Air leakage due to the cuff hanging on the vocal cords during nasotracheal intubation: a case report.

Nasotracheal intubation is commonly performed under general anesthesia in oral and maxillofacial surgery. For the convenience of surgery, nasal Ring-Adair-Elwyn (RAE) tubes are mainly used. Because the nasal RAE tubes were bent in an "L" shape, the insertion depth was limited. Particularly, it is necessary to accurately determine the appropriate depth of the RAE tubes in children. Several types of nasal RAE tubes are used in the medical market, which vary in material and length. We performed endotracheal intubation using a nasal RAE tube for double-jaw surgery, but air leakage persisted even when the air pressure in the cuff was increased. When checked with a laryngoscope, it was confirmed that the tube was pushed out, and the cuff was caught on the vocal cords, causing air leakage. Since inserting the tube deeply did not solve the problem, replacing it with a nasal RAE tube (Polar™, Preformed Tracheal Tube, Smith Medical, Inc., USA) did not cause air leakage; thus, we reported this case.

Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial.

Importance: Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia. Objective: To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery. Design, Setting, and Participants: This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017. Main Outcomes and Measures: The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation-Sedation Scale score of at least 1 and a Riker Sedation-Agitation Scale score of at least 5 immediately after extubation. Results: Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation-Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7). Conclusions and Relevance: The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA. Trial Registration: CRIS identifier: KCT0002145.

Carbon monoxide-induced TFEB nuclear translocation enhances mitophagy/mitochondrial biogenesis in hepatocytes and ameliorates inflammatory liver injury.

Carbon monoxide (CO) can confer protection against cellular stress, whereas the potential involvement of autophagy and lysosomal biogenesis remains incompletely understood. We demonstrate here that the activation of protein kinase R (PKR)-like endoplasmic reticulum (ER) kinase (PERK) with CO increased the nuclear translocation of transcription factor EB (TFEB). PERK activation by CO increased intracellular Ca2+ concentration and the phosphatase activity of calcineurin against TFEB. Moreover, we found that in the deficiency of TFEB, CO not only failed to recruit Parkin to the mitochondria but also failed to increase expression of lysosomal genes such as Lamp1, CathB, and TPP1. Therefore, we suggest that CO increases mitophagy through TFEB nuclear translocation by PERK-calcinuerin activation. In addition, the inhibition of TFEB with siRNA against TFEB abrogated the increase of mtDNA with CO, markers of mitochondrial biogenesis such as PGC1α, NRF1, and TFAM, and the mitochondrial proteins COX II, COX IV, and cytochrome c. To investigate the effects of CO on mitochondrial homeostasis in vivo, mice were treated with lipopolysaccharide (LPS)/D-galactosamine (D-GalN). CO inhalation reduced liver injury after challenge with LPS/GalN. Furthermore, CO inhalation increased TFEB activation, mitophagy and mitochondrial biogenesis in mice treated with LPS/GalN. Our findings describe novel mechanisms underlying CO-dependent cytoprotection in hepatocytes and liver tissue via activation of TFEB-dependent mitophagy and associated induction of both lysosomal and mitochondrial biogenesis.

Recurrent ST segment elevations in a patient with asymptomatic early repolarization during head and neck surgery: implications of vasospastic angina.

A 57-year-old woman scheduled for cochlear implant removal exhibited preoperative electrocardiographic findings of early repolarization (ER). Four episodes of transient ST segment elevations during surgery raised suspicion for vasospastic angina (VA). In the post-anesthetic care unit, the patient complained of chest discomfort and received sublingual nitroglycerin with uncertain effect. The patient refused to proceed with postoperative invasive coronary angiography, resulting in inconclusive diagnosis. Intraoperative circumstances limit the diagnosis of VA, which emphasizes the need for further testing to confirm the diagnosis. When VA is suspected in patients with underlying ER, it is reasonable to consider invasive examination to establish the diagnosis and prevent recurrence of VA. If ST changes are observed during surgery in patients with preoperative ER, careful monitoring is recommended. Due to general anesthesia, the absence of patient symptoms limits the definitive diagnosis of those with suspected VA. Therefore, additional postoperative surveillance is recommended.

Effect of intraoperative mannitol administration on acute kidney injury after robot-assisted laparoscopic radical prostatectomy: A propensity score matching analysis.

Mannitol, an osmotic diuretic, has been used to prevent acute kidney injury (AKI). However, studies have found divergent effects of intraoperative mannitol administration on postoperative AKI. We therefore evaluated the effects of intraoperative mannitol administration on AKI after robot-assisted laparoscopic radical prostatectomy (RALP) in prostate cancer patients.A total of 864 patients who underwent RALP were divided into mannitol (administered at 0.5 g/kg) and no-mannitol groups. Demographics, cancer-related data, preoperative laboratory values, intraoperative data, and postoperative outcomes such as AKI, chronic kidney disease at 12 months postoperation, duration of hospital stay, and intensive care unit admission rate and duration of stay were compared between the 2 groups using propensity score matching analysis. To determine the risk factors for AKI after RALP, univariate and multivariate logistic regression analyses were performed. Postoperative AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria.After performing 1:1 propensity score matching, the mannitol and no-mannitol groups included 234 patients each. The overall incidence of AKI after RALP was 5.1% and was not significantly different between the no-mannitol and mannitol groups in the propensity score-matched patients (13 [5.6%] vs. 11 [4.7%], P = .832). Univariate logistic regression analysis revealed that body mass index and operative time were associated with AKI in 864 patients who underwent RALP. However, intraoperative mannitol administration was not associated with AKI after RALP (P = .284). Multivariate logistic regression analysis revealed that operative time was significantly associated with AKI after RALP (odds ratio = 1.013, P = .001). The incidence of chronic kidney disease (13 [5.6%] vs. 12 [5.1%], P = 1.000) and other postoperative outcomes were not also significantly different between the no-mannitol and mannitol groups in the propensity score-matched patients.Intraoperative mannitol administration has no beneficial effect on the prevention of AKI after RALP in prostate cancer patients. This result provides useful information for clinical practice guidelines regarding intraoperative mannitol use.

Induction of endoplasmic reticulum stress under endotoxin tolerance increases inflammatory responses and decreases Pseudomonas aeruginosa pneumonia.

Endotoxin tolerance develops in the late phase of sepsis to protect cells from an early hyperinflammatory response. Nonetheless, because it induces an immunosuppressive environment, patients with sepsis in its late phase are affected by secondary infections, particularly bacterial pneumonia. Here, we showed that induction of endoplasmic reticulum (ER) stress leads to activation of glycogen synthase kinase 3ß (GSK-3ß) and X-box-binding protein 1 (XBP-1) in an inositol-requiring enzyme 1α (IRE1α)-mediated manner, which in turn restores the inflammatory response in endotoxin-tolerant macrophages. Animal and in vitro models of endotoxin tolerance were studied along with a model of LPS-induced endotoxin tolerance and a model of cecal ligation and puncture (CLP)-induced endotoxin tolerance. To detect the suppressed inflammatory response during endotoxin tolerance, inflammatory-cytokine expression levels were measured by quantitative real-time PCR and an ELISA. Our research revealed that induction of ER stress alleviated lung injury in a septic host infected with Pseudomonas aeruginosa via the activation of GSK-3ß and XBP-1 in an IRE1α-mediated manner. Consequently, in the lungs of the septic host infected with P. aeruginosa, symptoms of pneumonia improved and the infecting bacteria were cleared. Thus, for septic patients, determination of immune status may guide the selection of appropriate immunomodulation, and ER stress can be a novel therapeutic strategy restoring the immune response in patients with endotoxin tolerance.

Pulmonary aspiration during intubation in a high-risk patient: A video clip and clinical implications.

We report a case of pulmonary aspiration during induction of general anesthesia in a patient who was status post esophagectomy. Sudden, unexpected aspiration occurred even though the patient had fasted adequately (over 13 hours) and received rapid sequence anesthesia induction. Since during esophagectomy, the lower esophageal sphincter is excised, stomach vagal innervation is lost, and the stomach is flaccid, draining only by gravity, the patient becomes vulnerable to aspiration. As the incidence of perioperative pulmonary aspiration is relatively low, precautions to prevent aspiration tend to be overlooked. We present a video clip showing pulmonary aspiration and discuss the literature concerning the risk of aspiration and its preventive strategies.

Propofol for implantable cardioverter defibrillator implantation in patients with Brugada syndrome.

AIMS: Avoiding propofol in patients with Brugada syndrome has been suggested because of the theoretical risk of provoking ventricular arrhythmias, although propofol may be selected for conscious sedation during electrophysiological procedures in catheterization laboratories. This study aimed to document periprocedural electrocardiographic changes and adverse events in patients with Brugada syndrome undergoing implantable cardioverter defibrillator (ICD) implantation using propofol sedation. METHODS: We reviewed the clinical data of 53 consecutive patients who underwent ICD implantation during 1998-2011. Sedation was achieved by combining propofol with either midazolam or fentanyl, and a bolus propofol dose (0.5-1 mg/kg) was administered to induce deep sedation. Periprocedural events, including arrhythmias, defibrillations, and hyperthermia episodes, were evaluated, and electrocardiogram (ECG) variables were measured. The need for emergency anesthetic support/intubation and incidence of perioperative complications or mortality were analyzed. RESULTS: Procedure time and cumulative propofol dose for each patient was 125.2 (42.8) min and 204.6 (212.7) mg, respectively. During deep sedation, blood pressure, heart rate, and oxygen saturation were significantly decreased (P < 0.001) such that eight (15.1%) patients required manual ventilation and one (1.9%) needed atropine injection. No significant ECG changes were observed. Only two (3.7%) patients showed newly developed ST elevation in the anterior precordial lead, whereas three (5.6%) had isolated premature ventricular contractions. CONCLUSION: ICD implantation without significant ECG changes or adverse outcomes is feasible under propofol sedation in patients with Brugada syndrome. However, because of significant hemodynamic changes and respiratory compromise, close monitoring and meticulous propofol dose titration is warranted.

Effect of Mannitol on Ultrasonographically Measured Optic Nerve Sheath Diameter as a Surrogate for Intracranial Pressure During Robot-Assisted Laparoscopic Prostatectomy with Pneumoperitoneum and the Trendelenburg Position.

INTRODUCTION: CO2 pneumoperitoneum and the steep Trendelenburg position during robot-assisted laparoscopic prostatectomy (RALP) can increase intracranial pressure (ICP). Mannitol is widely used to treat increased ICP. However, no studies to date have specifically evaluated the effect of mannitol on ICP in patients undergoing RALP. Ultrasonographic measurement of the optic nerve sheath diameter (ONSD) is considered a reliable technique to noninvasively evaluate the ICP. Therefore, this study compared ONSDs as a surrogate for ICP before and after mannitol administration in prostate cancer patients undergoing RALP. METHODS: Mannitol (0.5 g/kg) was administered after pneumoperitoneum establishment and shifting to the Trendelenburg position. ONSDs were measured at six predetermined time points: 10 minutes after anesthesia induction (T0); 5 minutes after pneumoperitoneum and the Trendelenburg position before mannitol administration (T1); 30 minutes (T2), 60 minutes (T3), and 90 minutes (T4) after completion of mannitol administration during pneumoperitoneum and the Trendelenburg position; and at skin closure in the supine position (T5). Moreover, intraoperative hemodynamic and respiratory variables were evaluated simultaneously. RESULTS: Thirty-six patients were analyzed. ONSDs were significantly lower at T2, T3, and T4 than at T1 (all p < 0.001), with the greatest decrease observed at T4 compared with T1 (4.46 ± 0.2 mm vs 4.81 ± 0.3 mm, p < 0.001). Regional cerebral oxygen saturation, cardiac output, corrected flow time, peak velocity, body temperature, arterial CO2 partial pressure, peak airway pressure, plateau airway pressure, dynamic compliance, and static compliance were not significantly different during pneumoperitoneum and the Trendelenburg position; however, mean arterial blood pressure and heart rate were significantly different. CONCLUSIONS: Mannitol decreases the ONSD in patients undergoing RALP with CO2 pneumoperitoneum and the steep Trendelenburg position. This result provides useful information on the beneficial effects of mannitol administration on prostate cancer patients who may develop increased ICP during RALP.

Carbon monoxide protects against hepatic steatosis in mice by inducing sestrin-2 via the PERK-eIF2α-ATF4 pathway.

Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, has emerged as one of the most common causes of chronic liver disease in developed countries over the last decade. NAFLD comprises a spectrum of pathological hepatic changes, including steatosis, steatohepatitis, advanced fibrosis, and cirrhosis. Autophagy, a homeostatic process for protein and organelle turnover, is decreased in the liver during the development of NAFLD. Previously, we have shown that carbon monoxide (CO), a reaction product of heme oxygenase (HO) activity, can confer protection in NAFLD, though the molecular mechanisms remain unclear. We therefore investigated the mechanisms underlying the protective effect of CO on methionine/choline-deficient (MCD) diet-induced hepatic steatosis. We found that CO induced sestrin-2 (SESN2) expression through enhanced mitochondrial ROS production and protected against MCD-induced NAFLD progression through activation of autophagy. SESN2 expression was increased by CO or CO-releasing molecule (CORM2), in a manner dependent on signaling through the protein kinase R-like endoplasmic reticulum kinase (PERK), eukaryotic initiation factor-2 alpha (eIF2α)/ activating transcription factor-4 (ATF4)-dependent pathway. CO-induced SESN2 upregulation in hepatocytes contributed to autophagy induction through activation of 5'-AMP-activated protein kinase (AMPK) and inhibition of mechanistic target of rapamycin (mTOR) complex I (mTORC1). Furthermore, we demonstrate that CO significantly induced the expression of SESN2 and enhanced autophagy in the livers of MCD-fed mice or in MCD-media treated hepatocytes. Conversely, knockdown of SESN2 abrogated autophagy activation and mTOR inhibition in response to CO. We conclude that CO ameliorates hepatic steatosis through the autophagy pathway induced by SESN2 upregulation.

Differential Postoperative Effects of Volatile Anesthesia and Intraoperative Remifentanil Infusion in 7511 Thyroidectomy Patients: A Propensity Score Matching Analysis.

Although remifentanil is used widely by many clinicians during general anesthesia, there are recent evidences of opioid-induced hyperalgesia as an adverse effect. This study aimed to determine if intraoperative remifentanil infusion caused increased pain during the postoperative period in patients who underwent a thyroidectomy. A total of 7511 patients aged ≥ 20 years, who underwent thyroidectomy between January 2009 and December 2013 at the Asan Medical Center were retrospectively analyzed. Enrolled patients were divided into 2 groups: group N (no intraoperative remifentanil and only volatile maintenance anesthesia) and group R (intraoperative remifentanil infusion including total intravenous anesthesia and balanced anesthesia). Following propensity score matching analysis, 2582 patients were included in each group. Pain scores based on numeric rating scales (NRS) were compared between the 2 groups at the postoperative anesthetic care unit and at the ward until 3 days postoperation. Incidences of postoperative complications, such as nausea, itching, and shivering were also compared. The estimated NRS pain score on the day of surgery was 5.08 (95% confidence interval [CI] 4.97-5.19) in group N patients and 6.73 (95% CI 6.65-6.80) in group R patients (P < 0.001). There were no statistically significant differences in NRS scores on postoperative days 1, 2, and 3 between the 2 groups. Postoperative nausea was less frequent in group R (31.4%) than in group N (53.5%) (P < 0.001). However, the incidence of itching was higher in group R (4.3%) than in group N (0.7%) (P < 0.001). Continuous infusion of remifentanil during general anesthesia can cause higher intensity of postoperative pain and more frequent itching than general anesthesia without remifentanil infusion immediately after thyroidectomy. Considering the advantages and disadvantages of continuous remifentanil infusion, volatile anesthesia without opioid may be a good choice for minor surgeries, such as thyroidectomy.

Comparison of the Efficacy and Safety of a Pharmacokinetic Model-Based Dosing Scheme Versus a Conventional Fentanyl Dosing Regimen For Patient-Controlled Analgesia Immediately Following Robot-Assisted Laparoscopic Prostatectomy: A Randomized Clinical Trial.

Conventional, intravenous, patient-controlled analgesia, which is only administered by demand bolus without basal continuous infusion, is closely associated with inappropriate analgesia. Pharmacokinetic model-based dosing schemes can quantitatively describe the time course of drug effects and achieve optimal drug therapy. We compared the efficacy and safety of a conventional dosing regimen for intravenous patient-controlled analgesia that was administered by demand bolus without basal continuous infusion (group A) versus a pharmacokinetic model-based dosing scheme performed by decreasing the dosage of basal continuous infusion according to the model-based simulation used to achieve a targeted concentration (group B) following robot-assisted laparoscopic prostatectomy.In total, 70 patients were analyzed: 34 patients in group A and 36 patients in group B. The postoperative opioid requirements, pain scores assessed by the visual analog scale, and adverse events (eg, nausea, vomiting, pruritis, respiratory depression, desaturation, sedation, confusion, and urinary retention) were compared on admission to the postanesthesia care unit and at 0.5, 1, 4, 24, and 48 h after surgery between the 2 groups. All patients were kept for close observation in the postanesthesia care unit for 1 h, and then transferred to the general ward.The fentanyl requirements in the postanesthesia care unit for groups A and B were 110.0 ±â€Š46.4 µg and 77.5 ±â€Š35.3 µg, respectively. The pain scores assessed by visual analog scale at 0.5, 1, 4, and 24 h after surgery in group B were significantly lower than in group A (all P < 0.05). There were no differences in the adverse events between the 2 groups.We found that the pharmacokinetic model-based dosing scheme resulted in lower opioid requirements, lower pain scores, and no significant adverse events in the postanesthesia care unit following robot-assisted laparoscopic prostatectomy in comparison with conventional dosing regimen.