Neck Extension and Intraocular Pressure Elevation During Palatoplasty in a Patient with Patau Syndrome and Congenital Glaucoma: A Case Report.

Patau syndrome (trisomy 13) is a severe disorder associated with multiple systemic defects. Patau syndrome is commonly associated with ocular abnormalities but rarely associated with congenital glaucoma. To obtain a better surgical view, palatoplasty requires neck extension during surgery. The intraocular pressure (IOP) of patients with Patau syndrome can increase owing to the neck extension position while undergoing palatoplasty, particularly in those with congenital glaucoma. Here, we describe a case with increased IOP measured using a rebound tonometer during palatoplasty in a pediatric patient with Patau syndrome and congenital glaucoma. This case shows that it may be important to reduce the degree of neck extension and shorten the operation time to minimize any increase in the IOP during palatoplasty in pediatric patients with Patau syndrome accompanied by congenital glaucoma.

Effect of Papaverine on Renal Artery Blood Flow during Robot-Assisted Partial Nephrectomy: A Randomized Controlled Study.

BACKGROUND: During robot-assisted partial nephrectomy (RAPN), renal artery clamping is necessary to optimize the surgical field. However, renal artery clamping can induce renal blood flow reduction and postoperative renal dysfunction. Papaverine is used as a potent vasodilator agent. We determined if periarterial administration of papaverine after renal artery clamping improved intraoperative renal artery blood flow and early postoperative glomerular filtration rate (GFR) compared with placebo in RAPN. PATIENTS AND METHODS: In this randomized controlled trial, 96 patients who underwent RAPN were enrolled between November 2019 and December 2020. Patients were administered periarterial normal saline as a placebo (placebo group) or papaverine (papaverine group) just after renal artery declamping. The primary outcome was renal artery blood flow by Doppler ultrasound 2 min after periarterial administration of papaverine or placebo after renal artery declamping. The secondary outcome was GFR estimated by renal scan 3 months after RAPN. RESULTS: Renal artery blood flow and GFR were significantly higher in the papaverine group than in the placebo group (538.0 [376.6-760.0] mL/min versus 338.8 [205.8-603.4] mL/min, P = 0.002 and 93.5 ± 17.1 mL/min/1.73 m2 versus 85.9 ± 15.8 mL/min/1.73 m2, P = 0.033, respectively). CONCLUSIONS: Periarterial papaverine administration increased intraoperative renal artery blood flow and early postoperative GFR in RAPN, suggesting that papaverine administration has beneficial effects on renal perfusion after renal artery clamping and could be a valuable option for improving renal function after RAPN.

Effect of pneumoperitoneum and Trendelenburg position on internal carotid artery blood flow measured by ultrasound during robotic prostatectomy.

INTRODUCTION: Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS: Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS: A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3 ± 44.7 [T2] vs. 188.0 ± 49.6 ml/min [T1]; p = .002, 163.1 ± 39.9 [T3] vs. 188.0 ± 49.6 ml/min [T1]; p = .009). The ICA blood flow also differed significantly between Ta and T1 (236.8 ± 58.3 vs. 188.0 ± 49.6 ml/min; p < .001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION: Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident.

The lymphocyte/monocyte ratio and red blood cell transfusion during radical retropubic prostatectomy.

PURPOSE: Despite improvements of strategy in radical retropubic prostatectomy, blood loss is still a major concern. The lymphocyte/monocyte (LM) ratio is a prognostic indicator for various diseases. We identified the risk factors, including the LM ratio, for red blood cell (RBC) transfusion during radical retropubic prostatectomy. METHODS: This retrospective study assessed patients who underwent radical retropubic prostatectomy between March 2009 and December 2020. To determine the risk factors for RBC transfusion, a multivariate logistic regression analysis was conducted. A receiver operating characteristic (ROC) curve analysis was also performed. Postoperative outcomes, including acute kidney injury (AKI), hospitalization duration, and intensive care unit (ICU) admission, were also evaluated. RESULTS: Among 1302 patients, 158 patients (12.1%) received an intraoperative RBC transfusion. Multivariate logistic regression analysis demonstrated that the risk factors for RBC transfusion were the LM ratio, hemoglobin, 6% hydroxyethyl starch amount, and positive surgical margin. The area under the ROC curve of LM ratio was 0.706 (cut-off = 4.3). The LM ratio at ≤ 4.3 was significantly related to transfusion in multivariate-adjusted analysis (odds ratio = 4.598, P < 0.001). AKI and ICU admission were significantly higher, and the hospitalization duration was significantly longer in patients with RBC transfusion. CONCLUSIONS: The LM ratio was a risk factor for RBC transfusion in radical retropubic prostatectomy. The optimal cut-off value of the LM ratio to predict transfusion was 4.3. RBC transfusion was associated with poor postoperative outcomes. Therefore, our results suggest that the LM ratio provide useful information on RBC transfusion in radical retropubic prostatectomy.

Epidural Anesthesia and Arterial Maximal Flow Velocity of Free Flap in Patients Having Microvascular Lower Extremity Reconstruction: A Randomized Controlled Trial.

BACKGROUND: One of the critical factors for free flap survival is to maintain adequate perfusion. The authors evaluated the effect of epidural anesthesia on arterial maximal flow velocity of the free flap in microvascular lower extremity reconstruction. METHODS: This is a prospective randomized study where patients were allocated to receive either combined general-epidural anesthesia (epidural group, n = 26) or general anesthesia alone (control group, n = 26). After injecting epidural ropivacaine 10 ml in the epidural group, the effect on arterial maximal flow velocity of the free flap was analyzed using ultrasonography. The primary outcome measurement was the arterial maximal flow velocity 30 minutes after establishing the baseline. Intraoperative hemodynamics and postoperative outcomes such as postoperative pain, opioid requirements, surgical complications, intensive care unit admission, and hospital length of stay were also assessed. RESULTS: The arterial maximal flow velocity 30 minutes after the baseline measurement was significantly higher in the epidural group (35.3 ± 13.9 cm/second versus 23.5 ± 8.4 cm/second; p = 0.001). The pain score at 1 hour postoperatively and opioid requirements at 1 and 6 hours postoperatively were significantly lower in the epidural group [3.0 (interquartile range, 2.0 to 5.0) versus 5.0 (interquartile range, 3.0 to 6.0), p = 0.019; 0.0 µg (interquartile range, 0.0 to 50.0 µg) versus 50.0 µg (interquartile range, 0.0 to 100.0 µg), p = 0.005; and 46.9 µg (interquartile range, 0.0 to 66.5 µg) versus 96.9 µg (interquartile range, 41.7 to 100.0 µg), p = 0.014, respectively]. There were no significant differences in intraoperative hemodynamics or other postoperative outcomes between the two groups. CONCLUSION: Epidural anesthesia increased the arterial maximal flow velocity of the free flap and decreased postoperative pain and opioid requirements in microvascular lower extremity reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Low Preoperative Lymphocyte-to-Monocyte Ratio Is Predictive of the 5-Year Recurrence of Bladder Tumor after Transurethral Resection.

Many studies have investigated the prognostic significance of peripheral blood parameters-including lymphocyte-to-monocyte ratio (LMR)-in several cancers in recent decades. We evaluated the prognostic factors for five-year tumor recurrence after the transurethral resection of a bladder tumor (TURBT). In total, 151 patients with non-muscle invasive bladder tumors who underwent TURBT under spinal anesthesia were selected for this retrospective analysis. The time to tumor recurrence was determined by the number of days from surgery until there was a pathological confirmation of tumor recurrence. The preoperative and postoperative laboratory values were defined as results within one month prior to and one month after TURBT. Univariate and multivariate Cox regression analyses were performed. Seventy-one patients (47.0%) developed recurrent bladder tumors within five years after the first TURBT surgery. The multivariate Cox regression analysis revealed that preoperative LMR (hazard ratio, 0.839; 95% confidence interval, 0.739-0.952; p = 0.006) and multiple tumor sites (hazard ratio, 2.072; 95% confidence interval, 1.243-3.453; p = 0.005) were independent recurrence predictors in patients with recurrent bladder tumors within five years after the TURBT. A low preoperative LMR is an important predictor for the recurrence of a bladder tumor during a five-year follow-up period after surgery.

Elevated De Ritis Ratio as a Predictor for Acute Kidney Injury after Radical Retropubic Prostatectomy.

Acute kidney injury (AKI) is related to mortality and morbidity. The De Ritis ratio, calculated by dividing the aspartate aminotransferase by the alanine aminotransferase, is used as a prognostic indicator. We evaluated risk factors for AKI after radical retropubic prostatectomy (RRP). This retrospective study included patients who performed RRP. Multivariable logistic regression analysis and a receiver operating characteristic (ROC) curve analysis were conducted. Other postoperative outcomes were also evaluated. Among the 1415 patients, 77 (5.4%) had AKI postoperatively. The multivariable logistic regression analysis showed that estimated glomerular filtration rate, albumin level, and the De Ritis ratio at postoperative day 1 were risk factors for AKI. The area under the ROC curve of the De Ritis ratio at postoperative day 1 was 0.801 (cutoff = 1.2). Multivariable-adjusted analysis revealed that the De Ritis ratio at ≥1.2 was significantly related to AKI (odds ratio = 8.637, p < 0.001). Postoperative AKI was associated with longer hospitalization duration (11 ± 5 days vs. 10 ± 4 days, p = 0.002). These results collectively show that an elevated De Ritis ratio at postoperative day 1 is associated with AKI after RRP in patients with prostate cancer.

Diaphragm Thickening Fraction as a Prognostic Imaging Marker for Postoperative Pulmonary Complications in Robot-Assisted Laparoscopic Prostatectomy Requiring the Trendelenburg Position and Pneumoperitoneum.

BACKGROUND: Robot-assisted laparoscopic prostatectomy (RALP) frequently entails postoperative pulmonary complications (PPCs) due to the Trendelenburg position and pneumoperitoneum. Diaphragm thickening fraction (TF) as an imaging marker can offer the advantage of predicting respiratory outcomes. Therefore, we evaluated the effect of diaphragm TF on the occurrence of PPCs in RALP. METHODS: We measured the preoperative thickness of the diaphragm at peak inspiration (T pi) and end expiration (T ee) using ultrasonography. Diaphragm TF was calculated as TF = (T pi-T ee)/T ee. A receiver operating characteristic (ROC) curve analysis of TF was performed. After dividing patients into two groups according to the optimal TF cut-off value, we compared the occurrence of PPCs between the groups. The predictivity of diaphragm TF for the occurrence of PPCs was evaluated. RESULTS: Of 145 patients, 40 patients (27.6%) developed PPCs. Patients with PPCs had a significantly lower TF than those without PPCs (0.31 ± 0.09 vs. 0.39 ± 0.11, P < 0.001). In the ROC curve analysis, the optimal TF cut-off value was 0.28. The patients were divided into TF ≥ 0.28 group (n = 114) and TF < 0.28 group (n = 31). The incidence of PPCs was significantly higher in the TF < 0.28 group than in the TF ≥ 0.28 group (51.6% vs. 21.1%, P = 0.001). Diaphragm TF < 0.28 was associated with a higher incidence of PPCs than diaphragm TF ≥ 0.28 (odds ratio = 4.534, 95% confidence interval [1.763-11.658], P = 0.002). CONCLUSION: Preoperative diaphragm TF < 0.28 was associated with an increased incidence of PPCs, suggesting that diaphragm TF as a prognostic imaging marker provides useful information on PPCs in RALP requiring the Trendelenburg position and pneumoperitoneum. Trial Registry Number. This trial is registered with KCT0005028.

Sugammadex versus neostigmine on postoperative pulmonary complications after robot-assisted laparoscopic prostatectomy: a propensity score-matched analysis.

PURPOSE: Robot-assisted laparoscopic prostatectomy (RALP) requires particular surgical conditions, such as carbon dioxide pneumoperitoneum and steep Trendelenburg positioning, which may have adverse effects on the respiratory system. The effect of sugammadex on postoperative pulmonary complications (PPCs) is controversial. Therefore, we evaluated the incidence of PPCs according to the type of neuromuscular blockade reversal agents in RALP. METHODS: We retrospectively analyzed RALP patients. We compared the incidence of PPCs between patients receiving neostigmine (neostigmine group) and those receiving sugammadex (sugammadex group) as a neuromuscular blockade reversal agent. Propensity score-matched analysis was performed. Other postoperative outcomes, such as duration of hospital stays, major adverse cardiac events during hospital stays, and death during hospital stays, were also compared between the two groups. RESULTS: The incidence of PPCs was 28.9% (137/474) in RALP. The incidence of PPCs was significantly lower in the sugammadex group than in the neostigmine group (18.6% [44/237] vs. 39.2% [93/237], p < 0.001). The incidence of atelectasis was significantly lower in the sugammadex group than in the neostigmine group (18.6% vs. 39.2%, p < 0.001). The incidence of pneumonia was not significantly different between the sugammadex and neostigmine groups after RALP (0.0% vs. 0.4%, p > 0.999). Besides these, other postoperative outcomes were not significantly different between the two groups. CONCLUSIONS: The incidence of PPCs after RALP was significantly lower in patients receiving sugammadex than in those receiving neostigmine. These results can provide useful information on the appropriate selection of neuromuscular blockade reversal agents in RALP.

Head elevation and laryngeal mask airway Supreme insertion: A randomized controlled trial.

BACKGROUND: A laryngeal mask airway (LMA) is usually inserted by conventional 7 cm head elevation. However, little is known about the association of head elevation degree and LMA insertion. We hypothesized that 14 cm head elevation would increase the first attempt success rate of LMA Supreme insertion compared with conventional 7 cm head elevation in patients undergoing transurethral resection of bladder tumour. METHODS: Patients were randomly allocated to the high group (n = 55, 14 cm head elevation) or the control group (n = 55, conventional 7 cm head elevation). The primary outcome was the first attempt success rate of LMA Supreme insertion. RESULTS: The first attempt success rate was significantly higher in the high group than in the control group (53 [96.4%] vs 40 [72.7%], P = .001, relative risk = 1.30, 95% confidence interval [CI] = 1.12-1.57, absolute risk reduction = 23.7%). Fibreoptic bronchoscope grade 4 (ie optimal position of the LMA) was significantly higher in the high group (35 [64.8%] vs 18 [36.7%], P = .004, relative risk = 1.76, 95% CI = 1.16-2.68, absolute risk reduction = 30.9%). CONCLUSIONS: Head elevation of 14 cm height increased the first attempt success rate of LMA Supreme insertion and fibreoptic bronchoscopic grade in patients undergoing transurethral resection of bladder tumour. High head elevation can be an effective option for successful LMA Supreme insertion. Trial Registry Number: Clinicaltrials.gov (NCT04229862).

Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis.

BACKGROUND: Radical cystectomy is a standard treatment for muscle-invasive bladder cancer but frequently entails postoperative pulmonary complications (PPCs). Nutrition is closely associated with postoperative outcomes. Therefore, we evaluated the impact of preoperative prognostic nutritional index (PNI) on PPCs in radical cystectomy. METHODS: PNI was calculated as 10 × (serum albumin) + 0.005 × (total lymphocyte count). The risk factors for PPCs were evaluated using multivariate logistic regression analysis. A receiver operating characteristic curve analysis of PNI was performed, and an optimal cut-off value was identified. Propensity score-matched analysis was used to determine the impact of PNI on PPCs. Postoperative outcomes were also evaluated. RESULTS: PPCs occurred in 112 (13.6%) of 822 patients. Multivariate logistic regression analysis identified PNI, age, and serum creatinine level as risk factors. The area under the receiver operating characteristic curve of PNI for predicting PPCs was 0.714 (optimal cut-off value: 45). After propensity score matching, the incidence of PPCs in the PNI ≤ 45 group was significantly higher compared with the PNI > 45 group (20.8% vs. 6.8%; p < 0.001), and PNI ≤ 45 was associated with a higher incidence of PPCs (odds ratio 3.308, 95% confidence interval 1.779-6.151; p < 0.001). The rates of intensive care unit admission and prolonged (> 2 days) stay thereof were higher in patients who developed PPCs. CONCLUSIONS: Preoperative PNI ≤ 45 was associated with a higher incidence of PPCs in radical cystectomy, suggesting that PNI provides useful information regarding pulmonary complications after radical cystectomy.

C-reactive Protein/Albumin Ratio and Acute Kidney Injury after Radical Cystectomy among Elderly Patients: A Propensity Score-Matched Analysis.

BACKGROUND: The C-reactive protein (CRP)/albumin ratio is a useful index used to represent patient inflammation and nutritional status. Elderly patients are at the highest risk for acute kidney injury (AKI). We clarified the impact of the preoperative CRP/albumin ratio on AKI and evaluated the impact of postoperative AKI on end-stage renal disease (ESRD) among elderly cystectomy patients. METHODS: We included elderly patients ≥ 65 years of age who underwent radical cystectomy. Multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed to identify risk factors for AKI. Propensity score-matched analysis and conditional logistic regression analysis were performed to elucidate the impact of the CRP/albumin ratio on AKI. The incidence of ESRD was compared between the non-AKI and AKI groups at 12 months after radical cystectomy. RESULTS: AKI occurred in 110 patients (32.2%). The CRP/albumin ratio and 6% hydroxyethyl starch amount were risk factors for postoperative AKI. The optimal cut-off value for the CRP/albumin ratio predicting AKI was 0.1. After propensity score matching, the AKI incidence in the CRP/albumin ratio ≥ 0.1 group was higher than that in the CRP/albumin ratio < 0.1 group (46.7% vs. 20.6%, P < 0.001), and a CRP/albumin ratio ≥ 0.1 was associated with a higher AKI incidence (odds ratio = 4.111, P < 0.001). The ESRD incidence was higher in the AKI group than in the non-AKI group (7.3% vs. 1.2%, P = 0.017). CONCLUSION: A CRP/albumin ratio ≥ 0.1 was associated with an increased incidence of AKI, which was associated with higher ESRD incidence among elderly cystectomy patients.

Risk factors and outcomes of myocardial injury after non-cardiac surgery in high-risk patients who underwent radical cystectomy.

Radical cystectomy is considered the standard treatment for patients with muscle-invasive bladder tumors and has high postoperative complication rates among urological surgeries. High-risk patients, defined as those ≥45 years of age with history of coronary artery disease, stroke, or peripheral artery disease or those ≥65 years of age, can have a higher incidence of cardiac complications. Therefore, we evaluated the incidence, risk factors, and outcomes of myocardial injury after non-cardiac surgery (MINS) in high-risk patients who underwent radical cystectomy.This retrospective observational study analyzed 248 high-risk patients who underwent radical cystectomy. MINS was defined as serum troponin I concentration ≥0.04 mg/L within postoperative 3 days. The risk factors for MINS were evaluated by multivariate logistic regression analysis. Postoperative outcomes were evaluated. The 1-year survival after radical cystectomy was also compared between patients who developed MINS (MINS group) and those who did not (non-MINS group) by Kaplan-Meier analysis.MINS occurred in 35 patients (14.1%). Multivariate logistic regression analysis showed that early diastolic transmitral filling velocity (E)/early diastolic septal mitral annular velocity (E') ratio (odds ratio = 1.102, 95% confidence interval [1.009-1.203], P = .031) and large volume blood transfusion (odds ratio = 2.745, 95% confidence interval [1.131-6.664], P = .026) were significantly associated with MINS in high-risk patients who underwent radical cystectomy. Major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group (17.1% vs 6.1%, P = .035; 28.6% vs 12.7%, P = .021, respectively). Kaplan-Meier analysis showed significantly lower 1-year survival in the MINS group than in the non-MINS group (P = .010).MINS occurred in 14.1% of patients. High E/E' ratio and large volume blood transfusion were risk factors for MINS in high-risk patients who underwent radical cystectomy. Postoperative major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group. Preoperative evaluation of risk factors for MINS may provide useful information to detect cardiovascular complications after radical cystectomy in high-risk patients.

Comparison of a Significant Decline in the Glomerular Filtration Rate between Ileal Conduit and Ileal Neobladder Urinary Diversions after Radical Cystectomy: A Propensity Score-Matched Analysis.

Urinary diversion after radical cystectomy is associated with a risk of renal function impairment. A significant decline in the glomerular filtration rate (GFR) (i.e., a ≥30% decline in baseline GFR after 12 months) is associated with long-term renal function impairment. We compared the significant GFR decline between ileal conduit and ileal neobladder urinary diversions 12 months after radical cystectomy. We retrospectively included radical cystectomy patients. Propensity score-matched analysis was performed. The primary outcome was the incidence of a significant GFR decline in ileal conduit urinary diversion (ileal conduit group) and ileal neobladder urinary diversion (ileal neobladder group) 12 months after radical cystectomy. The secondary outcomes were the change of GFR and the incidence of end-stage renal disease (ESRD) in the two groups. After propensity score matching, the ileal conduit and neobladder groups had 117 patients each. The incidence of a significant GFR decline was not significantly different between ileal conduit and ileal neobladder groups (12.0% vs. 13.7%, p = 0.845). The change of GFR and ESRD incidence were not significantly different between the two groups (-8.4% vs. -9.7%, p = 0.480; 4.3% vs. 5.1%, p > 0.999, respectively). These results can provide important information on appropriate selection of the urinary diversion type in radical cystectomy.

Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor: A Randomized, Double-blind, Placebo-controlled Study.

BACKGROUND: Catheter-related bladder discomfort occurs because of involuntary contractions of the bladder smooth muscle after urinary catheterization. Magnesium is associated with smooth muscle relaxation. This study hypothesized that among patients having transurethral resection of bladder tumor, magnesium will reduce the incidence of postoperative moderate-to-severe catheter-related bladder discomfort. METHODS: In this double-blind, randomized study, patients were randomly allocated to the magnesium group (n = 60) or the control group (n = 60). In magnesium group, a 50 mg/kg loading dose of intravenous magnesium sulfate was administered for 15 min, followed by an intravenous infusion of 15 mg · kg · h during the intraoperative period. Patients in the control group similarly received normal saline. The primary outcome was the incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively. None, mild, moderate, and severe catheter-related bladder discomfort at 1, 2, and 6 h postoperatively, patient satisfaction, and magnesium-related adverse effects were also assessed. RESULTS: The incidence of catheter-related bladder discomfort above a moderate grade at 0 h postoperatively was significantly lower in the magnesium group than in the control group (13 [22%] vs. 46 [77%]; P < 0.001; relative risk = 0.283; 95% CI, 0.171 to 0.467; absolute risk reduction = 0.55; number needed to treat = 2); similar results were observed for catheter-related bladder discomfort above a moderate grade at 1 and 2 h postoperatively (5 [8%] vs. 17 [28%]; P = 0.005; relative risk = 0.294; 95% CI, 0.116 to 0.746; and 1 [2%] vs. 14 [23%]; P < 0.001; relative risk = 0.071; 95% CI, 0.010 to 0.526, respectively). Patient satisfaction on a scale from 1 to 7 was significantly higher in the magnesium group than in the control group (5.1 ± 0.8 vs. 3.5 ± 1.0; P < 0.001; 95% CI, 1.281 to 1.919). Magnesium-related adverse effects were not significantly different between groups. CONCLUSIONS: Magnesium reduced the incidence of catheter-related bladder discomfort above a moderate grade and increased patient satisfaction among patients having transurethral resection of bladder tumor.

Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction.

The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3), with a PNI <40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p <0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 ± 55.5 days vs. 28.3 ± 24.4 days, p <0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.

The role of age in determining the effects of lipo-PGE1 infusion on immediate arterial maximal flow velocity in patients with diabetes undergoing free flap surgery for lower extremity reconstruction: A prospective observational study.

BACKGROUND: Diabetes mellitus may have a negative effect on free flap perfusion in patients undergoing reconstructive surgery. Little is known of the effects of lipo-prostaglandin E1 (lipo-PGE1) on flap blood flow in diabetes. This study investigated the effects of lipo-PGE1 on maximal blood flow velocity of the free flap arterial pedicle in patients with diabetes. METHODS: This prospective observational study assessed maximal blood flow velocity in the arterial pedicle before and 30 min after infusion of 0.4 µg/h lipo-PGE1 in 40 patients with diabetes who received a free flap for lower extremity reconstruction. Multivariate logistic regression analysis was performed to determine whether age, hemoglobin A1c concentration, duration of diabetes, and flap type were significantly associated with increased maximal blood flow velocity after lipo-PGE1 infusion or not. RESULTS: The maximal blood flow velocity of the free flap did not differ significantly before and 30 min after lipo-PGE1 infusion. Multivariate logistic regression analysis showed that age <65 years was the only independent factor associated with increased maximal blood flow velocity after lipo-PGE1 infusion (odds ratio = 5.344; p = 0.022). CONCLUSION: Assessments of all patients with diabetes undergoing free flap surgery, when age was not taken into consideration, found that lipo-PGE1 did not significantly increase the maximal blood flow velocity of the free flap arterial pedicle. However, when age was taken into consideration, lipo-PGE1 increased blood flow velocity in patients <65 years old, suggesting that age influences the effect of lipo-PGE1 on the blood flow velocity.

Positive end-expiratory pressure increases arterial oxygenation in elderly patients undergoing urological surgery using laryngeal mask airway in lithotomy position.

Elderly patients undergoing urological surgery in the lithotomy position may be vulnerable to perioperative hypoxemia. Positive end-expiratory pressure (PEEP) can improve arterial oxygenation. Although laryngeal mask airway (LMA) is widely utilized in urological surgery, it is not known how PEEP affects arterial oxygenation in these patients. We, therefore, evaluated the effect of PEEP on arterial oxygen partial pressure (PaO2) in elderly patients using LMA during urological surgery in the lithotomy position. Patients randomly received zero end-expiratory pressure (group Z, n = 34) or PEEP of 7 cmH2O (group P, n = 33). Ventilatory, respiratory, and haemodynamic variables were measured at 5 min (T0), 30 min (T1), and 60 min (T2) after LMA Supreme™ (sLMA) insertion. The primary outcome was the difference of PaO2 at T2 between the two groups. Atelectasis score, the incidence of a significant leak, and complications associated with sLMA insertion were also evaluated. PaO2 at T2 was significantly higher in group P than in group Z (20.0 ± 4.9 vs. 14.7 ± 3.7 kPa, P < 0.001). Atelectasis score at T2 was lower in group P than in group Z (5.3 ± 1.7 vs. 8.4 ± 2.3, P < 0.001). However, the incidence of a significant leak and complications associated with LMA insertion did not significantly differ between the two groups. PEEP can improve arterial oxygenation and reduce atelectasis in elderly patients using sLMA during urological surgery in the lithotomy position, suggesting that PEEP may be useful for elderly patients with an increased risk of perioperative hypoxemia when using sLMA.

Intravenous Lidocaine for the Prevention of Postoperative Catheter-Related Bladder Discomfort in Male Patients Undergoing Transurethral Resection of Bladder Tumors: A Randomized, Double-Blind, Controlled Trial.

BACKGROUND: Male patients undergoing transurethral resection of bladder tumors (TURBT) are prone to suffer from catheter-related bladder discomfort (CRBD). Lidocaine administration has been widely performed to reduce postoperative pain. Here, the effect of intravenous lidocaine administration on moderate-to-severe CRBD was evaluated in male patients undergoing TURBT. METHODS: Patients were randomly allocated to receive intravenous lidocaine (1.5 mg/kg bolus dose followed by a 2 mg/kg/h continuous infusion during the intraoperative period, which was continued for 1 hour postsurgery; group L) or placebo (normal saline; group C). The primary outcome was moderate-to-severe CRBD at 0 hour postsurgery (on admission to the postanesthetic care unit), analyzed using the χ test. The secondary outcome was opioid requirement during the 24-hour postoperative period. None, mild, and moderate-to-severe CRBD at 1, 2, and 6 hours postsurgery, postoperative pain, patient satisfaction, side effects of lidocaine and rescue medications (tramadol and fentanyl), and surgical complications were also assessed. RESULTS: A total of 132 patients were included in the study (66 patients in each group). The incidence of moderate-to-severe CRBD at 0 hour postsurgery was significantly lower in group L than in group C (25.8% vs 66.7%, P < .001, relative risk: 0.386, 95% confidence interval: 0.248-0.602). Opioid requirements during the 24-hour postoperative period were significantly lower in group L than in group C (10.0 mg [interquartile range (IQR), 5.0-15.0 mg] vs 13.8 mg [IQR, 10.0-20.0 mg], P = .005). At 1 and 2 hours postsurgery (but not at 6 hours), the incidence of moderate-to-severe CRBD was significantly lower in group L than in group C (1 hour: 10.6% vs 27.3%, P = .026; 2 hours: 0.0% vs 15.2%, P = .003). Patient satisfaction was significantly greater in group L than in group C (5.0 [IQR, 4.8-6.0] vs 4.0 [IQR, 4.0-5.0], P < .001). No lidocaine-related side effects were reported. Rescue medication-related side effects and surgical complications did not differ significantly between the 2 groups. CONCLUSIONS: Intravenous lidocaine administration resulted in lower incidence of moderate-to-severe CRBD, lower opioid requirement, and higher patient satisfaction in male patients undergoing TURBT without evidence of significant side effects.

Effect of neck extension on ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in patients undergoing palatoplasty: A prospective observational study.

Palatoplasty is performed with neck extension in patients with a cleft palate. The neck extension required for a better surgical view during palatoplasty can affect intracranial pressure. We evaluated the effect of neck extension on intracranial pressure by measuring the optic nerve sheath diameter using ultrasonography during palatoplasty. The optic nerve sheath diameter was measured in 30 patients at 10 min after anesthetic induction in the supine position (T1), at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4). Hemodynamic and respiratory variables such as systolic blood pressure, heart rate, end-tidal carbon dioxide partial pressure, and peak airway pressure were also measured at the same time points. In comparison with the optic nerve sheath diameter measured at 10 min after anesthetic induction in the supine position (T1), the mean optic nerve sheath diameters were significantly increased at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4; 4.19 ±â€¯0.26, 5.20 ±â€¯0.29, 4.38 ±â€¯0.36, and 4.35 ±â€¯0.30 mm, respectively). However, hemodynamic and respiratory variables were not significantly different at all time points. We found that the optic nerve sheath diameter, an indicator of intracranial pressure, was increased during palatoplasty with neck extension, which suggests that the position may affect the intracranial pressure of patients with a cleft palate.