Association between postoperative shoulder pain and left-side laparoscopic urologic surgery: a single-center retrospective cohort study.

PURPOSE: Postoperative shoulder pain is a common problem after laparoscopic surgery. This study aimed to investigate the association between operative side and postoperative shoulder pain following urologic laparoscopic surgery performed in the lateral recumbent position. METHODS: This was a retrospective cohort study conducted at a single tertiary care center. A total of 506 patients who underwent urologic laparoscopic surgery (including adrenalectomy, radical nephrectomy, partial nephrectomy, and pyeloplasty) between January 2010 and December 2019 were included. Patients who underwent total nephroureterectomy or resection of other organs were excluded. The primary outcome was the incidence of postoperative shoulder pain. A multivariable logistic regression analysis investigated the association between the operative side and postoperative shoulder pain. RESULTS: Among the 506 included patients, there were an equal number of surgeries on the left and right sides. Eighty-eight patients had postoperative shoulder pain. The incidence of postoperative shoulder pain in the left-side group was significantly higher than that in the right-side group (21.3% [54/253] versus 13.4% [34/253], crude odds ratio = 1.75, 95% confidence interval [CI] 1.07-2.89). After adjustment for potential confounders (age, sex, body mass index, operation duration, operative technique, epidural block, peripheral nerve block, American Society of Anesthesiologists physical status classification, and intraoperative rocuronium dose), the left operative side was found to be associated with postoperative shoulder pain (adjusted odds ratio = 1.89, 95% CI 1.15-3.09). CONCLUSION: The left operative side is associated with an increased incidence of postoperative shoulder pain after urologic laparoscopic surgery performed in the lateral recumbent position.

Effects of pain management using nonsteroidal anti-inflammatory drug suppositories during brachytherapy for cervical cancer: A single-center prospective observational study.

INTRODUCTION: No standardized pain management protocol exists for intracavitary brachytherapy, and various methods of analgesia have been used in different countries and institutions. This study aimed to investigate the effects of pain management during intracavitary brachytherapy using nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen suppositories. METHODS: In this single-center, prospective, observational study, patients undergoing intracavitary brachytherapy for cervical cancer completed a questionnaire survey after each brachytherapy session, which comprised questions regarding pain intensity, satisfaction with analgesia, and desire for effective anesthesia. RESULTS: Data analysis was performed using data from 100 brachytherapy sessions of 27 patients. The median numerical rating scale (NRS; 0-10) score for each intracavitary brachytherapy session was 3-4. The median satisfaction scale score for analgesia (5-point scale, 1-5) for each session was approximately 4. Eight patients (29.6%) answered that they desired anesthesia more effective than suppositories at any session of brachytherapy. A comparison of the high (NRS ≥4) and low (NRS ≤3) NRS groups during the first session revealed that the high NRS group tended to have higher NRS scores and lower satisfaction with analgesia during all sessions. A positive correlation was observed between tumor size and the NRS score during the first brachytherapy session. CONCLUSIONS: The NRS score was approximately 3-4, and satisfaction with analgesia was approximately 4 out of 5 when NSAIDs or acetaminophen suppositories were used as analgesics during intracavitary brachytherapy for cervical cancer. Although the current pain management protocol is clinically acceptable, inadequate analgesia is indicated in approximately 30% of patients.

Postgraduate Developments Among Perianesthesia-Trained Nursing Graduates in Japan: A Cross-Sectional Survey.

PURPOSE: To elucidate the postgraduation situation of those who have completed a perianesthesia nurse (PAN) educational course offered in master's degree programs in Japan. DESIGN: This cross-sectional study used an anonymous self-administered questionnaire. METHODS: Of the 42 individuals who completed a PAN educational course offered in master's degree programs in Japan by March 2021, 41 were targeted, excluding the author of this study. The questionnaire was distributed by mail between November 20, 2021, and January 14, 2022, and the participants were asked to return the completed questionnaire by mail. Those working as PANs were asked about their work content, work satisfaction, and thoughts on their prospects in the perianesthesia nursing field. Those not working as a PAN were asked about their future intentions to do so. FINDINGS: The response rate was 95.1% (39/41). PANs are involved in various perianesthesia tasks, and there were no respondents who answered "No" to the question of whether they were glad to have become a PAN. However, of those working as PANs, only 16 (53.3%) indicated that they would like to continue working in that role. Few respondents (n = 3; 10.0%) considered future PAN prospects to be "good," while eight (26.7%) respondents answered "poor," and many (n = 19; 63.3%) stated "neither." CONCLUSIONS: Under the current situation, PANs in Japan do not necessarily have a positive outlook for the future, the causes for which must be analyzed to make the necessary improvements.

Association between Intraoperative Early Warning Score and Mortality and In-Hospital Stay in Lower Gastrointestinal Spontaneous Perforation.

Background: Early warning scores (EWSs) can be easily calculated from physiological indices; however, the extent to which intraoperative EWSs and the corresponding changes are associated with patient prognosis is unknown. In this study, we investigated whether EWS and the corresponding time-related changes are associated with patient outcomes during the anesthetic management of lower gastrointestinal perforation. Methods: This was a single-center, retrospective cohort study conducted at a tertiary emergency care center. Adult patients who underwent surgery for spontaneous lower gastrointestinal perforations between September 1, 2012, and December 31, 2019, were included. The National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) were calculated based on the intraoperative physiological indices, and the associations with in-hospital death and length of hospital stay were investigated. Results: A total of 101 patients were analyzed. The median age was 70 years, and there were 11 cases of in-hospital death (mortality rate: 10.9%). There was a significant association between the intraoperative maximum NEWS and in-hospital death (odds ratio (OR): 1.60, 95% confidence interval (CI): 1.10-2.32, p=0.013) and change from initial to maximum NEWS (OR: 1.60, 95% CI: 1.07-2.40, p=0.023) in the crude analysis. However, when adjustments were made for confounding factors, no statistically significant associations were found. Other intraoperative EWS values and changes were not significantly associated with the investigated outcomes. The preoperative sepsis-related organ failure assessment score and the intraoperative base excess value were significantly associated with in-hospital death. Conclusions: No clear association was observed between EWSs and corresponding changes and in-hospital death in cases of lower gastrointestinal perforation. The preoperative sepsis-related organ failure assessment score and intraoperative base excess value were significantly associated with in-hospital death.

Association between diaphragmatic dysfunction after adult cardiovascular surgery and prognosis of mechanical ventilation: a retrospective cohort study.

BACKGROUND: Diaphragmatic dysfunction often occurs after adult cardiovascular surgery. The prognostic effect of diaphragmatic dysfunction on ventilatory management in patients after cardiovascular surgery is unknown. This study aimed to investigate the association between diaphragmatic dysfunction and prognosis of ventilatory management in adult postoperative cardiovascular surgery patients. METHODS: This study was a single-center retrospective cohort study conducted at a tertiary care university hospital. This study included adult patients admitted to the intensive care unit under tracheal intubation after cardiovascular surgery. Spontaneous breathing trial was performed, and bilateral diaphragmatic motion was assessed using ultrasonography; diaphragmatic dysfunction was classified as normal, incomplete dysfunction, or complete dysfunction. The primary outcome was weaning off in mechanical ventilation. The duration of mechanical ventilation was defined as duration from the date of ICU admission to the date of weaning off in mechanical ventilation. The secondary outcomes were reintubation, death from all causes, improvement of diaphragm position assessed by chest radiographs. The subdistribution hazard ratio or hazard ratio (HR) with 95% confidence of intervals (CIs) were estimated by Fine-Gray models or Cox proportional hazard models adjusted for potential confounders. RESULTS: Of 153 patients analyzed, 49 patients (32.0%) had diaphragmatic dysfunction. Diaphragmatic dysfunction consisted of incomplete dysfunction in 38 patients and complete dysfunction in 11 patients. Diaphragmatic dysfunction groups had longer duration of mechanical ventilation (68 h [interquartile range (IQR) 39-114] vs 23 h [15-67], adjusted subdistribution HR 0.63, 95% CIs 0.43-0.92). There was a higher rate of reintubation (12.2% vs 2.9%, univariate logistic regression analysis p = 0.034, unadjusted odds ratio = 4.70, 95% CIs 1.12-19.65), and a tendency to have higher death from all causes in the diaphragmatic dysfunction group during follow-up period (maximum 6.5 years) (18.4% vs 9.6%, adjusted HR 1.64, 95% CIs 0.59-4.53). The time to improvement of diaphragm position on chest radiograph was significantly longer in the diaphragmatic dysfunction group (14 days [IQR 6-29] vs 5 days [IQR 2-10], adjusted subdistribution HR 0.54, 95% CIs 0.38-0.77). CONCLUSIONS: Diaphragmatic dysfunction after adult cardiovascular surgery was significantly associated with longer duration of mechanical ventilation and higher reintubation.

Incidence of perioperative hypotension in patients undergoing transurethral resection of bladder tumor after oral 5-aminolevulinic acid administration: a retrospective multicenter cohort study.

PURPOSE: Tumors can be visualized using 5-Aminolevulinic acid hydrochloride (5-ALA) during transurethral resection of bladder tumors (TURBT). Hypotension is an adverse effect of 5-ALA; however, its incidence and morbidity rates are unknown. This study aimed to describe the incidence of perioperative hypotension and identify risk factors for hypotension among patients after 5-ALA administration in TURBT. METHODS: This retrospective multicenter cohort study was conducted at three general hospitals in Japan. Adult patients who underwent elective TURBT after 5-ALA administration between April 2018 and August 2020 were included. The primary outcome was the incidence of perioperative hypotension (mean blood pressure < 65 mmHg). The secondary outcomes were the use of vasoactive agents and adverse events, including urgent intensive care unit (ICU) admission. Multivariate logistic regression analysis was performed to investigate risk factors of the incidence of intraoperative hypotension. RESULTS: The median age of 261 patients was 73 years. General anesthesia was induced in 252 patients. The intraoperative hypotension was observed in 246 (94.3%) patients. Three patients (1.1%) were urgently admitted to the ICU for continued vasoactive agent use after surgery. All three patients had renal dysfunction. Multivariate logistic regression analysis revealed that general anesthesia was significantly associated with intraoperative hypotension (adjusted odds ratio, 17.94; 95% confidence interval, 3.21-100.81). CONCLUSION: The incidence of hypotension in patients undergoing TURBT after 5-ALA administration was 94.3%. The incidence of urgent ICU admission with prolonged hypotension was 1.1% in all patients with renal dysfunction. General anesthesia was significantly associated with intraoperative hypotension.

Risk factors for cardiovascular diseases in patients with systemic lupus erythematosus: an umbrella review.

Cardiovascular disease in patients with systemic lupus erythematosus (SLE) remains one of the most common causes of death and is caused by several factors, including both traditional and disease-specific risk factors. We aimed to systematically appraise the evidence of cardiovascular disease risk factors focusing on the SLE population. The protocol for this umbrella review is registered in PROSPERO (registration no. CRD42020206858). A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library from database inception to June 22, 2022, for systematic reviews and meta-analyzes that examined cardiovascular disease risk factors in patients with SLE. Two reviewers independently extracted data and assessed the quality of the included studies using the "Assessing the Methodological Quality of Systematic Reviews 2 (AMSTER 2)" tool. Of the 102 identified articles, nine systematic reviews were included in this umbrella review. All included systematic reviews were assessed as critically low quality according to the AMSTER 2 tool. The traditional risk factors identified in this study were older age, male sex, hypertension, dyslipidemia, smoking, and a family history of cardiovascular disease. SLE-specific risk factors were long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant. This umbrella review identified some cardiovascular disease risk factors in patients with SLE; however, the study quality of all included systematic reviews was critically low. Key Points • We examined the evidence of cardiovascular disease risk factors focusing on patients with systemic lupus erythematosus. • We found that long-term disease duration, lupus nephritis, neurological disorders, high disease activity, organ damage, use of glucocorticoids, azathioprine, and antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant, were cardiovascular disease risk factors among patients with systemic lupus erythematosus. • The review indicates the need for well-validated and high-quality future reviews that assess major adverse cardiovascular events as an outcome in patients with systemic lupus erythematosus.

Long-Term Analgesic Efficacy of Neurolytic Splanchnic Nerve Block via the Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study.

INTRODUCTION: The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via the transintervertebral disc approach was the first choice of treatment. The short-term efficacy of this technique has been reported, but the long-term efficacy is not clear. In the present study, we investigated the long-term analgesic efficacy of this technique. METHODS: This multicenter, retrospective, observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via the transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the long-term analgesic efficacy of a one-time NSNB via the transintervertebral disc approach. RESULTS: In total, 76 patients were included in the analysis. The median lowest numerical rating scale (NRS) score was 1 within 14 days. At 1, 2, 3, and 6 months after the nerve block, the median NRS score was also ≤ 2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times. CONCLUSION: The long-term analgesic efficacy of NSNB via the transintervertebral disc approach in patients with intractable cancer pain has been demonstrated.

The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. The celiac plexus nerve block relieves intractable cancer pain arising from the pancreas or other organs in close proximity, and the splanchnic nerve block is considered clinically equivalent to the celiac plexus block for analgesia. At our affiliated institution, fluoroscopy-guided neurolytic splanchnic nerve block with a single needle via the transintervertebral disc approach is the first choice of treatment because it is technically simpler and less invasive than other approaches. While the short-term efficacy of this technique is known, its long-term efficacy remains unclear. Thus, this multicenter, retrospective, observational study aimed to investigate the long-term analgesic efficacy of a neurolytic splanchnic nerve block via the transintervertebral disc approach. The medical records of patients in whom intractable cancer pain was managed using this technique at five tertiary hospitals in Japan were analyzed. The primary outcome was the long-term analgesic efficacy of a one-time neurolytic splanchnic nerve block via the transintervertebral disc approach. The median lowest numerical rating scale score was 1 within 14 days. At 1, 2, 3, and 6 months after the nerve block, the median numerical rating scale score was also ≤ 2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times. This technique may reduce opioid dose and associated side effects compared with long-term conventional pharmacotherapy alone.

Venoarterial-extra corporeal membrane oxygenation-assisted parathyroidectomy for hypercalcemic crisis due to parathyroid carcinoma complicated by severe circulatory and respiratory failure: a case report.

BACKGROUND: Hypercalcemia crisis is a rare but severe form of hypercalcemia complicated by multiple organ failure. Hypercalcemia crisis due to hyperparathyroidism is commonly caused by a parathyroid tumor, which often requires surgical resection. However, there are no clear recommendations on when the surgery should be performed. CASE PRESENTATION: A 64-year-old female patient developed hyperparathyroidism due to a parathyroid tumor and hypercalcemic crisis, which was complicated by severe circulatory and respiratory failure refractory to medical therapy, and an emergent surgery was planned to resect the parathyroid tumor. To prevent intraoperative circulatory and respiratory collapse, venoarterial-extra corporeal membrane oxygenation (VA-ECMO) was introduced, resulting in a safe operation and anesthetic management. CONCLUSIONS: In patients with hypercalcemic crisis complicated by severe circulatory and respiratory failure, induction of prophylactic VA-ECMO was useful for safe anesthetic management. Surgical resection should be performed as soon as the diagnosis is made before VA-ECMO is required.

Opioid withdrawal symptoms after neurolytic splanchnic nerve block in cancer patients.

PURPOSE: Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB. METHODS: This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5 mg/day (equivalent oral morphine dose) within 14 days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them. RESULTS: Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195 days; P < 0.043 and median opioid use duration 486 vs. 136 days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40 mg; P < 0.046). CONCLUSIONS: OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

Efficacy and Safety of Neurolytic Splanchnic Nerve Block via Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study.

INTRODUCTION: Celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. Several guiding techniques such as fluoroscopy, computed tomography, and endoscopy have been devised, and the target of the block has varied in previous studies as both the celiac plexus and splanchnic nerve, which is the main origin of the celiac plexus, have been targeted. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via transintervertebral disc approach is the first choice. However, there have been few reports on the use of this technique. This study investigated the efficacy and safety of this technique. METHODS: This multicenter retrospective observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the clinical success ratio of NSNB, and the secondary outcome was the incidence ratio of NSNB-related adverse events. RESULTS: In total, 103 patients were included in the analysis. Of these, 77 patients met the definition of clinical success, with a ratio of 74.8%. The incidence ratio of NSNB-related adverse events was 40.8% (hypotension, 21.4%; alcohol intoxication, 13.6%; diarrhea, 11.7%; and vascular puncture, 3.9%; duplicates were present). All adverse events improved with observation and symptomatic treatment only. No patient had infection or serious adverse events such as organ or nerve damage. CONCLUSIONS: The clinical success ratio of this technique was 74.8%. Although the incidence of adverse events was 40.8%, all events were mild and no serious adverse events were observed. The findings demonstrate the efficacy and safety of our NSNB in patients with intractable cancer pain.

In patients with intractable pain from abdominal cancer, fluoroscopy-guided neurolytic splanchnic nerve block via transintervertebral disc approach is an effective and safe procedure. It can be completed with a single needle puncture, and is anatomically less likely to cause organ or nerve damage compared with other approaches. The analgesia produced by this technique, along with conventional pharmacotherapy for cancer pain, may reduce opioid dose and its side effects and improve patients' quality of life.

The Elevation of Double-Lumen Tube Cuff Pressure During Lung Surgery: A Single-Center Prospective Observational Study☆,☆.

OBJECTIVES: Excessive tracheal tube cuff pressure can cause postoperative complications; however, the variations in the double-lumen tube cuff pressure in lung surgery have not been investigated. This study aimed to determine the incidence and variations in excess double- lumen tube cuff pressure during one-lung ventilation. DESIGN: A prospective observational study. SETTING: Single secondary-care hospital. PARTICIPANTS: Patients aged ≥18 years scheduled for elective lung surgery using a left-sided double-lumen tube. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Each cuff of the double-lumen tube was connected to a pressure transducer, and the cuff pressure was continuously measured. The excess cuff pressure and its duration (%) were defined as ≥22 mmHg, and the ratio of the duration of excess cuff pressure to the duration of one-lung ventilation, respectively. In total, 147 patients were included in the final analysis. Eighty patients (54.5%) developed cuff pressure elevation in either cuff and 28 patients (19%) in both cuffs. Younger age, male sex, and left-sided surgery were associated with elevated bronchial cuff pressure. Concurrently, younger age, maximal peak inspiratory pressure, and obstructive respiratory dysfunction were associated with an elevated tracheal cuff pressure. A duration of excess cuff pressure >50% in either cuff was found in 34 patients (23%), and both cuffs in 5 patients (3.4%). The correlation between the duration of tracheal and bronchial excess cuff pressure was poor. CONCLUSIONS: A high incidence and long duration of excess tracheal and bronchial cuff pressure were observed during one-lung ventilation for lung surgery.

Poor oral function is associated with loss of independence or death in functionally independent older adults.

AIM: To clarify the association of poor oral function with loss of independence (LOI) or death in functionally independent older adults in the community. METHODS: We conducted a secondary analysis of data from a prospective cohort study in two municipalities in Japan. We included participants who were older than 65 years of age and had no certification in long-term care at baseline. Poor oral function was evaluated by the Kihon Checklist. Among participants with poor oral function, they were further classified by the degree of quality of life (QOL) impairment due to dysphagia. Main outcome is LOI or death from all cause. The hazard ratio (HR) and 95% confidence of intervals (CIs) were estimated by Cox proportional hazard models adjusted for potential confounders. RESULTS: Of 1,272 participants, 150 participants (11.8%) had poor oral function. The overall incidence of LOI or death was 10.0% in the participants with poor oral function, while 3.3% in the participants without. Participants with poor oral function were more likely to develop LOI or death than those without (crude HR = 3.17 [95% CIs 1.74-5.78], adjusted HR = 2.30 [95% CIs 1.22-4.36]). 10 participants (0.79%) were classified as poor oral function with QOL impairment, and were more likely to develop LOI or death than those without poor oral function (crude HR = 7.45 [95% CIs 1.80-30.91], adjusted HR = 8.49 [95% CIs 1.88-38.34]). CONCLUSIONS: Poor oral function was associated with higher risk of LOI or death in functionally independent older adults in the community.

Association of chorioamnionitis with failed conversion of epidural labor analgesia to cesarean delivery anesthesia: A retrospective cohort study.

AIM: This study aimed to examine the association between clinically diagnosed chorioamnionitis and failed conversion of epidural labor analgesia to cesarean delivery anesthesia. METHODS: This retrospective, single-center cohort study, conducted in a university hospital, enrolled term parturients undergoing emergency cesarean section after induction of epidural labor analgesia between September 2015 and May 2019. For the purpose of this study, all cases were re-examined to ensure that they fulfilled the criteria of chorioamnionitis, regardless of the actual indication for cesarean section proposed by obstetricians at the time of application. The primary outcome was failure of conversion of epidural labor analgesia to cesarean delivery anesthesia. Multivariable logistic regression analysis was performed to investigate the association between chorioamnionitis and failure of anesthesia for cesarean section. RESULTS: Among the 180 parturients reviewed, 58 (43.9%) fulfilled the criteria for chorioamnionitis. Failure of epidural conversion in the chorioamnionitis (+) group was significantly higher than in the chorioamnionitis (-) group (46.6% [27/58] vs. 18.9% [14/74], crude odds ratio = 3.7, 95% confidence interval: 1.7-8.3). After adjustment for potential confounders (age, body mass index, multiparity, and duration for epidural labor analgesia), chorioamnionitis was found to be associated with failure of anesthesia for cesarean sections (adjusted odds ratio = 3.6, 95% confidence interval: 1.6-8.4). CONCLUSIONS: Chorioamnionitis is associated with the failed conversion of epidural labor analgesia to cesarean delivery anesthesia.

Prevalence of neuropathic pain in terminally ill patients with cancer admitted to a general ward: a prospective observational study.

OBJECTIVES: To determine the prevalence of neuropathic pain among terminally ill patients with cancer admitted to a general ward, using the International Association for the Study of Pain algorithm. METHODS: This prospective observational study was conducted at a tertiary care center. We enrolled terminally ill patients with cancer admitted to the general ward between September 2018 and September 2019. On the day of consultation with our palliative care team, pain management clinicians examined and diagnosed neuropathic pain using the International Association for the Study of Pain diagnostic criteria. RESULTS: A total of 108 patients were enrolled during the study period. The median age was 69 years (interquartile range [IQR] 58.3-76.8 years), 72 patients (66.7%) were men, and the median survival time was 33 days (IQR 14.3-62 days). Of the 108 patients, 33 (30.6%) had neuropathic pain. Patients with neuropathic pain had more severe pain than those without neuropathic pain. CONCLUSIONS: The prevalence of neuropathic pain in terminally ill patients with cancer admitted to a Japanese general ward was 30.6%. Further studies are warranted to elucidate whether the accurate diagnosis of neuropathic pain can improve pain control and/or patient conditions.

A modified algorithm for choosing the most appropriate intraoperative pacemaker mode for patients with permanent pacemaker in non-cardiac surgery.

To avoid the risk of R-on-T incident and the unnecessary decrease of cardiac output, we devised an algorithm consisting of six steps for choosing the most appropriate intraoperative pacemaker (PM) mode, which is modified from Heart Rhythm Society and the American Society of Anesthesiologists expert consensus statement. Following this algorithm, we reviewed previous operations at our hospital to evaluate the appropriateness of the choices. Six of 78 cases (7.7%) were unfit to the algorithm because of an inappropriate mode change. The PM mode was changed preoperatively in four patients, even though the surgical site was under the umbilicus. In one case of the two other cases, the PM mode was changed from AAI to VOO. This case could not be avoided by the previous algorithm of the expert clinical statements. In another case, the anesthesiologist did not change PM mode even though the patient underwent parotidectomy and his heart rate depended on PM. Prospective research on this algorithm could clarify its usefulness in the future. Moreover, discussions about this algorithm could help develop this field of study and improve the intraoperative management of PMs.

Perioperative and anesthetic risk factors of surgical site infection in patients undergoing pancreaticoduodenectomy: A retrospective cohort study.

BACKGROUND: Surgical site infection is a major perioperative issue. The morbidity of surgical site infection is high in major digestive surgery, such as pancreaticoduodenectomy. The comprehensive risk factors, including anesthetic factors, for surgical site infection in pancreaticoduodenectomy are unknown. The aim of this study was to investigate the perioperative and anesthetic risk factors of surgical site infection in pancreaticoduodenectomy. METHODS: This was a retrospective cohort study conducted in a single tertiary care center. A total of 326 consecutive patients who underwent pancreaticoduodenectomy between January 2009 and March 2018 were evaluated. Patients who underwent resection of other organs were excluded. The primary outcome was the incidence of surgical site infection, based on a Clavien-Dindo classification of grade 2 or higher. Multivariable logistic regression analysis was performed to investigate the association between surgical site infection and perioperative and anesthetic factors. RESULTS: Of the 326 patients, 116 (35.6%) were women. The median age was 70 years (interquartile range; 64-75). The median duration of surgery was 10.9 hours (interquartile range; 9.5-12.4). Surgical site infection occurred in 60 patients (18.4%). The multivariable analysis revealed that the use of desflurane as a maintenance anesthetic was associated with a significantly lower risk of surgical site infection than sevoflurane (odds ratio, 0.503; 95% confidence interval [CI], 0.260-0.973). In contrast, the duration of surgery (odds ratio, 1.162; 95% CI, 1.017-1.328), cerebrovascular disease (odds ratio, 3.544; 95% CI, 1.326-9.469), and ischemic heart disease (odds ratio, 10.839; 95% CI, 1.887-62.249) were identified as significant risk factors of surgical site infection. CONCLUSIONS: Desflurane may be better than sevoflurane in preventing surgical site infection in pancreaticoduodenectomy. Cerebrovascular disease and ischemic heart disease are potential newly-identified risk factors of surgical site infection in pancreaticoduodenectomy.

Introduction of evolving roles of Japanese perianesthesia nurses.

The aim of this special article is to introduce Perianesthesia Nurses (PANs) who play an essential role in assisting anesthesiologists to ensure the safety of patients undergoing anesthesia and to improve the quality of anesthetic care. In Japan, there is no national license for nurse anesthesia providers. Therefore, most of the tasks related to anesthesia are performed by the anesthesiologists. Due to the size and complexity of the aging population, higher quality perioperative care is needed. In search of a solution, PANs were introduced to improve anesthetic care in Japan, enabling anesthesiologists to delegate some of their tasks to PANs who work within the scope of registered nurse's policies. They are a new type of anesthesia care provider in Japan, and different from Certified Registered Nurse Anesthetists in the United States. Currently, six schools provide 2-year master's degree perianesthesia nursing programs, and graduates are now providing anesthetic care both inside and outside of the operating room under the direct supervision of anesthesiologists. PANs not only assist anesthesiologists and help to reduce anesthesiologists' workload, but also contribute to the expansion of anesthesia services. They ensure patient safety and improve the quality of patient care before, during, and after the patient undergoing anesthesia.

Comparison between High- and Low-Cost Transmission of Tele-Anesthesia in Japan.

Background: We previously reported a tele-anesthesia system that connected Sado General Hospital (SGH) to Yokohama City University Hospital (YCUH) using a dedicated virtual private network (VPN) that guaranteed the quality of service. The study indicated certain unresolved problems, such as the high cost of constantly using a dedicated VPN for tele-anesthesia. In this study, we assessed whether use of a best-effort system affects the safety and cost of tele-anesthesia in a clinical setting. Methods: One hundred patients were enrolled in this study. We provided tele-anesthesia for 65 patients using a guaranteed transmission system (20 Mbit/s; guaranteed, 372,000 JPY per month: 1 JPY = US$0.01) and for 35 patients using a best-effort system (100 Mbit/s; not guaranteed, 25,000 JPY per month). We measured transmission speed and number of commands completed from YCUH to SGH during tele-anesthesia with both transmission systems. Results: In the guaranteed system, anesthesia duration was 5780 min (88.9 min/case) and surgical duration was 3513 min (54.0 min/case). In the best-effort system, anesthesia duration was 3725 min (106.4 min/case) and surgical duration was 2105 min (60.1 min/case). The average transmission speed in the best-effort system was 17.3 ± 3.8 Mbit/s. The system provided an acceptable delay time and frame rate in clinical use. All commands were completed, and no adverse events occurred with both systems. Discussion: In the field of tele-anesthesia, using a best-effort internet VPN system provided equivalent safety and efficacy at a better price as compared to using a guaranteed internet VPN system.

Enhancement of glycolysis by inhibition of oxygen-sensing prolyl hydroxylases protects alveolar epithelial cells from acute lung injury.

Cellular bioenergetic failure caused by mitochondrial dysfunction is a key process of alveolar epithelial injury during acute respiratory distress syndrome (ARDS). Prolyl hydroxylases (PHDs) act as cellular oxygen sensors, and their inhibition activates hypoxia-inducible factor (HIF), resulting in enhanced cellular glycolytic activity, which could compensate for impaired mitochondrial function and protect alveolar epithelial cells from ARDS. Here, we evaluated the effects of pharmacological PHD inhibition with dimethyloxalylglycine (DMOG) on alveolar epithelial cell injury using in vitro and in vivo ARDS models. We established an in vitro model of alveolar epithelial injury mimicking ARDS by adding isolated neutrophils and LPS to cultured MLE12 alveolar epithelial cells. DMOG treatment protected MLE12 cells from neutrophil-LPS-induced ATP decline and cell death. Knockdown of HIF-1α or inhibition of glycolysis abolished the protective effect of DMOG, suggesting that it was exerted by HIF-1-dependent enhancement of glycolysis. Additionally, intratracheal DMOG administration to mice protected the alveolar epithelial barrier and improved arterial oxygenation, preventing ATP decline during LPS-induced lung injury. In summary, enhancement of glycolysis by PHD inhibition is a potential therapeutic approach for ARDS, protecting alveolar epithelial cells from bioenergetic failure and cell death.- Tojo, K., Tamada, N., Nagamine, Y., Yazawa, T., Ota, S., Goto, T. Enhancement of glycolysis by inhibition of oxygen-sensing prolyl hydroxylases protects alveolar epithelial cells from acute lung injury. FASEB J. 32, 2258-2268 (2018). www.fasebj.org.