Impact of the combination of abdominal peripheral nerve block and neuromuscular blockade on the surgical space during robot-assisted laparoscopic surgery: a prospective randomized controlled study.

PURPOSE: The impact of the combination of abdominal peripheral nerve block (PNB) and the depth of neuromuscular blockade on the surgical field were assessed. METHODS: Thirty-eight patients undergoing elective robot-assisted laparoscopic radical prostatectomy (RARP) were randomized into two groups: a PNB group (moderate neuromuscular block [train-of-four 1-3 twitches] with abdominal PNB) and a non-PNB group (deep neuromuscular block [post-tetanic count 0-2 twitches] without abdominal PNB). The primary outcome was the change in the depth of the abdominal cavity relaxation assessed by the change in the distance (Δdistance) between the umbilicus port and peritoneum upon pneumoperitoneal pressure increase from 8 to 12 mmHg. The secondary outcomes were the CO2 usage for the pneumoperitoneal pressure increase and the subjective differences in the Surgical Rating Score (SRS) during surgery. RESULTS: The Δdistance and the CO2 usage from 8 to 12 mmHg did not differ significantly between the non-PNB and PNB groups (1.34 ± 0.65 vs. 1.28 ± 0.61 cm, p = 0.763 and 3.64 ± 1.68 vs. 4.34 ± 1.44 L, p = 0.180, respectively). There was also no significant difference in SRS. Comparisons of the Δdistance values for pressure increases from 6 to 8 mmHg, 6 to 10 mmHg and 6 to 12 mmHg between the non-PNB and PNB groups also showed no between-group differences, despite significant intra-group differences (p < 0.001) by pressure increment. CONCLUSIONS: Our findings indicate that moderate neuromuscular block with abdominal PNB maintained an adequate surgical space for RARP, with no significant difference from the space achieved by deep neuromuscular block.

Association between regional oxygen saturation and central venous saturation in pediatric patients undergoing cardiac surgery: A prospective observational study.

BACKGROUND: We evaluated the correlation between regional oxygen saturation (rSO2 ) in the frontal and right renal dorsum (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy (INVOS™ 5100C, Medtronic) and central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter (PediaSat™, Edwards Lifesciences) during surgery in order to determine whether noninvasive rSO2 could be used as an alternative to ScvO2 in pediatric cardiac surgery patients. We evaluated the correlation between regional tissue oxygen saturation (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy and other patient measures with central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter to track global oxygen supply demand as a potential alternative or supplement to ScvO2 . PATIENTS AND METHODS: This single-center prospective observational study enrolled 33 children (weight < 10 kg) who underwent cardiac surgery for congenital heart disease between February 2018 and November 2021. ScvO2 , cerebral rSO2 , and somatic rSO2 were recorded simultaneously after anesthesia induction and central venous catheter placement. Pearson's correlation coefficient and Bland-Altman analysis were used to determine the relationship between ScvO2 and rSO2 . We conducted correlation, Bland Altman, and multiple regression analyses to identify associations between rSO2 , patient measures, and ScvO2 values. RESULTS: The patients' median age was 11.0 (quartile 2.0-16.0) months. Their weight was 7.2 (quartile 4.5-9.2) kg. Cerebral rSO2 was significantly positively correlated with ScvO2 (r2 = 0.29, p = .002 in all patients; r2 = 0.61, p = .013 in the patients without mixing at the atrial level), whereas somatic rSO2 was not. The Bland-Altman analysis demonstrated biases [95% confidence interval; 95% CI] (lower and upper limits of agreement [95% CI]) of 0.27% [-4.26 to 4.80] (-24.79 [-32.61 to -16.96] to 25.33 [17.50 to 33.16]) between cerebral rSO2 and ScvO2 and 0.91% [-5.48 to 7.30] (-34.43 [-45.47 to -23.39] to 36.25 [25.21 to 47.29]) between somatic rSO2 and ScvO2 . Preoperative brain natriuretic peptide (BNP) and SpO2 were independent variables associated with ScvO2 and cerebral and somatic rSO2 . CONCLUSION: Cerebral rSO2 , SpO2 , and BNP were significantly correlated with ScvO2 , although the cerebral rSO2 correlation was greater for lesions without atrial mixing. rSO2 , BNP, and SpO2 might be used to track changes in ScvO2 but cerebral rSO2 is not sufficiently precise to replace it.

Clotting functional stability of withdrawing blood in storage for acute normovolemic hemodilution: a pilot study.

PURPOSE: This study was conducted to time-course changes of clotting function of withdrawing blood for acute normovolemic hemodilution (ANH). METHODS: Twelve enrolled patients who underwent ANH from August, 2018 to January, 2019. Blood was withdrawn into blood collection pack and shaken at 60-80 rpm for 24 h in room temperature. Clot formation was evaluated using rotational thromboelastometry (ROTEM™) just after blood withdrawal (control) and 4, 8, 12 and 24 h after blood withdrawal. We compared with the control value and each value of extrinsically-activated test with tissue factor (EXTEM), intrinsically-activated test using ellagic acid (INTEM) and fibrin-based extrinsically activated test with tissue factor (FIBTEM). RESULTS: Maximum clot firmness (MCF) of FIBTEM did not change significantly. MCF of EXTEM was significantly decreased time-dependent manner but all MCF of EXTEM were within a normal range. Maximum percent change in MCF of EXTEM was 12.4% [95% confidence interval (CI): 9.0-15.8%]. The difference in the maximum clot elasticity (MCE) between EXTEM and FIBTEM (MCEEXTEM-MCEFIBTEM) was significantly decrease from 8 h after blood withdrawal. Maximum percent change in MCEEXTEM-MCEFIBTEM was 30.2% (95% CI:17.6-42.9%) at 24 h after blood withdrawal. CONCLUSION: Even though the MCE significantly decreased in a time-dependent manner, MCF of FIBTEM and EXTEM was normal up to 24 h storage. The blood of ANH can use for the purpose of hemostasis at least 8 h stored at room temperature after blood withdrawal. Future studies are needed to elucidate the clinical impact on the patient after delayed transfusion of ANH blood with regard to patient's hemostasis.

Preoperative cerebral and renal oxygen saturation and clinical outcomes in pediatric patients with congenital heart disease.

We examined the predictability of preoperative cerebral and renal rSO2 values for outcomes in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Patients who underwent pediatric cardiac surgery under CPB between September 2015 and September 2017 were enrolled in this study. Patients monitored with both cerebral and renal rSO2 at the beginning of surgery were included. The primary outcome was the prediction of outcomes after pediatric cardiac surgery. Outcome was defined as any of: (1) death within 30 days after surgery, or the need for (2) renal replacement therapy or (3) extracorporeal membrane oxygenation, (4) shorten mechanical ventilator-free day,(5) shorten ICU-free survival day. We included 59 patients: cyanotic n = 31; non-cyanotic n = 28. Among all patients, 15 (25%) had poor outcomes, including three deaths. The cerebral and renal rSO2 values were significantly lower in the cyanotic patients with poor outcomes compared to those without poor outcomes (cerebral: 59 ± 11 vs. 50 ± 5, p = 0.021; renal: 59 ± 15 vs. 51 ± 14, p = 0.015) but only the renal rSO2 value was significantly lower in the non-cyanotic patients (77 ± 10 vs. 61 ± 14, p = 0.011). The cut-off value (51%) of cerebral rSO2 were associated with risk of mechanical ventilator-free day and ICU-free survival day [ORs of 22.8 (95% CI 2.21-235.0, p = 0.0087) and 15.8 (95% CI 1.53-164.0, p = 0.0204), respectively] in the cyanotic patients. The cut-off value (66%) of cerebral rSO2 value was associated with risk of mechanical ventilator-free day [OR of 11.3 (95% CI 1.05-25.3, p = 0.0456)] and the cut-off value (66%) of renal rSO2 value was associated with risk of ICU-free survival day [ORs of 33.0 (95% CI 2.25-484.0, p = 0.0107)] in the noncyanotic patients. The preoperative low rSO2 values were associated with outcomes including 30-day mortality and might be reflective of the severity of cardiopulmonary function. Further studies are needed to confirm our results.

Efficacy of abdominal peripheral nerve block and caudal block during robot-assisted laparoscopic surgery: a retrospective clinical study.

PURPOSE: We retrospectively analyzed the efficacy of abdominal peripheral nerve block (PNB) and caudal block (CB) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP). METHODS: Patients who underwent elective RARP at our hospital (Jan. 2015-Sept. 2016) were enrolled. We reviewed the 188 patients' anesthesia charts and medical records and divided the patients into three groups based on the anesthesia used in their cases: 76 patients in the total intravenous anesthesia (TIVA) group, 51 patients in the TIVA + abdominal PNB group (TI-PB group), and 61 patients in the TIVA + abdominal PNB + CB (TI-PB-CB group). We compared the groups' amounts of anesthetic drug usage, anesthesia times, and the presence/absence of additional opioid administration in the recovery room. RESULTS: The perioperative opioid use during anesthesia was significantly greater in the TIVA group than in the TI-PB-CB group. The total amount of muscle relaxant was significantly higher (p < 0.001) in the TIVA group than the TI-PB-CB group: 60.0 (50.0-70.0) mg vs. 50.0 (40.0-60.0) mg. Although there were no significant differences in the operation time, the frequency of the use of additional opioid administration was significantly higher (p < 0.01) in the TIVA group than the TI-PB group: 23.7% vs. 2.0%, respectively. CONCLUSIONS: Although there was no influence on the anesthesia time, the muscle relaxant dose and the perioperative amount of opioid use were significantly less in the combined PNB + CB group. Our analyses suggest that not only PNB but also CB was useful for perioperative management in RARP. CLINICAL TRIAL REGISTRATION: 2016-1059.

Factors affecting phantom limb pain in patients undergoing amputation: retrospective study.

PURPOSE: The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. METHODS: Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. RESULTS: Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). CONCLUSION: The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.

Family-Centered Care in Neonatal Intensive Care Units: Combining Intensive Care and Family Support.

Advances in treatment in neonatal intensive care units (NICU) for preterm and sick newborns have improved the mortality rate of patients, but admission to the NICU may disrupt parent-infant interaction, with adverse consequences for infants and their families because of physical, psychological, and emotional separation. The concept of family centered care (FCC), in which family members are part of the care team and infants are close to the family, is important and has become popular in NICU. In 2013, we created a team called "Kodomo-Kazoku Mannaka" to promote FCC in Japan, and visited the NICU at Uppsala University Hospital in Sweden, which is internationally famous for FCC. Since this fruitful visit, we have been promoting FCC in Japan by exhibitions and presentations of the FCC ideas at academic conferences and using internet services. A questionnaire survey conducted in 2015 revealed that the importance and the benefits of FCC in NICU are recognized, although there are some barriers to FCC in each facility. It is hard to change facilities and social systems right away, but it is easier and more important to change people's minds. Our role is to spread the concept of FCC and to help each facility find its own way to adopt it. We will continue to make efforts encourage to promote FCC in Japan.

[Successful High Flow Nasal Cannula Therapy in a Patient with Myotonic Dystrophy during Perioperative Period].

A 44-year-old woman (body mass index 32) with myotonic dystrophy was admitted for bilateral para- thyroidectomy. Her risk of post-operative respiratory complications was high due to respiratory muscle weakness (%VC 52.8%) and high sputum volume. Difficulties in surgery were anticipated under local anesthesia due to obesity and bilateral tumors. There- fore, general anesthetic management without muscle relaxant was selected and early extubation conducted to prevent respiratory complications. She was extubated 1 hour after surgery in the intensive care unit (ICU) and F102 0.6, 10 l · min⁻¹ oxygen mask was administrated. Paco2 gradually increased (54 mmHg 15 minutes later, 61 mmHg 2 hours later after extubation). A high flow nasal can- nula was administered to facilitate CO2 elimination, and Paco2 decreased to 46 mmHg after 4 hours. An intra- pulmonary percussive ventilator was administered for the purpose of sputum discharge which facilitated effi- cient expectoration of sputum. She was discharged from the ICU on postoperative day (POD) 1 and from hospital on POD 6 without complications.

Reversible Motor Paralysis and Early Cardiac Rehabilitation in Patients With Advanced Heart Failure Receiving Left Ventricular Assist Device Therapy.

Advanced heart failure (HF) is sometimes complicated with brain impairment because of a microthrombosis caused by decreased left ventricular contraction or reduced brain circulation. Some patients may recover after left ventricular assist device (LVAD) implantation. However, little is known about the perioperative therapeutic strategy in patients suffering from such complications, particularly from a cardiac rehabilitation viewpoint. We report on a 58-year-old male patient with a previous history of poliomyelitis and a light paralysis in the left upper extremity, who suffered left hemiplegia with no evidence of stroke after hemodynamic deterioration. The combination therapy of perioperative cardiac rehabilitation and LVAD therapy improved his left hemiplegia as well as activities of daily living, and the patient was discharged on foot on postoperative day 72 after briefing the family on LVAD home management. Early initiation of cardiac rehabilitation before LVAD implantation may be a key for the smooth discharge and resocialization of patients suffering from brain impairment complicated with advanced HF.

A case report of sudden thrombocytopenia detected only by in vitro analysis.

We experienced an unexpected thrombocytopenia detected only in vitro during radical prostatectomy for a 66-year-old patient. Thrombocytopenia with platelet aggregation was observed in a blood sample obtained using a heparinized syringe (not by ethylene diamine tetra-acetic acid tube). Although we could not exclude platelet agglutination in vivo, no thrombosis or coagulation disorder was observed. We changed the anti-coagulant in the arterial catheter carrier fluid (saline) from heparin to argatroban, and continued with the operation. No embolic complications were observed during the perioperative period. Although pseudothrombocytopenia or heparin-induced thrombocytopenia was highly suspected in the present case, we were not able to confirm which of the two developed. Multi-directional attention and care may be required for perioperative unexpected thrombocytopenia.

Impact of robot-assisted laparoscopic prostatectomy on the management of general anesthesia: efficacy of blood withdrawal during a steep Trendelenburg position.

INTRODUCTION: Robot-assisted laparoscopic prostatectomy (RALP) is being increasingly used. However, a steep Trendelenburg position and pneumoperitoneum during RALP has an impact on the respiratory, cardiovascular and cerebrovascular systems. To prevent complications, restrictive fluid management and blood withdrawal have been utilized in our hospital. We examined differences in the anesthetic management between RALP and radical retropubic prostatectomy (RRP), and the efficacy of blood withdrawal. METHODS: Medical records of patients who underwent radical prostatectomy in our hospital between January 2012 and October 2013 were retrospectively reviewed. Demographic data, intraoperative blood and fluid administration, perioperative complications and the length of hospital stay were compared among patients receiving RRP, and those receiving RALP with and without blood withdrawal (n = 78, 46 and 68, respectively). RESULTS: Patients receiving RALP with and without blood withdrawal received a smaller volume of crystalloid during surgery than those receiving RRP (mean ± SD, 5.8 ± 2.3 and 4.2 ± 1.6 vs 14.3 ± 4.1 ml/kg/h, p < 0.001). Median estimated blood loss was 885 g (80-2,800 g) for RRP and 50 g for RALP (3-950 g and 3-550 g, respectively), p < 0.001. None of the patients undergoing RALP received red blood cells, but three patients undergoing RRP did so. RALP with blood withdrawal reduced postoperative hospital stay by 45 % (6 vs 11 days). Four patients receiving RALP without blood withdrawal had delayed extubation due to severe laryngeal edema, which did not occur in any of the patients receiving RALP who had blood withdrawal. Renal function did not differ among the groups. CONCLUSIONS: RALP was associated with less blood loss, no allogeneic transfusion and shorter postoperative hospital stay. This study indicated that blood withdrawal could prevent severe laryngeal edema.

[Anesthetic Management of Laparoscopic Nephrectomy for a Renal Cancer Patient with Distal Myopathy of Rimmed Vacuole].

A 56-year-old male with distal myopathy of rimmed vacuoles underwent laparoscopic nephrectomy. Anesthesia was induced with propofol, remifentanil and ketamine. Tracheal intubation using McGRATH was uneventful without using muscle relaxants. Then ultrasound-guided right thoracic paravertebral (TPVB) block was performed using 20 ml 0.75% ropivacaine with 10 ml 2% lidocaine by 3 injections of 10 ml each at T9 to T11. General anesthesia was maintained with propofol, remifentanil and ketamine monitoring bispectral index. Good surgical condition and pneumoperitoneum were maintained without using muscle relaxants. His postoperative course was smooth and uneventful, even though a small amount of fentanyl was administrated to relieve wound pain. This case suggests that McGRATH and ultrasound-guided TPVB can be one of the options to avoid using muscle relaxants in patient with neuromuscular disease.

[Case of urgent surgical cricothyrotomy in CICV situation during induction of anesthesia for hemostasis after tonsillectomy].

A 38-year-old man (BMI 31) underwent bilateral tonsillectomy for sleep apnea syndrome under general anesthesia without any airway difficulty. On the fifth post-operative day excessive bleeding occurred suddenly. Emergency tracheostomy was planned, not under local anesthesia but general anesthesia in the presence of otolaryngologists for urgent tracheostomy, since the patient could not lie in the supine position. Tracheal intubation was tried using rapid sequence technique. However, excessive bleeding in the oral cavity did not allow successful direct laryngoscopy, resulting in CICV situation. When CICV situation was con- firmed associated with SpO2 91%, surgical cricothyrotomy was started by otolaryngologists. SpO2 decreased to 13% associated with heart rate of 38 beats · min-1 immediately before restoration of ventilation and oxygenation. After hemostasis, he showed uneventful post-operative course. On the occasion of airway management for excessive laryngopharyngeal bleeding, emergency surgical crycothyrotomy should be performed immediately before the fall of oxygen tension, if rapid sequence tracheal intubation had failed.

Relationship between degree of disability, usefulness of assistive devices, and daily use duration: an investigation in children with congenital upper limb deficiencies who use upper limb prostheses.

Upper limb prostheses can help children with congenital upper limb deficiencies (ULDs) perform activities of daily living. Although the degree of disability and prosthesis usefulness may be related to becoming accustomed to wearing a prosthesis, these relationships have not been confirmed. This study was aimed at investigating the relationship between motor function, the usefulness of prostheses in everyday activities, and daily duration of prosthesis use in children with congenital ULDs. Eleven children with congenital transcarpal or transradial ULDs and their caregivers participated in this study. The caregivers were asked to complete a questionnaire concerning their children's everyday activities and the daily duration of prosthesis wearing. The adaptive behavior scale was used to measure motor function prior to intervention. Correlations analyses revealed no significant correlation between the children's adaptive behavior, including motor skills before intervention, and daily duration of prosthesis wearing, but revealed a positive correlation between the number of activities that the children performed more effectively with their prostheses and the daily use duration. To ensure that children with congenital ULDs become accustomed to wearing their prostheses, the prostheses should meet the requirements of everyday activities.

Drastic improvement of cardiac function after living-donor renal transplantation in a long-term hemodialysis patient with severe mitral regurgitation.

BACKGROUND: Although there are reports of recovery of cardiac function after renal transplantation, the feasibility of renal transplantation in patients with low cardiac function remains controversial. CASE PRESENTATION: A 59-year-old Japanese male was scheduled to undergo living-donor renal transplantation (LDRT) under general anesthesia. Preoperative transthoracic echocardiography revealed severe mitral regurgitation (MR) and a left ventricular ejection fraction (LVEF) at 30%. LDRT was conducted prior to cardiac surgery with restrictive fluid management and close monitoring of cardiac function. The patient's renal function improved promptly after the LDRT, and his hemodynamics were stable throughout the perioperative period. Along with improvements in the patient's renal function and anemia, the patient's cardiac function improved to LVEF 50% and achieved drastically improved MR as well as cardiac function, without intervention. CONCLUSION: This case indicates that LDRT has the potential to improve cardiac function in patients who have been on hemodialysis for more than 20 years.