Remimazolam Anaphylaxis during Induction of General Anesthesia Confirmed by Provocation Test-A Case Report and Literature Review.

Background: Remimazolam besylate, a newly developed drug, is linked to various anaphylaxis cases. We present a case of remimazolam anaphylaxis confirmed using a provocation test. Case: A 51-year-old female patient was scheduled for humeral pinning. General anesthesia was induced using remimazolam, rocuronium, and remifentanil. After tracheal intubation, the patient experienced decreased blood pressure, increased heart rate, and a systemic rash. Epinephrine was administered repeatedly, and the patient's vital signs stabilized. Acute phase tryptase levels were within normal limits. After four weeks, intradermal test results were negative. When remimazolam was administered intravenously for the provocation test, facial swelling, flushing, and coughing occurred, which improved with epinephrine. The culprit drug was identified as remimazolam using a provocation test. Conclusions: When anaphylaxis occurs during anesthesia induction, remimazolam should not be ruled out as the causative drug. If the skin test result for remimazolam is negative, a provocation test should be considered. The provocation test should be initiated cautiously at a low dose under careful patient monitoring.

A new technique for controlling intractable pain in lumbar spinal stenosis using steroid injection to ligamentum flavum: A case series.

BACKGROUND: Lumbar spinal stenosis is a common degenerative disease that causes low back and lower-extremity pain that increases with age. The treatment of lumbar spinal stenosis is either conservative or surgical. ESI is a commonly performed conservative treatment, but evidence of its effectiveness in lumbar spinal stenosis is limited. CASE SERIES: We encountered the three patients with back pain and claudication due to lumbar spinal stenosis, which could not be controlled by conservative therapy including ESIs. Trimacinolone acetonide was injected into the patients' ligamentum flavum. All patients experienced dramatic improvement in their symptoms. CONCLUSIONS: Trimacinolone acetonide injection into the ligamentum flavum may be effective for lumbar spinal stenosis that does not improve with ESIs.

The Level of Urine Dipstick Proteinuria and Its Relation to the Risk of Incident Cholelithiasis.

BACKGROUND: Previous studies have suggested the potential association between renal diseases and gallstone. The extent of proteinuria is recognized as a marker for the severity of chronic kidney disease. However, little data is available to identify the risk of incident gallstone according to the level of proteinuria. METHODS: Using a data of 207,356 Koreans registered in National Health Insurance Database, we evaluated the risk of gallstone according to the levels of urine dipstick proteinuria through an average follow-up of 4.36 years. Study subjects were divided into 3 groups by urine dipstick proteinuria (negative: 0, mild: 1+ and heavy: 2+ or greater). Multivariate Cox-proportional hazard model was used to assess the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident cholelithiasis according to urine dipstick proteinuria. RESULTS: The group with higher urine dipstick proteinuria had worse metabolic, renal, and hepatic profiles than those without proteinuria, which were similarly observed in the group with incident cholelithiasis. The heavy proteinuria group had the greatest incidence of cholelithiasis (2.39%), followed by mild (1.54%) and negative proteinuria groups (1.39%). Analysis for multivariate Cox-proportional hazard model indicated that the heavy proteinuria group had higher risk of cholelithiasis than other groups (negative: reference, mild proteinuria: HR 0.97 [95% CI, 0.74-1.26], and heavy proteinuria: HR 1.46 [95% CI, 1.09-1.96]). CONCLUSION: Urine dipstick proteinuria of 2+ or greater was significantly associated with increased risk for incident gallstone.

Aesthetic Nasal Lobule Correction Using a Three-Dimensional Printed Polycaprolactone Implant.

ABSTRACT: Nasal tip plasty is a surgery that determines important rhinoplasty outcomes. A variety of autologous and alloplastic implants are utilized in this procedure, including 1 synthetic material known as polycaprolactone (PCL). This study provides background on the ready-made three-dimensional printed PCL implant for nasal lobule correction, before discussing the usefulness and effectiveness of the implant. A total of 23 patients who visited our hospital between January 2018 and January 2020 were evaluated in this study. We used 3 types of PCL implant to get an ideal shape for the nasal tip: tipball (globular shape), droneball (rugby ball shape), and dumbbell (dumbbell shape). The authors compared nasolabial angle and tip projection at the preoperative and postoperative period via photographic anthropometric analysis. In 4 patients, we also examined the dead space between the implant and soft tissue via ultrasonography. The follow-up period averaged 9.5 months and no serious complications were found after surgery. The nasolabial angle and tip projection had an average postoperative increase of 6.4° and 0.044, respectively. Ultrasonography revealed the attachment of the implant at the insertion site and no dead space was found. This is the first attempt to apply a ready-made three-dimensional printed PCL implant to a nasal lobule correction procedure. As the implant was easy to use and showed good results, it may be useful for aesthetic purposes in future nasal tip plasty procedures.

Transforaminal Epiduroscopic Laser Ablation for Removal of a Postlaminectomy Synovial Cyst: A Case Report.

Background: Synovial cysts rarely occur after a laminectomy and are difficult to detect if there are no symptoms; however, they can cause lower back pain or symptoms of radiculopathy. Various methods are used to treat synovial cysts. Here, we will introduce the first case with treatment using the transforaminal epiduroscopic laser annuloplasty (TELA) system. Case report: A 64-year-old female patient visited the pain clinic with lower back pain and pain radiating from the left lower extremity. An MRI T2 image showed a synovial cyst of facet joint origin at the L4-L5 level; the patient had undergone a laminectomy 10 years ago at the same spinal level. The patient rated the pain an 8 on the numerical rating scale (NRS), and pain was reduced after epidural steroid injection, but symptoms recurred a month later. The cyst ablation was performed using the TELA system with a 1414 nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, and after the procedure, pain decreased to 4 points immediately and was reduced to 2 points on the NRS after 1 week. Six months after the procedure, the pain level was measured on NRS 2 and cyst was not recurred in the additional MRI. Conclusion: We introduced the TELA system as a noninvasive therapy for treating synovial cysts. Ablation of cystic necks using a 1414 nm Nd:YAG laser could be a method to prevent cyst recurrence, but long-term follow-up and large scale control studies will be needed to verify the effectiveness of this method.

Comparison of the Analgesic Effect of Ropivacaine with Fentanyl and Ropivacaine Alone in Continuous Epidural Infusion for Acute Herpes Zoster Management: A Retrospective Study.

Background and Objectives: Currently, few studies have reported the effects of opioids during continuous epidural infusion (CEI) to control pain owing to herpes zoster (HZ). This study aimed to retrospectively compare the effectiveness of epidural opioids in the treatment of acute HZ pain. Materials and Methods: We reviewed medical records of 105 patients who were divided into two groups: R group (CEI with ropivacaine) and RF group (CEI with ropivacaine and fentanyl). Clinical efficacy was evaluated using the numeric rating scale (NRS) score for 6 months after the procedures. We compared the percentage of patients with complete remission in each group. We investigated the complication rates during CEI. Results: No significant differences in the NRS scores were observed between the two groups in the 6-month period. The adjusted odds ratio (OR) for patients included in the complete remission was 0.6 times lower in the RF group than in the R group (95% confidence interval: 0.22-1.71, p = 0.35). The OR for complications during CEI was higher in the RF group than in the R group. However, the difference was not statistically significant. Conclusions: No difference was observed in the management of HZ pain and the prevention of postherpetic neuralgia between the two groups. The incidence of complications tended to be higher in the RF group than in the R group.

Correlation of Pressure Pain Threshold with Segmental Water Content among Female Farmers.

Body composition (BC) is related to the pathogenesis of musculoskeletal disease, especially research focused on the role of fat and muscle mass. This study aimed to identify the associations between the pressure pain threshold (PPT) and pain-related factors including BC. A total of 64 healthy farmers (21 males and 43 females) were recruited, and baseline data were analyzed cross-sectionally. Demographic characteristics (sex, age, marital status, education duration, current status of smoking and alcohol drinking, height, body weight, and underlying diseases) and a psychologic characteristic (a Korean version of the Beck Depression Inventory [BDI]) were assessed. Additionally, body composition analysis using bioelectrical impedance analysis (BIA) was performed. PPT was measured by applying an increasing amount of blunt pressure using a 1 cm2 hard rubber end at the thenar region of the right hand with a constant increase in pressure of 50 kPa/s. The PPT was measured on a single day, and the average value was used for analysis. The male group (67.00 ± 9.12 years) was older than the female group (62.21 ± 6.77 years; p = 0.021). In the body composition analysis, only segmental water of the right arm was positively related to PPT (ß = 0.331, p = 0.030) in the multivariate linear regression analysis. In conclusion, hydration status was related to PPT with clinical implication that sufficient hydration could reduce the pain susceptibility. Thus, when assessing the painful condition, checking the hydration status could be helpful before the intensive treatment.

An Unusual Delayed Onset of Systemic Toxicity After Fluoroscopy-Guided Cervical Epidural Steroid Injection With Levobupivacaine: A Case Report.

BACKGROUND: Cervical epidural steroid injection (CESI) with local anesthetics is commonly used to treat neck pain and radicular pain of the upper extremity. Local anesthetic systemic toxicity (LAST) occurs shortly after injection as a complication; however, delayed onset is a very rare event, especially in central nervous system (CNS) block. CASE REPORT: We present a case in which delayed onset of LAST occurred in a patient who received CESI for cervical and arm radiating pain due to a cervical disc protrusion. We performed the interlaminar approach for CESI using fluoroscopic guidance. After confirming the location of the epidural space using the loss of resistance technique and spreading of contrast agent (Telebrix® 30), a mixture of 0.25% levobupivacaine 12.5 mg (5 mL in volume), hyaluronidase 1,500 IU (1 mL), dexamethasone 5 mg (1 mL), and normal saline 3 mL was administrated. After 50 minutes of injection, the patient showed CNS toxicity (unconsciousness, seizure) with normal blood pressure and tachycardia; therefore, she was immediately sedated with intravenous midazolam (3 mg), and 15 L/min of oxygen was administered. The patient fully recovered after 30 minutes of sedation without any sequelae. CONCLUSION: Delayed onset of LAST is a rare complication of a common procedure in CESI, so it is important to be aware of this complication and the presentation of toxicity.

Effect of remifentanil during drug-induced sleep endoscopy in patients with obstructive sleep apnea.

PURPOSE: During drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea, the increased depth of propofol anesthesia is related to the increased collapsibility of the upper airway with dose-dependent. We examined the effect of remifentanil on propofol concentration during DISE. METHODS: In a prospective randomized trial, 56 adult patients were divided into remifentanil-propofol (n = 28) and propofol alone (n = 28) groups. Anesthesia was administered using a target-controlled infusion system. In the remifentanil-propofol group, 0.5 ng/ml remifentanil was administered prior to propofol infusion and its concentration maintained; thereafter, in the propofol alone group, normal saline was injected instead of remifentanil. Propofol was infused at a concentration of 1.5 µg/ml after the target concentration of remifentanil was reached. In both groups, the concentration of propofol was increased by 0.5 µg/ml if the degree of sedation was not sufficient. The sedation level was targeted at observer's assessment of alertness/sedation (OAA/S) scale 3. RESULTS: The mean propofol concentration was 2.87 ± 0.60 µg/ml in the remifentanil-propofol group, which was lower than that in the propofol alone group (3.38 ± 0.72 µg/ml, P < 0.001). The time until sufficient sedation to perform DISE was shorter in the remifentanil-propofol group (P < 0.001). Apnea-hypopnea index and the lowest peripheral capillary oxygen saturation (SpO2) during polysomnography showed no statistical difference between groups (P > 0.05). The lowest SpO2 and VOTE classification during DISE were also not statistically different (P > 0.05). CONCLUSIONS: Use of remifentanil during DISE reduces the target concentration of propofol required for patient sedation to perform DISE without respiratory depression.

Comparison of Hemodynamic Parameters Based on the Administration of Remimazolam or Sevoflurane in Patients under General Anesthesia in the Beach Chair Position: A Single-Blinded Randomized Controlled Trial.

Background: We aimed to evaluate whether the administration of remimazolam as a maintenance agent for general anesthesia affects the occurrence of hypotension compared with sevoflurane when switching to the beach chair position (BCP). Methods: We conducted a prospective randomized controlled trial from June 2023 to October 2023 in adult patients undergoing orthopedic surgery under general anesthesia in the BCP. A total of 78 participants were randomly allocated to the remimazolam (R) or sevoflurane (S) groups. The primary outcome was the incidence of hypotension that occurred immediately after switching to a BCP. The secondary outcomes included differences between the study groups in perioperative blood pressure (BP), heart rate (HR), endotracheal tube extubation time, postoperative complications, and hospital length of stay (LOS). Results: The incidence of hypotension immediately after switching to a BCP was significantly higher in the S group. The risk factors associated with hypotension included sevoflurane administration and a high baseline systolic BP. In the receiver operating characteristic curve analysis for the occurrence of hypotension after the transition to a BCP, the cutoff value for systolic BP was 142 mmHg. The perioperative BP and HR were higher in the R group at several timepoints. Postoperative endotracheal tube extubation time was shorter in the R group. There were no significant differences in the postoperative complications or hospital LOS between the two groups. Conclusions: Remimazolam should be considered as an anesthetic agent to prevent hypotension when switching to BCP, and hypotension may occur frequently in patients with high baseline BP.

Hemodynamic changes in the prone position according to fluid loading after anaesthesia induction in patients undergoing lumbar spine surgery: a randomized, assessor-blind, prospective study.

INTRODUCTION: A change from the supine to prone position causes hemodynamic alterations. We aimed to evaluate the effect of fluid preloading in the supine position, the subsequent hemodynamic changes in the prone position and postoperative outcomes. PATIENTS AND METHODS: This prospective, assessor-blind, randomized controlled trial was conducted between March and June 2023. Adults scheduled for elective orthopaedic lumbar surgery under general anaesthesia were enrolled. In total, 80 participants were randomly assigned to fluid maintenance (M) or loading (L) groups. Both groups were administered intravenous fluid at a rate of 2 ml/kg/h until surgical incision; Group L was loaded with an additional 5 ml/kg intravenous fluid for 10 min after anaesthesia induction. The primary outcome was incidence of hypotension before surgical incision. Secondary outcomes included differences in the mean blood pressure (mBP), heart rate, pleth variability index (PVi), stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index and cardiac index before surgical incision between the two groups. Additionally, postoperative complications until postoperative day 2 and postoperative hospital length of stay were investigated. RESULTS: Hypotension was prevalent in Group M before surgical incision and could be predicted by a baseline PVi >16. The mBP was significantly higher in Group L immediately after fluid loading. The PVi, SVV and PPV were lower in Group L after fluid loading, with continued differences at 2-3 time points for SVV and PPV. Other outcomes did not differ between the two groups. CONCLUSION: Fluid loading after inducing general anaesthesia could reduce the occurrence of hypotension until surgical incision in patients scheduled for surgery in the prone position. Additionally, hypotension could be predicted in patients with a baseline PVi >16. Therefore, intravenous fluid loading is strongly recommended in patients with high baseline PVi to prevent hypotension after anaesthesia induction and in the prone position. TRIAL NUMBER: KCT0008294 (date of registration: 16 March 2023).

Fluid preloading could reduce the occurrence of hypotension in the prone position. Hypotension could be predicted in patients with a baseline PVi >16. Intravenous fluid preloading is strongly recommended in patients with high baseline PVi to prevent hypotension after anaesthesia induction and in the prone position.

Postoperative Nausea and Vomiting According to Target-Controlled or Manual Remifentanil Infusion in Gynecological Patients Undergoing Pelviscopic Surgery: A Randomized Controlled Trial.

BACKGROUND: We compared the incidence of postoperative nausea and vomiting (PONV) and postoperative outcomes, according to the remifentanil infusion method, during surgery in patients with a high-risk of PONV. METHODS: Ninety patients undergoing elective gynecological pelviscopic surgery were randomly allocated to either target-controlled infusion (TCI, T) or manual (M) infusion. The primary outcome was the incidence of PONV until postoperative day (POD) 2. The secondary outcomes were perioperative heart rate (HR), blood pressure (BP), numerical rating scale pain scores up to POD2, and postoperative hospital length of stay. RESULTS: Forty-four patients in the T group and 45 patients in the M group were analyzed. The total dose of remifentanil infusion was significantly higher in the T group (T group: 0.093 (0.078-0.112) µg/kg/min; M group: 0.062 (0.052-0.076) µg/kg/min, p < 0.001). Within POD2, the overall PONV was not significantly different (27 (61.4%) vs. 27 (60.0%), p = 0.895). The HR (82 ± 11.5/min vs. 87 ± 11.1/min, p = 0.046) and mean BP (83 ± 17.2 mmHg vs. 90 ± 16.7 mmHg, p = 0.035) were significantly lower in the T group after tracheal intubation. The other postoperative outcomes were comparable between the two groups. CONCLUSIONS: Although the total remifentanil infusion dose was higher in the T group than in the M group, the postoperative outcomes were similar. If stable vital signs are desired during tracheal intubation, remifentanil infusion with TCI should be considered.

The effect on vital signs of concomitant administration of nicardipine and dexmedetomidine sedation after spinal anesthesia: A double-blind, randomized controlled trial.

BACKGROUND: We evaluated heart rate (HR) and blood pressure (BP) trends when nicardipine (NCD) was co-administered during dexmedetomidine (DEX) sedation after spinal anesthesia. METHODS: Sixty patients aged 19 to 65 were randomly assigned to the DEX or DEX-NCD groups. Five minutes after infusion of the loading dose of DEX, the NCD was administered intravenously at a rate of 5 µg/kg for 5 minutes in the DEX-NCD group. The study starting point was set at 0 minute when the DEX loading dose was initiated. The primary outcomes were the differences in HR and BP between the 2 groups during the study drug administration. Secondary outcomes included the number of patients whose HR was < 50 beats per minute (bpm) after the DEX loading dose infusion, and associated factors were evaluated. The incidence of hypotension in the postanesthesia care unit, postanesthesia care unit length of stay, postoperative nausea and vomiting, postoperative urinary retention, time to first urination after spinal anesthesia, acute kidney injury, and postoperative hospital length of stay were evaluated. RESULTS: The HR was significantly higher at 14 minutes, and the mean BP was significantly lower at 10 minutes in the DEX-NCD group than in the DEX group. The number of patients with an HR < 50 bpm during surgery was significantly higher in the DEX group than in the DEX-NCD group at 12, 16, 24, 26, and 30 minutes. The DEX group and a low initial HR were independently associated with the occurrence of an HR < 50 bpm after DEX loading dose infusion. Postoperative outcomes were not significantly different between the 2 groups. CONCLUSIONS: Simultaneous administration of NCD during the administration of a loading dose of DEX prevented severe bradycardia. Co-administration of NCD may be considered in patients with a low initial HR when severe bradycardia is expected during the DEX loading dose infusion. NCD and DEX may be safely infused simultaneously without affecting postoperative complications (see Figure S1, Supplemental Digital Content, http://links.lww.com/MD/J241 , Graphical abstract).

Comparison of the Incidence of Postoperative Acute Kidney Injury Following the Administration of Remimazolam or Sevoflurane in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: We evaluated the incidence of postoperative acute kidney injury (AKI) and complications when remimazolam (RMMZ) or sevoflurane (SEVO) were used in elderly patients undergoing total knee arthroplasty. METHODS: Seventy-eight participants aged ≥65 were randomly allocated to either the RMMZ or SEVO group. The primary outcome was the incidence of AKI on postoperative day (POD) 2. The secondary outcomes included intraoperative heart rate (HR), blood pressure (BP), total drug administered, emergence time, postoperative complications on POD 2, and hospital length of stay (HLOS). RESULTS: The incidence of AKI was comparable between the RMMZ and SEVO groups. The doses of intraoperative remifentanil, vasodilators, and additional sedatives were significantly higher in the RMMZ group than in the SEVO group. Overall intraoperative HR and BP tended to remain higher in the RMMZ group. The emergence time in the operating room was significantly faster in the RMMZ group; however, the time required for an Aldrete score ≥ 9 was comparable between the RMMZ and SEVO groups. Postoperative complications and HLOS were comparable between the RMMZ and SEVO groups. CONCLUSION: RMMZ may be recommended for patients who are expected to decrease in intraoperative vital signs. However, stable hemodynamics with RMMZ were not sufficient to influence the prevention of AKI.

Comparison of oxygen reserve index according to the remimazolam or dexmedetomidine for intraoperative sedation under regional anesthesia-A single-blind randomized controlled trial.

Introduction: We aimed to evaluate the difference in intraoperative oxygen reserve index (ORi) between the sedatives remimazolam (RMMZ) and dexmedetomidine (DEX). Methods: Seventy-eight adult patients scheduled for sedation under regional anesthesia were randomly assigned to either the DEX (n = 39) or RMMZ (n = 39) group. The primary outcome was the difference in perioperative ORi between the groups. The secondary outcomes included respiratory depression, hypo- or hypertension, heart rate (HR), blood pressure, respiratory rate and postoperative outcomes. Additionally, the number of patients who experienced a decrease in intraoperative ORi to < 50% and the associated factors were analyzed. Results: The ORi was significantly higher in the RMMZ group at 15 min after sedation maintenance. There were no significant differences in respiratory depression between the two groups. The intraoperative HR was significantly higher in the RMMZ group after the induction of sedation, 15 min after sedation maintenance, and at the end of surgery. No other results were significantly different between the two groups. The incidence of a decrease in intraoperative ORi to < 50% was significantly higher in the DEX group. Factors associated with a decrease in the intraoperative ORi to < 50% were diabetes mellitus, low baseline peripheral oxygen saturation (SpO2), and DEX use. In the receiver operating characteristic curve analysis for a decrease in the intraoperative ORi to < 50%, the cutoff baseline SpO2 was 97%. Conclusion: RMMZ is recommended as a sedative for patients with a low baseline SpO2 and intraoperative bradycardia. Further studies should be conducted to establish the criteria for a significant ORi reduction.

Is the Mirroring Technology Reliable in the Use of Computer-Aided Design for Orbital Reconstruction? Three-Dimensional Analysis of Asymmetry in the Orbits.

BACKGROUND: Reconstruction of the orbital area remains a challenge in many cases. The recently introduced mirroring technology provides surgeons with patient-specific information for accurate orbital reconstruction; its premise is that the three-dimensional anatomy of craniofacial bone is symmetric. The purpose of this study was to verify this premise of the mirroring technology by assessing three-dimensional asymmetry. METHODS: Facial computed tomographic data of 104 patients were imported into iPlan software. Four reference points (i.e., zygomaticofrontal suture, frontomaxillary suture, infraorbital foramen, and optic canal) were set, and the three-dimensional distances from these points to the anterior nasal spine on the mirroring plane were calculated. In addition, the orbital cavity volume and the three-dimensional distances from point optic canal to the other reference points were calculated for the assessment of the orbit anatomy. Three plastic surgeons performed these processes independently. RESULTS: No statistically significant difference was found in the three-dimensional distances between anterior nasal spine and the four reference points bilaterally. Also, no statistically significant difference in the three-dimensional distances between the point representing the optic canal and other reference points was detected bilaterally. Orbital cavity volume showed a mild asymmetry, but the discrepancy was acceptable for computer-aided design applications. For all reference points, the maximum value of the 95 percent CI was less than 1.4 mm. CONCLUSIONS: The three-dimensional location of the orbits and the three-dimensional anatomy of the orbit were symmetric. Thus, the mirroring technology could be a reliable first step in computer-aided design, computer-assisted surgery, and navigation-assisted surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A randomized controlled trial of the effect of ramosetron on postoperative restoration of bowel motility after gynecologic laparoscopic surgery.

OBJECTIVE: To investigate the effect of ramosetron after gynecological laparoscopic surgery on the recovery of bowel function. METHODS: A prospective randomized controlled trial conducted at Kyung Hee University hospital, South Korea, from August 2016 to September 2017. Patients were randomized to receive either 10 mg dexamethasone before induction of anesthesia (control group C), followed by intravenous administration of patient-controlled analgesia (IV-PCA) or 2 ml normal saline before induction of anesthesia and 0.6 mg ramosetron (study group R) administered with IV-PCA. RESULTS: A total of 88 patients were enrolled. Times to first flatus (group C 23.98 ± 6.31 vs. group R 27.14 ± 9.56 h; P = 0.148) and first defecation (group C 36.16 ± 16.04 vs. group R 43.41 ± 20.01 h; P = 0.138) showed no statistically significant differences. No significant differences were observed in the frequency of postoperative nausea and vomiting (PONV) and demand for additional analgesics. Multiple linear regression for analysis of factors affecting time to first flatus revealed no significant results. CONCLUSION: Ramosetron did not delay bowel movement recovery after gynecologic laparoscopic surgery and was as effective as dexamethasone in regulating PONV. Ramosetron can be used with IV-PCA without concerns about delay in recovery of bowel function. CLINICALTRIALS: gov registration number: NCT02849483.

General anesthesia for old Werner syndrome patient: a case report.

Werner syndrome (WS) is a rare autosomal recessive, premature aging disorder whose clinical manifestations include short stature, bilateral cataracts, diabetes mellitus, hypertension, and atherosclerosis. WS first manifests during adolescence and patients usually die at 40-50 years of age. Only symptomatic treatment options available according to clinical manifestations. In anesthetic management, they need to be considered to elderly patients. Difficult intubation is expected and the patients are regarded as a high-risk group for anesthesia, owing to the concomitant cardiovascular and cerebrovascular disorders. The anesthetic management of WS requires a meticulous preoperative history taking, physical examination, and preparation for cardiovascular events.

Respiration monitoring in PACU using ventilation and gas exchange parameters.

The importance of perioperative respiration monitoring is highlighted by high incidences of postoperative respiratory complications unrelated to the original disease. The objectives of this pilot study were to (1) simultaneously acquire respiration rate (RR), tidal volume (TV), minute ventilation (MV), SpO2 and PETCO2 from patients in post-anesthesia care unit (PACU) and (2) identify a practical continuous respiration monitoring method by analyzing the acquired data in terms of their ability and reliability in assessing a patient's respiratory status. Thirteen non-intubated patients completed this observational study. A portable electrical impedance tomography (EIT) device was used to acquire RREIT, TV and MV, while PETCO2, RRCap and SpO2 were measured by a Capnostream35. Hypoventilation and respiratory events, e.g., apnea and hypopnea, could be detected reliably using RREIT, TV and MV. PETCO2 and SpO2 provided the gas exchange information, but were unable to detect hypoventilation in a timely fashion. Although SpO2 was stable, the sidestream capnography using the oronasal cannula was often unstable and produced fluctuating PETCO2 values. The coefficient of determination (R2) value between RREIT and RRCap was 0.65 with a percentage error of 52.5%. Based on our results, we identified RR, TV, MV and SpO2 as a set of respiratory parameters for robust continuous respiration monitoring of non-intubated patients. Such a respiration monitor with both ventilation and gas exchange parameters would be reliable and could be useful not only for respiration monitoring, but in making PACU discharge decisions and adjusting opioid dosage on general hospital floor. Future studies are needed to evaluate the potential clinical utility of such an integrated respiration monitor.