Association of Mechanical Energy and Power with Postoperative Pulmonary Complications in Lung Resection Surgery: A Post Hoc Analysis of Randomized Clinical Trial Data.

BACKGROUND: Mechanical power (MP), the rate of mechanical energy (ME) delivery, is a recently introduced unifying ventilator parameter consisting of tidal volume, airway pressures, and respiratory rates, which predicts pulmonary complications in several clinical contexts. However, ME has not been previously studied in the perioperative context, and neither parameter has been studied in the context of thoracic surgery utilizing one-lung ventilation. METHODS: The relationships between ME variables and postoperative pulmonary complications were evaluated in this post hoc analysis of data from a multicenter randomized clinical trial of lung resection surgery conducted between 2020 and 2021 (n = 1,170). Time-weighted average MP and ME (the area under the MP time curve) were obtained for individual patients. The primary analysis was the association of time-weighted average MP and ME with pulmonary complications within 7 postoperative days. Multivariable logistic regression was performed to examine the relationships between energy variables and the primary outcome. RESULTS: In 1,055 patients analyzed, pulmonary complications occurred in 41% (431 of 1,055). The median (interquartile ranges) ME and time-weighted average MP in patients who developed postoperative pulmonary complications versus those who did not were 1,146 (811 to 1,530) J versus 924 (730 to 1,240) J (P < 0.001), and 6.9 (5.5 to 8.7) J/min versus 6.7 (5.2 to 8.5) J/min (P = 0.091), respectively. ME was independently associated with postoperative pulmonary complications (ORadjusted, 1.44 [95% CI, 1.16 to 1.80]; P = 0.001). However, the association between time-weighted average MP and postoperative pulmonary complications was time-dependent, and time-weighted average MP was significantly associated with postoperative pulmonary complications in cases utilizing longer periods of mechanical ventilation (210 min or greater; ORadjusted, 1.46 [95% CI, 1.11 to 1.93]; P = 0.007). Normalization of ME and time-weighted average MP either to predicted body weight or to respiratory system compliance did not alter these associations. CONCLUSIONS: ME and, in cases requiring longer periods of mechanical ventilation, MP were independently associated with postoperative pulmonary complications in thoracic surgery.

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.

Performance of a new auxiliary device based on wrist brace to improve accuracy and feasibility in neuromuscular monitoring with acceleromyography in prone-positioned patients undergoing lumbar spine surgery: a prospective randomized clinical trial.

Accuracy of acceleromyography (AMG) is not be comparable to that of mechanomyography or electromyography (EMG). In particular, the prone position may reduce the accuracy and feasibility of AMG. We developed a new device based on wrist brace to allow free thumb movement and fix the other parts of the hand and wrist. We aimed to test whether the brace applied to the AMG would increase precision of AMG and agreement with the EMG in the prone position. Fifty-seven patients, undergoing lumbar surgery under general anesthesia, were randomly assigned to groups to which AMG was applied with or without (no) brace (29 in group B vs. 28 in group NB). EMG was performed in the contralateral arm. Repeatability coefficients of the first twitch height (T1) and train-of-four (TOF) ratio were assessed from nine consecutive measurements during spontaneous recovery from rocuronium-induced neuromuscular block and the AMGs of the two groups were compared in prone position. The agreement between AMG and EMG in each group was assessed using the Bland-Altman method. In group B, the repeatability coefficient of T1 was significantly lower during the recovery to T1 of 25% and TOF ratio of 0.9 (P = 0.017 and 0.033, respectively), indicating higher precision. The mean differences of bias (95% limits of agreement) between AMG and EMG in TOF ratio of 0.9 were 6.839 (- 26.54 to 40.22) in group NB and 3.922 (- 21.83 to 29.67) in group B. The wide limits of agreement in group NB was slightly narrowed in group B but without significance. Trial registration: registered on the UMIN Clinical Trials Registry in August 2020 (UMIN000041310).

Spinal Cord Injury and Postdural Puncture Headache following Cervical Interlaminar Epidural Steroid Injection: A Case Report.

Background: Cervical interlaminar epidural steroid injection (CIESI) is increasingly used as an interventional treatment for pain originating from the cervical spine. However, serious neurological complications may occur during CIESI because of direct nerve damage following inappropriate needle placement. Case report: A 35-year-old woman presented with posterior neck pain radiating to the left upper arm. Cervical magnetic resonance imaging (MRI) revealed left C6 nerve impingement. CIESI under fluoroscopic guidance was performed at another hospital using the left C5/6 interlaminar approach. Immediately after the procedure, the patient experienced dizziness, decreased blood pressure, motor weakness in the left upper arm, and sensory loss. She visited our emergency department with postdural puncture headache (PDPH) that worsened after the procedure. Post-admission cervical MRI revealed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a diagnosis of spinal cord injury was made. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment with steroids, the decrease in abduction of the left fifth finger and loss of sensation in the dorsum of the left hand persisted for up to 6 months after the procedure. As noticed in the follow-up MRI performed 6 months post-procedure, the T2 high signal intensity in the left intramedullary region had decreased compared to that observed previously; however, cord swelling persisted. Furthermore, left C7/8 radiculopathy with acute denervation was confirmed by electromyography performed 6 months after the procedure. Conclusions: Fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly due to intrathecal perforation or drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 levels, where the epidural space is relatively large, rather than at the C5/6 level or higher.

Risk Assessment of Perioperative Respiratory Adverse Events and Validation of the COLDS Score in Children with Upper Respiratory Tract Infection.

Background and objectives: Children are at greater risk of upper respiratory tract infection (URTI), which can pose a higher risk of perioperative respiratory adverse events (PRAEs), than adults. The purpose of this study was to validate the COLDS score as a pre-anesthetic risk assessment tool for predicting the possibility of PRAEs. Materials and methods: Children aged under 18 years and undergoing elective surgery were retrospectively included. Logistic regression analysis and the area under the receiver-operating characteristic (ROC) curve (AUC) were used to estimate the ability of the COLDS score to predict PRAEs. Propensity-matched comparison was evaluated using the cut-off value from the ROC curve. Results: Among the 6252 children, 158 children had a recent URTI and 34 cases of PRAEs were reported. Age, current symptoms, and COLDS score were found to be significant variables in predicting PRAEs. From the ROC curve, values of 0.652 (p = 0.007) for AUC and 12.5 for the cut-off value of the COLDS score were calculated. Propensity-matched comparison revealed that each and every component of COLDS contributed to the higher COLDS score group. In addition to higher COLDS score, younger age and current URTI symptoms were found to be significant risk factors for PRAEs. Conclusions: This study validated the predictive power of COLDS score as a risk assessment tool for children with URTI undergoing elective surgery under general anesthesia.

Remimazolam for General Anesthesia in a Patient with Severe Aortic Stenosis Undergoing High-Risk Surgery: A Case Report.

High-risk surgeries for patients with severe aortic stenosis (AS) are challenging for anesthesiologists and can result in hemodynamic deterioration and even mortality. We describe a case in which remimazolam was used to induce and maintain general anesthesia for a high-risk, noncardiac surgery accompanied by ongoing bleeding. An 86-year-old man with severe AS was scheduled to undergo proximal gastrectomy due to ongoing gastrointestinal bleeding and severe anemia. Remimazolam, a novel, ultra-short-acting benzodiazepine, was administered along with remifentanil for the induction and maintenance of general anesthesia. Throughout the anesthetic process, the patient's cardiac index and systemic vascular resistance were well preserved without any vasopressor support. Remimazolam seems to have possible effectiveness as a relatively safe agent for the induction and maintenance of general anesthesia in patients with severe AS who are undergoing high-risk, noncardiac surgery with bleeding.

Effect of sugammadex on chest radiographic abnormality in the early postoperative period after video-assisted thoracoscopic lobectomy

Background/aim: Sugammadex, which offsets the effects of neuromuscular blocking agents (NMBs), has advantages over traditional reversal agents like pyridostigmine, as it enables fast and reliable recovery from neuromuscular blockade. This study compared the incidence of early postoperative chest radiographic abnormalities (CRA) between sugammadex (group S) and pyridostigmine (group P) following video-assisted thoracoscopic (VAT) lobectomy for lung cancer. Materials and methods: We performed a retrospective cohort analysis by reviewing the medical records of patients who underwent VAT lobectomy at a single university medical center. We defined the early postoperative CRA as a characteristic appearance on chest radiograph up to 2 days after surgery. Arterial blood gas analysis (ABGA), surgical time, anaesthesia time, extubation time, and the total dose of rocuronium were analysed. Postoperative nausea and vomiting (PONV) and pain scores were observed until 2 days after surgery. Results: A total of 257 patients underwent VAT lobectomy during the study period; 159 were included in the final analysis. Ninety patients received sugammadex while 69 received pyridostigmine. The incidence of early postoperative atelectasis was significantly lower in group S than in group P (26.7%, 95% CI: 17.5%‒35.8% and 43.5%, 95% CI: 31.8%‒55.2%, respectively, P = 0.013). The median dose of rocuronium was higher in group S than in group P (120 mg vs. 90 mg, P < 0.001). ABGA, extubation time, and PONV were similar in both groups. Conclusion: Sugammadex decreased the incidence of CRA in the early postoperative period despite higher NMB consumption.

In vitro investigation of the effects of exogenous sugammadex on coagulation in orthopedic surgical patients.

BACKGROUND: Previous studies have shown that sugammadex resulted in the prolongation of prothrombin time and activated partial thromboplastin time. In this study, we aimed to investigate the in vitro effects of exogenous sugammadex on the coagulation variables of whole blood in healthy patients who underwent orthopedic surgery. METHODS: The effects of sugammadex on coagulations were assessed using thromboelastography (TEG) in kaolin-activated citrated blood samples taken from 14 healthy patients who underwent orthopedic surgery. The in vitro effects of three different concentrations of sugammadex (42, 193, and 301 µg mL- 1) on the TEG profiles were compared with those of the control (0 µg mL- 1). Previous studies indicated that these exogenous concentrations correspond to the approximate maximum plasma concentrations achieved after the administration of 4, 16, and 32 mg kg- 1 sugammadex to healthy subjects. RESULTS: Increased sugammadex concentrations were significantly associated with reduced coagulation, as evidenced by increases in reaction time (r), coagulation time, and time to maximum rate of thrombus generation (TMRTG), and decreases in the angle, maximum amplitude, and maximum rate of thrombus generation. Compared with the control, the median percentage change (interquartile range) in the TEG values of the samples treated with the highest exogenous sugammadex concentration was the greatest for r, 53% (26, 67.3%), and TMRTG, 48% (26, 59%). CONCLUSIONS: This in vitro study suggests that supratherapeutic doses of exogenous sugammadex might be associated with moderate hypocoagulation in the whole blood of healthy subjects. TRIAL REGISTRATION: identifier:  UMIN000029081 , registered 11 September 2017.

Clinical Value of Intraoperative Transit-Time Flow Measurement for Autogenous Radiocephalic Arteriovenous Fistula in Patients with Chronic Kidney Disease.

BACKGROUND: The intraoperative assessment of autogenous arteriovenous fistulas (AVF) is crucial for achieving an optimal surgical outcome; however, it is not easy to predict the adequacy of surgically created AVF. We used the transit-time flow measurement (TTFM) method to assess the anastomotic quality of AVF and to identify the cutoff value for predicting prognosis of established AVF. METHODS: Retrospective study, a total of 187 patients were included in this study. History of diabetes mellitus, hypertension, preoperative vein size, blood pressure, and other demographic data were collected. Surgery for creating radiocephalic AVF was performed by one surgeon, and intraoperative TTFM was performed. Flow parameters were recorded, including the maximal, mean, and minimal flow, and the pulsatility index (PI). Only mean flow ≤70 mL/min regarded as failure. We reviewed patients' follow-up, and we defined "successful AVF" when the patients who managed hemodialysis using established AVF without clinical problems during follow-up. RESULTS: All patients had a successful operation with adequate mean flow. The established mean flow from the radial artery to the cephalic vein was 199.8 ± 92.7 mL/min, and the PI was 0.57 ± 0.16. None of the patients had any complication during the immediate postoperative period, including infection. Mean follow-up period were 72.4 ± 42.7 weeks. Hemodialysis was maintained in 77.5% of the patients by using the established AVF, and the time to first hemodialysis with the established AVF after surgery was 61.0 ± 22.7 days. Correlation analysis revealed that the time to first hemodialysis was related with mean flow (P = 0.049) and PI (P = 0.009) and successful AVF was related only with PI (P = 0.028). According to curve fit and regression analysis, PI for 95% limit of successful AVF was from 0.43 to 0.77. CONCLUSIONS: Intraoperative TTFM is valuable for the assessment of the quality of established AVFs. Especially PI was correlated successful hemodialysis management for over 12 months, the recommended acceptable range was 0.43-0.77.

Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial.

BACKGROUND: To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. METHODS: This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 µg/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. RESULTS: Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 µg/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 µg/kg; P = 0.04). CONCLUSIONS: As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

Optimal Respiratory Rate for Low-Tidal Volume and Two-Lung Ventilation in Thoracoscopic Bleb Resection.

OBJECTIVES: One-lung ventilation is considered to be mandatory in video-assisted thoracoscopic surgery. However, the authors showed in a previous report that two-lung ventilation with low tidal volume is feasible in thoracoscopic bleb resection (TBR). In this study, they evaluated optimal respiratory rate during TBR under two-lung ventilation with low-tidal volume anesthesia. DESIGN: A prospective, randomized, single-blinded intervention study. SETTING: An operating room in a teaching hospital. PARTICIPANTS: Forty-eight patients who underwent scheduled TBR under general anesthesia. INTERVENTIONS: TBR was performed under low-tidal-volume (5 mL/kg), two-lung ventilation. Respiratory rate (RR) varied according to the protocol: 15 (group I), 18 (group II), and 22 cycles/min (group III). Using block randomization method, 16 patients were assigned to each of 3 groups. MEASUREMENTS AND MAIN RESULTS: Minute ventilation of group I was lowered significantly compared with the other groups (p<0.001). The results of arterial blood gas analysis were in the physiologic range in all patients. Surgery and anesthetic times and number of endostaples used were not significantly different among the 3 groups. CONCLUSIONS: The RR of 15 cycles/min with low-tidal volume (5 mL/kg) and two-lung ventilation did not produce abnormal physiologic changes including arterial pH, partial arterial oxygen pressure, and partial pressure of carbon dioxide and guaranteed an optimal surgical field. Therefore, these setting are considered acceptable for two-lung ventilation during TBR.

Slow injection of nefopam reduces pain intensity associated with intravenous injection: a prospective randomized trial.

PURPOSE: We aimed to investigate the frequency and severity of pain associated with intravenous injection of nefopam and to determine whether a slow rate of administration can effectively reduce such pain. METHODS: We used a solution containing 30 mg nefopam diluted to 20 ml in saline. In all, 102 adult patients undergoing minor surgery were randomly allocated to one of three administration groups: A (60 ml/h, n = 34); B (120 ml/h, n = 34); or C (180 ml/h, n = 34). All patients scored the maximal pain experienced during the 120-s infusion period, using the visual analogue scale (VAS) and the verbal pain score (VPS). Adverse events including phlebitis were recorded. RESULTS: Eighty-three patients (29 in group A, 27 each in groups B and C) were included in the final analysis. The incidence of injection pain was lower in group A (86.2 %) than in groups B (96.3 %) and C (100 %), but this difference was not statistically significant. The proportion of patients with a tolerable level of pain (VAS 0-3 and VPS 0-1) was significantly higher in group A (79.3 %) versus groups B (7.4 %) and C (3.7 %). The mean VAS scores for groups A, B, and C were 2.2 ± 1.3, 5.1 ± 1.6, and 7.2 ± 1.7, respectively, and these differences were statistically significant. CONCLUSIONS: At the slower rate of infusion (60 ml/h) of the 1.5 mg/ml nefopam solution, injection pain intensity was attenuated to a significantly greater degree than at the faster rates.

Physicochemical Stability and Compatibility of Mixtures of Ropivacaine with Dexamethasone or Betamethasone for Epidural Steroid Injections: An In Vitro Study.

BACKGROUND: Epidural steroid injections are widely used to treat spinal and radiating pain. However, crystal formation has recently been reported in mixtures of ropivacaine and nonparticulate steroids, commonly used in epidural steroid injections. OBJECTIVES: Our study assessed the physicochemical stability of mixtures of different nonparticulate steroids and ropivacaine and aimed to propose a safe regimen for epidural steroid injections. STUDY DESIGN: An in vitro protocol was used to examine the physicochemical stability of epidural steroid injection mixtures most commonly used at our institution. SETTING: In vitro laboratory study. METHODS: Twelve solutions were prepared by mixing 0.75% or 0.2% ropivacaine with dexamethasone or betamethasone at volume ratios of 1:1, 2:1, and 3:1 in propylene syringes at 24°C. The physical properties of the mixtures were observed with the naked eye and under a microscope, and their pH was measured. The concentration of each drug in the mixture was evaluated using high-performance liquid chromatography. RESULTS: None of the ropivacaine and dexamethasone mixtures showed macroscopic or microscopic crystal formation after 2 hours, and there were no significant changes in pH. The concentrations of the 2 drugs remained stable for up to 2 hours. In contrast, at least 10 mu-m crystals were observed microscopically and macroscopically in all mixtures of ropivacaine and betamethasone; the ropivacaine concentration was reduced by > 10% after one hour. LIMITATIONS: Confirming the stability of drugs in vitro does not ensure that their pharmacokinetics and pharmacodynamics remain unaltered in vivo. CONCLUSION: The combination of ropivacaine and betamethasone should be avoided because of their physicochemical instability. Combinations of ropivacaine and dexamethasone should be administered cautiously because they are more physicochemically stable than combinations of ropivacaine and betamethasone.

Risk factors for new vertebral compression fracture after vertebroplasty and efficacy of osteoporosis treatment: A STROBE-compliant retrospective study.

Vertebroplasty (VP) effectively treats vertebral compression fractures (VCFs). However, the issue of secondary new VCFs (SNVCFs) after VP is yet to be addressed. Therefore, identification of risk factors for SNVCFs after VP may aid the development of strategies to minimize SNVCF risk. This study aimed to retrospectively evaluate risk factors for SNVCFs after VP, including those associated with the type of anti-osteoporotic treatment administered after VP. Data from 128 patients who underwent single-level VP were collected and reviewed. Patients were divided into 2 groups: those with (n = 28) and without (n = 100) SNVCF within 1 year of VP. We collected the following patient data: age, sex, site of compression fracture, medical history, bone mineral density (BMD), history of long-term steroid use, history of osteoporosis drug use, duration between fracture and VP, VP implementation method (unilateral or bilateral), cement usage in VP, cement leakage into the disc, compression ratio before VP, pre- and postoperative recovery ratio of the lowest vertebral body height, and kyphotic angle of fractured vertebrae. These data were analyzed to identify factors associated with SNVCFs after VP and to investigate the effects of the type of anti-osteoporotic treatment administered for SNVCFs. SNVCFs occurred in 28 patients (21.9%) within 1 year of VP. Logistic regression analysis identified BMD, cement leakage into the disc, and long-term steroid use to be significantly associated with the occurrence of SNVCFs. The group treated with zoledronate after VP had a significantly reduced SNVCF incidence compared with the group treated with calcium (P < .001). In addition, the zoledronate group had a lower SNVCF incidence compared with the groups treated with alendronate (P = .05), selective estrogen receptor modulators (P = .26), or risedronate (P = .22). This study showed that low BMD, presence of an intradiscal cement leak, and long-term steroid use were risk factors for developing SNVCFs following VP. Additionally, among osteoporosis treatments prescribed for VP, zoledronate may be the preferred choice to reduce the risk of SNVCFs.

A comparative evaluation of rotation thromboelastometry and standard coagulation tests in hemodilution-induced coagulation changes after cardiac surgery.

BACKGROUND: Coagulopathy after cardiopulmonary bypass (CPB) is caused by multiple perturbations in cellular and humoral elements of coagulation. A timely and comprehensive method to evaluate hemostasis would be helpful in the management of bleeding patients after CPB. The assessment of whole blood coagulation using rotation thromboelastometry (ROTEM) was compared to coagulation tests routinely performed during cardiac surgery. STUDY DESIGN AND METHODS: Blood was obtained from 26 patients undergoing CPB surgery at baseline, at 60 minutes on CPB, at the end of CPB, and on admission to intensive care unit. ROTEM tests (extrinsically activated [EXTEM], intrinsically activated [INTEM], specific clot formation [FIBTEM]), prothrombin time, activated partial thromboplastin time, platelet (PLT) count, fibrinogen, prothrombin level, antithrombin level, and thrombin generation (TG) measurement were performed. RESULTS: We observed strong correlations between FIBTEM-amplitude at 10 minutes (A10) and fibrinogen level (r=0.87; p<0.001) and between EXTEM/ INTEM-A10 variables and PLT count (r=0.72 and 0.67, respectively; p<0.001). Receiver operating characteristic analysis demonstrated that EXTEM-A10 and INTEM-A10 are predictive of thrombocytopenia below 80×10(9)/L (area under the curve [AUC], 0.83 and 0.82, respectively), and FIBTEM-A10 was highly predictive of fibrinogen level below 200 mg/dL (AUC, 0.96). There were only weak correlations found between TG peak and clot formation time of EXTEM or INTEM (r=0.30 and 0.29, respectively; p<0.05). CONCLUSION: ROTEM variables demonstrated clinically relevant correlations with PLT counts and fibrinogen levels. In particular, decreasing levels of fibrinogen can be quickly determined (<15-20 min) using FIBTEM.

The effects of MDCO-2010, a serine protease inhibitor, on activated clotting time in blood obtained from volunteers and cardiac surgical patients.

BACKGROUND: The activated clotting time (ACT) is widely used for monitoring heparin anticoagulation during cardiac surgery. Celite-based ACT values are prolonged when aprotinin is administered. MDCO-2010, a novel serine protease inhibitor, is currently being evaluated as a possible alternative to aprotinin. Therefore, we evaluated the in vitro effects of this novel agent on ACT values using 3 different point-of-care instruments with kaolin or celite as an activator. METHODS: The study was performed in 2 parts. In the first part, blood samples were obtained from 15 healthy volunteers. Samples were pipetted into small Eppendorf tubes and 2 concentrations of the MDCO-2010 (100 and 500 nM, final concentration) alone or with heparin (1.2 or 2.4 U/mL) were added. ACTs were measured using Helena (celite), Hemochron (kaolin), and Medtronic (kaolin) devices. In the second part of the study, blood samples were obtained intraoperatively, at 5 time points, from 15 patients undergoing cardiopulmonary bypass. MDCO-2010 at a final concentration of 100 or 500 nM was added and ACT testing was performed as before. Additional coagulation tests included prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin, prothrombin, and anti-Xa levels. RESULTS: Addition of MDCO-2010 concentration-dependently prolonged ACTs in volunteers' and patients' blood samples regardless of the ACT activator or device used. In volunteer samples (no heparin) and in patient samples (baseline and intensive care unit) percent changes in ACTs due to MDCO-2010 were on average 3.1 ± 1.8 times higher (95% confidence interval 2.6-3.6; P < 0.001) for the celite-based Helena device compared with either Hemochron or Medtronic devices. CONCLUSION: MDCO-2010 causes less ACT prolongation with kaolin than with celite activation.

Nystagmus caused by epidural fentanyl.

Anesthesiologists commonly use opioids for pain control in the operating room and postanesthesia care unit, and are constantly vigilant in looking for possible adverse outcomes. Therefore, common complications such as nausea, vomiting, and pruritus are well known. However, neurologic complications after opioid administration are relatively rare except for reduced consciousness, for example drowsiness or sedation. We recently experienced a case in which a 73-year-old woman presented predominantly vertical nystagmus as a neurological complication after epidural administration of fentanyl. A few previous reports on opioids as causative agents for nystagmus have all after use of epidural morphine, and there are yet no publications reporting epidural fentanyl as the cause of nystagmus. Physicians should keep in mind that epidural fentanyl could cause the nystagmus as a neurological complication even though it is used within conventional dosage ranges, although this is very rare. Also, when a patient develops nystagmus after epidural fentanyl, it could be a benign side effect caused by epidural fentanyl as we have experienced, but it could also be a sign of serious central nervous system lesions especially in patients with underlying risk factors such as old age, diabetes mellitus, hypertension, and cerebrovascular disease, and thus special attention should be paid to this.

Risk factors for new vertebral compression fracture after kyphoplasty and efficacy of osteoporosis treatment: A STROBE-compliant retrospective study.

Kyphoplasty (KP) has been widely used to treat vertebral compression fractures (VCFs). However, the issue of new VCFs after KP remains controversial. Identification of risk factors for new VCF after KP may help prevent their occurrence in patients. This study aimed to retrospectively determine the major risk factors for new VCF after KP, including those associated with osteoporosis drugs used after kyphoplasty. We reviewed 117 patients who underwent single-level KP. During the follow-up period of 1 year after KP, the demographic data of these patients were compared by dividing them into two groups: those with new fractures (n = 19) and those without new fractures (n = 98). We investigated the age, sex, fracture location, medical history, steroid use history, bone mineral density (BMD), type of osteoporosis treatment, period from fracture to KP, KP method (unilateral or bilateral), bone cement dose, intradiscal cement leakage, preoperative and postoperative compression ratio, kyphotic angle (KA), and lowest vertebral body height in the fractured vertebrae. Based on these data, the factors related to new VCFs after KP were investigated using univariate and multivariate logistic regression analyses. We also investigated whether there were differences in new VCFs according to the type of osteoporosis treatment. During the 1-year follow-up period after KP, the rate of new VCFs was 16.2%. Factors related to new VCFs were BMD, intradiscal cement leakage, KA recovery rate after 1 day, and baseline height in the univariate and multivariate logistic regression analyses. The group treated with zoledronate after KP tended to show a lower frequency of developing new VCFs than the groups treated with alendronate (P = .07), calcium (P = .05), selective estrogen receptor modulator (SERM) (P = .15), and risendronate (P = .02). This study showed that for patients with new VCFs after KP, lower BMD, greater intradiscal cement leakage, greater KA recovery rate, and lower baseline vertebral height were likely risk factors for the development of new VCFs. Additionally, among the drugs used for the treatment of osteoporosis after KP, zoledronate tends to reduce the development of new VCFs compared with other bisphosphonates, SERMs, or calcium.

The effect of newly designed dual-channel elastomeric pump for intravenous patient-controlled analgesia after total laparoscopic hysterectomy: a randomized, double-blind, prospective study.

BACKGROUND: A newly designed intravenous patient-controlled analgesia (PCA) device with a dual-channel elastomeric infusion pump has been recently introduced. One channel is a continuous line with a constant flow rate basal infusion, while the other channel has an adjustable flow rate and bolus function and is labeled as a selector-bolus channel. This study compared dual and single-channel intravenous PCA in terms of clinical effect and quality of recovery. METHODS: Eighty-four patients undergoing total laparoscopic hysterectomy were randomly allocated to a 1-channel group (n = 41) or a 2-channel group (n = 43). Only the selector-bolus channel was utilized, but the continuous channel was not utilized in the 1-channel group, but both channels were utilized in the 2-channel group. In the 1-channel group, 16 µg/kg of fentanyl, 2 mg/kg of ketorolac, and 12 mg of ondansetron with normal saline were administered to the selector-bolus channel and normal saline only in the continuous channel for blinding. In the 2-channel group, 16 µg/kg of fentanyl was administered to the selector-bolus channel, and ketorolac (2 mg/kg) and ondansetron (12 mg) were administered via the continuous channel. The quality of recovery was evaluated preoperatively and 24 h postoperatively using the Quality of Recovery-40 (QoR-40). Cumulative PCA consumption, postoperative pain rated using the numeric rating scale (NRS; during rest/cough), and postoperative nausea were evaluated 6, 12, 24, 36, and 48 h after surgery. Incidence of vomiting and use of antiemetics and rescue analgesics was measured. RESULTS: The 24-h postoperative QoR-40 score was higher in the 2-channel group than in the 1-channel group (P=0.031). The incidence of nausea at 12 h and 36 h was significantly higher in the 1-channel group (P=0.043 and 0.040, respectively), and antiemetic use was more frequent in the 1-channel group (P=0.049). Patient satisfaction was higher in the 2-channel group (P=0.036). No significant differences were observed in pain scores during resting/cough or cumulative PCA consumption. CONCLUSIONS: The 2-channel PCA showed better patient satisfaction with higher QoR-40 during the recovery compared with the 1-channel PCA. Better satisfaction was associated with lower nausea and reduced rescue antiemetics by maintaining the infusion of adjuvant analgesic agents and antiemetic agents constantly by utilizing dual channels. TRIAL REGISTRATION: Registered at ClinicalTrials.gov , NCT04082039 on 9 September 2019.

Internal jugular vein thrombosis associated with venous hypoplasia and protein S deficiency revealed by ultrasonography.

A 41-year-old woman, who had no thrombotic risk factors and past history except congenital scoliosis, underwent central venous catheterization (CVC) before correction of the scoliosis. When internal jugular vein (IJV) catheterization using the anatomical landmark technique failed, CVC under ultrasound guidance was tried. As a consequence, thrombosis and hypoplasia of the right IJV were incidentally detected by ultrasonography. Central venous catheters were then successfully placed in other veins under ultrasound guidance. Also, after examinations to rule out the possibility of pulmonary embolism and to clarify the causes of the IJV thrombosis, the patient was found to have protein S deficiency. CVC under ultrasound guidance should be recommended to prevent the failure of cannulation and complications such as thromboembolism in patients who could possibly have anomalies of vessels as a result of anatomical deformities caused by severe scoliosis, even if patients do not have thrombotic risk factors such as a history of central catheter insertion or intravenous drug abuse, cancer, advanced age, cerebral infarction, and left ventricular dysfunction. Also, if venous thrombosis is found in patients without predisposing risk factors, one should ascertain the cause of the hypercoagulable state, for example protein S deficiency, and perform appropriate treatment and prevention of venous thromboembolism.