fentanyl can provide adequate postoperative analgesia for VATS.

Convenient method for resolving degeneracies due to symmetry of the magnetic susceptibility tensor and its application to pseudo contact shift-based protein-protein complex structure determination.

Pseudo contact shifts (PCSs) induced by paramagnetic lanthanide ions fixed in a protein frame provide long-range distance and angular information, and are valuable for the structure determination of protein-protein and protein-ligand complexes. We have been developing a lanthanide-binding peptide tag (hereafter LBT) anchored at two points via a peptide bond and a disulfide bond to the target proteins. However, the magnetic susceptibility tensor displays symmetry, which can cause multiple degenerated solutions in a structure calculation based solely on PCSs. Here we show a convenient method for resolving this degeneracy by changing the spacer length between the LBT and target protein. We applied this approach to PCS-based rigid body docking between the FKBP12-rapamycin complex and the mTOR FRB domain, and demonstrated that degeneracy could be resolved using the PCS restraints obtained from two-point anchored LBT with two different spacer lengths. The present strategy will markedly increase the usefulness of two-point anchored LBT for protein complex structure determination.

Nakijiquinones J--R, sesquiterpenoid quinones with an amine residue from okinawan marine sponges.

Nine new sesquiterpenoid quinones, nakijiquinones J-R (1-9), have been isolated from three collections of Okinawan marine sponges of the family Spongiidae, and the structures and configurations were elucidated from the spectroscopic data and chemical correlations. Nakijiquinones J-L (1-3), M and N (4 and 5, respectively), O (6), P and Q (7 and 8, respectively), and R (9) are new sesquiterpenoid quinones possessing (S)-2-methylbutylamine, isopentylamine, isobutylamine, phenethylamine, and taurine residues, respectively, attached to each quinone ring.

[Anesthetic management of a patient with deep brain stimulators].

A 68-year man with severe Parkinson's disease who had been implanted with deep brain stimulators into both sides, received an emergency surgery uneventfully under general anesthesia with standard monitoring. During the operation, the surgeon turned off the impulse generators and used bipolar diathermy. Postoperatively, he had transient episodes of severe Parkinson symptoms, which were controled by levodopa drugs.