Incidence and risk factors of intraoperative hyperglycemia in non-diabetic patients: a prospective observational study.

BACKGROUND: Intraoperative hyperglycemia has been associated with multiple postoperative complications such as surgical site infection, myocardial infarction, stroke, and death. These complications are not confined to only diabetic patients. However, the incidence of intraoperative hyperglycemia in non-diabetic patients has not been fully elucidated. Additionally, these patients' risk factors were not well established in previous studies. METHODS: Four hundred forty non-diabetic patients who underwent intermediate- to high-risk surgery were included in the study. We prospectively measured the capillary blood glucose level in all patients during surgery. The incidence of intraoperative hyperglycemia was defined as at least one episode of blood glucose level of more than 180 mg/dL. Risk factors for hyperglycemia were assessed using multivariable logistic regression analysis. RESULTS: Sixty-five (14.7%) patients developed hyperglycemia during surgery. The independent risk factors for intraoperative hyperglycemia were an American Society of Anesthesiologists status ≥ 3 (odds ratio [OR] 6.09, 95% confidence interval [CI]: 2.67-13.89, p < 0.001), preoperative impaired fasting blood sugar (OR 2.28, 95%CI:1.13-4.61, p = 0.021), duration of anesthesia ≥ 3 h (OR 4.06, 95%CI: 1.23-13.45, p = 0.021), intraoperative hypotension (OR 5.37, 95%CI: 2.35-12.29, p < 0.001), intraoperative blood transfusion (OR 4.35, 95%CI: 2.15-8.79, p < 0.001), and steroid use (OR 2.39, 95%CI: 1.20-4.76, p = 0.013). Surgical site infection was higher in patients with intraoperative hyperglycemia compared with patients without intraoperative hyperglycemia (4 [6.1%] vs. 6 [1.6%], respectively, p = 0.035). CONCLUSION: The incidence of intraoperative hyperglycemia was significant in non-diabetic patients during intermediate- to high-risk surgery. Risk factors should be identified to prevent intraoperative hyperglycemia. TRIAL REGISTRATION: The study was prospectively registered at https://www.thaiclinicaltrials.org (TCTR20191114001).

Myocardial injury in patients with hemodynamic derangements during and/or after liver transplantation.

Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1 ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.

Perioperative complications in liver transplantation using donation after cardiac death grafts: a propensity-matched study.

Donation after cardiac death (DCD) is an important source for expanding the donor pool for liver transplantation (LT). Although the long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aim of this study was to determine whether DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After institutional review board approval, the medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD grafts and patients receiving donation after brain death (DBD) grafts. In all, 74 patients received DCD grafts during the study period, and 1369 patients received DBD grafts. An initial comparison showed that many preoperative, prereperfusion, and donor variables in the DCD group differed significantly from those in the DBD group. Propensity matching was chosen so that adjustments could be made for the differences. A postmatching analysis showed that the preoperative, prereperfusion, and donor variables no longer differed between the 2 groups. The postreperfusion requirements for blood products and vasopressors, the posttransplant ventilation times, the incidence of posttransplant acute renal injury, and the 30-day and 1-year patient and graft survival rates were comparable between the 2 groups. However, patients receiving DCD grafts experienced significantly higher rates of hyperkalemia (33.8% versus 18.9%, P < 0.05) and postreperfusion syndrome (PRS; 25.7% versus 12.3%, P < 0.05). In conclusion, after adjustments for preoperative and prereperfusion risks via propensity matching, DCD grafts remained a risk factor for postreperfusion hyperkalemia and PRS. A prophylactic regimen aimed at decreasing postreperfusion hyperkalemia and PRS is recommended for the management of LT using DCD grafts.

A comparison of dexmedetomidine and propofol in Patients undergoing electrophysiology study.

BACKGROUND: Dexmedetomidine provides profound levels of sedation without affecting cardiovascular and respiratory stability based on its pharmacological profile. It may be a valuable sedative for procedures with minimal to mild pain. Electrophysiology study (EP study) is a mildly painful procedure that requires conscious sedation. The authors hypothesized that dexmedetomidine would cause lower respiratory and cardiovascular depression than propofol during equal sedation level in an electrophysiology study. MATERIAL AND METHOD: The present study protocol was approved by the clinical research ethics committee at Ramathibodi Hospital. Thirty-four patients were randomly allocated into two groups to receive either dexmedetomidine or propofol for an electrophysiology study. Patients in the dexmedetomidine group received a loading dose of dexmedetomidine (0.5 mcg/kg) infused over 10 minutes followed by 0.4 mcg/kg/h. Each patient in the propofol group received propofol 1 mg/kg over 10 minutes followed by 3 mg/kg/h. All patients received pethidine (0.5 mg/kg) before the initiation of EP study. Sedation was determined using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S). The Modified Observer's Assessment of Alertness/Sedation scores, hemodynamic and respiratory variables were recorded regularly during the EP study. RESULTS: Thirty-four patients were enrolled in the present study. The Modified Observer's Assessment Alertness/Sedation values were similar in both groups. Respiratory rate values with dexmedetomidine were significantly higher than those in the propofol group (p = 0.048) and the oxygen supplement in the dexmedetomidine group were significantly lower than those in the propofol group (p < 0.001). Moreover mean arterial blood pressure values of dexmedetomidine at the five and 15-minute were significantly higher than those of the propofol group (p = 0.024). No incidence of severe bradycardia or hypotension was found in both groups. CONCLUSION: The present study demonstrated that comparable sedation could be achieved by a combination of pethidine with either dexmedetomidine or propofol during EP study. Dexmedetomidine group provided more hemodynamic and respiratory stability than propofol group.

Endotracheal intubation of patients in left semi-prone position before endoscopic retrograde cholangiopancreatography: A randomised controlled study.

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is generally performed with the patient in the left semi-prone position. The patients are usually intubated in the supine position and subsequently turned to the left semi-prone position. This turning procedure may cause the injuries to the patient or unstable haemodynamics. Previous studies show that the success rates of intubation in the lateral position are comparable to that of intubation in the supine position, even so, there are some difficulties. Therefore, this study is aimed to investigate the effect of the semi-prone position on the success rate of intubation. Methods: This randomised controlled trial included 88 patients aged 18 to 80 years with an American Society of Anesthesiologists physical status (ASA PS) of I-III with no predicted difficult intubation, and who were undergoing ERCP. The subjects were randomly assigned to be intubated in the supine or semi-prone position. The 44 patients in the supine group were intubated in the supine position. The other 44 patients were intubated in the semi-prone position. The primary outcome was the success rate of the first intubation attempt. Results: There were no differences between the two groups in age, ASA PS and preoperative airway characteristics. Endotracheal intubation was successful in all patients with the first intubation attempt successful in 43 patients (97.7%) in the supine group and 42 (95.5%) in the semi-prone group (P = 0.556). Conclusion: For patients undergoing ERCP, the success rate of endotracheal intubation in the left semi-prone position was comparable to that in the supine position.

Effect of local anaesthetic infiltration on postoperative pain after laparoscopic cholecystectomy: randomized clinical trial.

BACKGROUND: Local anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC. METHODS: Patients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed. RESULTS: Out of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007). CONCLUSIONS: Local anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery. REGISTRATION NUMBER: TCTR20201103002 (http://www.thaiclinicaltrials.org).

Modified Mallampati Class Rating Before and After Cesarean Delivery: A Prospective Observational Study.

BACKGROUND: The modified Mallampati classification (MMC) provides an estimate of the tongue size relative to the oral cavity size, and is a usual screening tool for predicting difficult laryngoscopy. Previous studies have indicated an increase of MMC during the progression of pregnancy, but there is no comprehensive study in pregnant women undergoing cesarean delivery. The primary aim of this study was to evaluate the MMC before and after cesarean delivery. METHODS: This is a prospective observational study of 104 women who underwent cesarean section. MMC, thyromental distance, neck circumference, and upper lip bite test were evaluated at 4 different time points: during the pre-anesthetic visit (T0) and at 1 (T1), 6 (T2), and 24 (T3) hours after delivery. Factors evaluated for their predictive validity included gestational weight gain, operation time, amount of intravascular fluids, oxytocin dosage, and blood loss. The correlation between each factor and the MMC classification was tested by logistic regression. RESULTS: From 104 participants, 59.6% experienced Mallampati class changes. The proportions of patients classified as Mallampati III and IV at different time points were: T0 = 48.1% (MMC III only), T1 = 75.0%, T2 = 80.8%, and T3 = 84.6%, respectively. Gestational weight gain, duration of surgery, anesthetic method, blood loss, oxytocin dosage, or amount of intravenous fl uid were not correlated with the MMC change. CONCLUSION: The number of patients with initial Mallampati III was high. In addition, a significant increase in MMC occurred after cesarean delivery. The data confirm the particular risk status of women undergoing cesarean delivery particularly regarding airway anatomy.

Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks.

BACKGROUND: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle/catheter tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. Epidural waveform analysis can be carried out through the tip of the needle (EWA-N) or the catheter (EWA-C). In this randomized trial, we compared the two methods. We hypothesized that, compared with EWA-C, EWA-N would result in a shorter performance time. METHODS: One hundred and twenty patients undergoing thoracic epidural blocks for thoracic or abdominal surgery were randomized to EWA-N or EWA-C. In the EWA-N group, LOR was confirmed by connecting the epidural needle to a pressure transducer. After obtaining a satisfactory waveform, the epidural catheter was advanced 5 cm beyond the needle tip. In the EWA-C group, the epidural catheter was first advanced 5 cm beyond the needle tip after the occurrence of LOR. Subsequently, the catheter was connected to the pressure transducer to detect the presence of waveforms. In both study groups, the block procedure was repeated at different intervertebral levels until positive waveforms could be obtained (through the needle or catheter as per the allocation) or until a predefined maximum of three intervertebral levels had been reached. Subsequently, the operator administered a 4 mL test dose of lidocaine 2% with epinephrine 5 µg/mL through the catheter. An investigator present during the performance of the block recorded the performance time (defined as the temporal interval between skin infiltration and local anesthetic administration through the epidural catheter). Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Success was defined as a bilateral block in at least two dermatomes. Furthermore, postoperative pain scores, local anesthetic consumption, and breakthrough analgesic consumption were recorded. RESULTS: No intergroup differences were found in terms of performance time, success rate, postoperative pain, local anesthetic requirement, and breakthrough analgesic consumption. CONCLUSION: EWA can be carried out through the needle or through the catheter with similar efficiency (performance time) and efficacy (success rate, postoperative analgesia). TRIAL REGISTRATION NUMBER: NCT03603574.

Pretransplant neurological presentation and severe posttransplant brain injury in patients with acute liver failure.

BACKGROUND: Alterations in the central nervous system in patients with acute liver failure (ALF) present unique challenges in the perioperative period. In this retrospective study, we examined pretransplant neurological presentation and the incidence, clinical presentation, and risk factors associated with severe posttransplant brain injury (BI) in ALF patients undergoing orthotopic liver transplantation (OLT). METHODS: After institutional review board approval, ALF patients who underwent OLT between 2004 and 2010 at our center were reviewed. Pretransplant neurological presentation and severe posttransplant BI were examined. Risk factors for the latter were identified. RESULTS: During the study period, 90 (67 adults and 23 children) ALF patients underwent primary OLT. Preoperatively, all patients developed encephalopathy, 6 had seizure activity, 32 had radiological evidence of cerebral edema, and 11 had severe cerebral edema. After OLT, 7 patients developed severe posttransplant BI. Of these 7 patients, 4 had brain death, and 3 had irreversible injury that precluded them from living independently. Severe pretransplant cerebral edema and a higher posttransplant international normalized ratio (odds ratios and 95% confidence intervals: 50.2, 5.8-433.5 [P<0.001] and 3.1, 1.1-8.8 [P=0.031], respectively) were risk factors associated with severe posttransplant BI. CONCLUSIONS: Pretransplant neurological complications were prevalent, and severe posttransplant BI occurred at a rate of 7.8% and was significantly associated with severe pretransplant cerebral edema and postoperative international normalized ratio. Our findings support the use of pretransplant computed tomography. If severe pretransplant cerebral edema is confirmed, efforts should be made to aggressively control intracranial pressure and select a proper donor to minimize the risk of severe posttransplant BI and futile transplantation.