Effect of high-dose intravenous iron injection on hepatic function in a rat model of cirrhosis.

OBJECTIVE: To investigate the hepatic effects of high-dose intravenous (IV) iron, including those on liver function and the degree of fibrosis, in a rat model of cirrhosis. METHODS: We evenly allocated 25 Sprague-Dawley rats into five groups: normal rats (control group), cirrhotic rats receiving IV normal saline (liver cirrhosis [LC] group), and cirrhotic rats receiving 20, 40, or 80 mg/kg IV ferric carboxymaltose (LC-iron20, LC-iron40, and LC-iron80 group, respectively). Biochemical parameters were compared at 0, 7, 14, 21, and 28 days. The degrees of hepatic fibrosis and iron deposition were evaluated. Inflammatory and oxidative stress markers were also compared. RESULTS: There were no significant differences in the 28-day serum alanine aminotransferase levels among the LC-iron20, LC-iron40, and LC-iron80 groups (69 ± 7, 1003 ± 127, 1064 ± 309, 919 ± 346, and 820 ± 195 IU/L in the control, LC, LC-iron20, LC-iron40, and LC-iron80 groups, respectively). Hepatic iron accumulation increased in a dose-dependent manner, but the degree of hepatic fibrosis was comparable among the groups. The inflammatory and oxidative stress marker levels did not differ significantly according to the IV iron dose. CONCLUSIONS: Administration of IV iron at various high doses appears safe in our rat model of cirrhosis.

Initial experience with the enhanced recovery after surgery (ERAS) protocols in gynecologic surgery at an urban academic tertiary medical center.

Background: The enhanced recovery after surgery (ERAS) protocols have been consistently associated with improved patient experience and surgical outcomes. Despite the release of ERAS Society guidelines specific to gynecologic oncology, the adoption of ERAS in gynecology on global level has been disappointingly low and some centers have shown minimal improvement in clinical outcomes after adopting ERAS. The aim of this study is to describe the development and early experience of ERAS protocols in gynecologic surgery at an urban academic tertiary medical center. Methods: This was an observational prospective cohort study. The target patient population included those with low comorbidities who were scheduled to undergo various types of gynecologic surgeries for both benign and malignant diseases between October 2020 and February 2021. Two attending surgeons implemented the protocols for their patients (ERAS cohort) while three attending surgeons maintained the conventional perioperative care for their patients (non-ERAS cohort). Baseline characteristics, surgical outcomes and patients' answers to a 12-question survey were compared. A case-matched comparative analysis was also performed between the ERAS cohort and the historical non-ERAS cohort (those who received the same types of surgical procedures from the two ERAS attending surgeons prior to the implementation of the protocols). Results: A total of 244 patients were evaluated (122 in the ERAS cohort vs. 122 in the non-ERAS cohort). The number of vials of opioid analgesia used during the first two postoperative days was significantly lower whereas the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen was more frequent in the ERAS cohort group. The patients in the ERAS group reported less postoperative pain, feelings of hunger and thirst, and greater amount of exercise postoperatively. These benefits of the ERAS cohort were more pronounced in the patients who underwent laparotomic surgeries than those who underwent laparoscopic surgeries. The case-matched comparative analysis also showed similar results. The length of hospital stay did not differ between those who underwent the ERAS protocols and those who did not. Conclusions: The results of the study demonstrated the safety, clinical feasibility and benefits of the ERAS protocols for patients undergoing gynecologic surgeries for both benign and malignant indications.

Analgesic efficacy of erector spinae plane block in patients undergoing major gynecologic surgery: A randomized controlled study.

STUDY OBJECTIVE: To investigate the analgesic efficacy of erector spinae plane block (ESPB) in major gynecologic surgery, expressed as cumulative opioid consumption 24 h after surgery. DESIGN: A single-center, patient-assessor blinded, randomized controlled study. SETTING: Samsung medical center (tertiary university hospital), between February 2022 to January 2023. PATIENTS: Eighty-eight females undergoing major surgery with long midline incision for gynecologic malignancy. INTERVENTIONS: Patients were randomly assigned to receive standard systemic analgesia (Control group) or ESPB (ESPB group). ESPB was performed bilaterally at the level of the 9th thoracic vertebra with a mixture of 20 mL of 0.5% ropivacaine and 100 µg of epinephrine. MEASUREMENTS: The primary outcome was cumulative opioid consumption at 24 h postoperatively. Secondary outcomes included opioid consumption and pain severity during the 72 h after surgery. The variables regarding postoperative recovery and patient-centered outcomes were compared. MAIN RESULTS: The mean cumulative opioid consumption 24 h after surgery was 35.8 mg in the ESPB group, which was not significantly different from 41.4 mg in the control group (mean difference, 5.5 mg; 95% CI -1.7 to 12.8 mg; P = 0.128). However, patient satisfaction regarding analgesia was significantly higher in the ESPB group compared with the control group at 24 h postoperative (median difference, -1; 95% CI -3 to 0; P = 0.038). There were no significant differences in the variables associated with postoperative recovery. CONCLUSION: ESPB did not reduce opioid consumption during the 24 h postoperative but attenuated pain intensity during the early period after surgery.

The Effect of Intrathecal Morphine on Postoperative Opioid Consumption in Patients Undergoing Abdominal Surgery for Gynecologic Malignancy: A Randomized Sham-Controlled Trial.

BACKGROUND: Surgery for gynecologic malignancy via midline-laparotomy leads to severe postoperative pain. Adequate pain control while sparing opioid consumption does offer benefits in postoperative complications and recovery. Intrathecal morphine (ITM) provides simple and effective analgesia. In this randomized trial, we compared postoperative opioid consumption in patients who received either ITM or a sham procedure. METHODS: We enrolled 68 adult patients undergoing open gynecologic oncology surgery from June 2021 to November 2021. They were randomly allocated to the ITM group (ITM; 200 µg injection) or sham group (sham procedure) to achieve a final 1:1 ratio between groups. We compared opioid consumption and pain severity during 72 hours after surgery. The variables regarding postoperative recovery and patient-centered outcomes were collected. The primary outcome is cumulative intravenous (IV) opioid consumption 24 hours after surgery. RESULTS: The median (interquartile range) cumulative IV opioid consumption during 24 hours after surgery was 18 mg (12-29) in the ITM group and 36 mg (27-42) in the sham group (median difference, 13; 95% confidence interval, 7.2-20.7; P < .001). Patient satisfaction regarding pain control was statistically significantly higher in the ITM group than in the sham group at postoperative 24 and 48 hours ( P < .001 and P = .005, respectively). There were no significant differences in the variables associated with postoperative recovery and frequency of complications requiring treatment. CONCLUSIONS: ITM is a safe and effective analgesic method after curative intent laparotomy for gynecologic malignancy. ITM provides better pain relief, reduces opioid consumption, and improves patient satisfaction without additional evident adverse events.

Intravenous iron injection does not impair liver function in a rat model of cirrhosis.

BACKGROUND: There is a lack of convincing data concerning the safety of iron therapy in patients with advanced liver cirrhosis (LC). This study investigated the hepatic effects of ferric carboxymaltose, an intravenous iron supplement, in a rat model of cirrhosis. METHODS: In total, 45 Sprague-Dawley rats were allocated into three groups: normal rats (control group, n=15), cirrhotic rats receiving intravenous normal saline (LC group, n=15), and cirrhotic rats receiving 20 mg/kg intravenous ferric carboxymaltose (LC-iron group, n=15). LC was induced by twice-weekly intraperitoneal injection of carbon tetrachloride. Biochemical parameters were compared at 0, 2, 14, and 28 days. Additionally, liver tissue samples were extracted from five rats in each group at 2, 14, and 28 days for evaluation of the degrees of hepatic fibrosis and iron deposition. Inflammatory and oxidative stress markers were also compared among groups. RESULTS: Serum alanine transferase levels did not significantly differ between the LC and LC-iron groups at 0 (443±110 vs. 444±117 IU/L, P>0.99), 2 (453±117 vs. 479±136 IU/L, P=0.84), 14 (1,535±1,058 vs. 1,578±711 IU/L, P=0.55), or 28 days (2,067±641 vs. 2,533±914 IU/L, P=0.15). The degree of hepatic fibrosis was comparable between the groups, although hepatic iron accumulation was greater in the LC-iron group than in the LC group. The levels of inflammatory and oxidative stress markers were significantly lower in the LC-iron group than in the LC group. CONCLUSIONS: In our rat model of cirrhosis, the administration of intravenous iron appears safe. However, further preclinical and clinical studies are warranted to confirm the safety and efficacy of intravenous iron in patients with LC or end-stage liver disease.

Comparison of Jaw Elevation Device vs. Conventional Airway Assist during Sedation in Chronic Kidney Diseases Undergoing Arteriovenous Fistula Surgery: A Randomized Controlled Trial.

Patients with chronic renal failure (CRF) are likely to have obstructive sleep apnea (OSA) underdiagnosed, and maintaining airway patency is important during sedation. This study compared Jaw elevation device (JED) with conventional airway interventions (head lateral rotation, neck extension, oral or nasal airway insertion, and jaw thrust maneuver) during sedation and hypothesized that JED may be effective to open the airway. A total of 73 patients were allocated to a conventional group (n = 39) and a JED group (n = 34). The number of additional airway interventions was the primary outcome. Percentage of patients with no need of additional interventions and apnea-hypopnea index (AHI) were secondary outcomes. The number of additional interventions was significantly less in the JED group compared to the conventional group (0 (0-0) vs. 1 (0-2); p = 0.002). The percentage of patients with no requirement for additional interventions was significantly higher in the JED group compared to the conventional group (76.5% vs. 43.6%; p = 0.004). AHI was significantly lower in the JED group compared to the conventional group (4.5 (1.5-11.9) vs. 9.3 (3.8-21.9), p = 0.015). In conclusion, JED seems to be effective in opening the airway patency during sedation in CRF patients.

Utility of ultrasound evaluation of I-Gel® placement in children: An observational study.

BACKGROUND: Ultrasound is not widely used to evaluate optimal supraglottic airway positioning even though it could potentially be used to identify and correct problem areas. AIMS: We evaluated a new ultrasound scoring method to identify the position of the supraglottic airway and detect the location of air leaks during ventilation in pediatric patients. METHODS: Using a prospective observational study design, we enrolled 90 pediatric patients of ASA physical status I-III scheduled for elective surgery under general anesthesia. After anesthesia induction, patients were assigned to a noncorrection group or a correction group after their first ultrasound evaluation. Noncorrection group comprised patients with tolerable I-Gel positioning based on ultrasound evaluation and no problems with clinical parameters, while the correction group comprised patients with I-Gel mispositioning based on ultrasound. RESULTS: After the first ultrasound evaluation, 61 patients did not need I-Gel correction (noncorrection group), while 29 patients needed I-Gel correction (correction group) and underwent a second ultrasound evaluation. Airway sealing pressure and total ultrasound score showed a negative correlation (r = -.845, p < .001). The area under the receiver operating curve for total ultrasound score was 0.97 (95% confidence interval, 0.94-0.99; p < .001). In the correction group, ultrasound score and ventilation parameters improved after correction based on ultrasound evaluation. CONCLUSIONS: Ultrasound scores were negatively correlated with airway sealing pressure in pediatric patients. Ultrasound evaluation is useful for detecting misplacement of the I-Gel and can be a useful tool for correction.

Ischemic Preconditioning Protects Against Hepatic Ischemia-Reperfusion Injury Under Propofol Anesthesia in Rats.

BACKGROUND: Propofol is widely used in general anesthesia, and it has been reported to protect various organs against ischemia-reperfusion injury (IRI), including liver. To evaluate the hepatoprotective effects of ischemic preconditioning (IP) under propofol anesthesia, we investigated the possible underlying mechanisms in rats. METHODS: Male Sprague-Dawley rats were randomly assigned to 3 groups: sham group (n = 5), non-IP group (n = 9; 45 minutes of hepatic ischemia followed by 2 hours of reperfusion), and IP group (n = 9; IP applied as 10 minutes of hepatic ischemia followed by 15 minutes of reperfusion before 45 minutes of ischemia). Anesthesia was maintained with intravenous (IV) infusion of propofol (800 µg/kg/min). Liver enzymes, histopathological changes, and cytokine expression were examined. RESULTS: The IP group showed significantly lower liver enzyme levels (aspartate aminotransferase, P = .045; alanine aminotransferase, P = .006) and reduced the histologic grades of hepatic injury 2 hours after reperfusion (P = .004) compared to the non-IP group. Lactate dehydrogenase activity (P < .001) and interleukin-6 mRNA levels were significantly higher in the non-IP group than in the sham and IP groups (P = .002, both groups). CONCLUSIONS: Our results demonstrate that IP under propofol anesthesia significantly attenuated hepatic IRI. The principal mechanism of the protective effects appeared to involve reduced expression of the IL-6 pro-inflammatory cytokine and subsequent reduction of the degree of necrosis.

Neutral Position Facilitates Nasotracheal Intubation with a GlideScope Video Laryngoscope: A Randomized Controlled Trial.

The optimal head position for GlideScope facilitated nasotracheal intubation has not yet been determined. We compared the neutral and sniffing positions to establish the degree of intubation difficulty. A total of 88 ASA I-II patients requiring nasotracheal intubation for elective dental surgery with normal airways were divided into two groups according to head position, neutral position (group N), and sniffing position (group S). The primary outcome was the degree of intubation difficulty according to the Intubation Difficulty Scale (IDS): Easy (IDS = 0), mildly difficult (IDS = 1 to 4), and moderately to severely difficult (IDS ≥ 5). Eighty-seven patients completed the study and their data were analyzed. The degree of intubation difficulty was significantly different between the two groups (p = 0.004). The frequency of difficult intubation (IDS > 0) was 12 (27.9%) in group N and 28 (63.6%) in group S (difference in proportion, 35.7%; 95% confidence interval [CI], 14.8 to 52.6%; p = 0.001). The neutral position facilitates nasotracheal intubation with GlideScope by aligning the nasotracheal tube and the glottis inlet more accurately than the sniffing position.

Combination of a pulmonary recruitment maneuver and intraperitoneal bupivacaine for the reduction of postoperative shoulder pain in gynecologic laparoscopy: a randomized, controlled trial.

OBJECTIVE: To compare the efficacy of a pulmonary recruitment maneuver using lower airway pressure (30 cm H2O) and intraperitoneal bupivacaine, alone or in combination, for reducing shoulder pain after gynecologic laparoscopy. METHODS: A prospective controlled study was performed in a teaching hospital with patients who underwent elective gynecologic laparoscopic surgery. Two hundred eighty-seven patients were randomized into 1 of 4 groups: group A, placebo; group B, intraperitoneal instillation of bupivacaine; group C, CO2 removal by a pulmonary recruitment maneuver; group D, combination of intraperitoneal bupivacaine and pulmonary recruitment maneuver. The interventions were performed at the end of surgery. Shoulder pain was recorded on a visual analog scale (VAS) at 1, 6, 12, and 24 hours postoperatively. RESULTS: The overall incidence of shoulder pain was 49.8% and the incidence tended to gradually decrease from group A to group D (59.0% in group A, 54.8% in group B, 44.4% in group C, and 41.5% in group D; P=0.026). In addition, the VAS scores gradually decreased from group A to D, although a statistically significant difference was only found at 6 hours postoperatively (P=0.03). There were no complications related to the interventions. CONCLUSION: The combination of a pulmonary recruitment maneuver with intraperitoneal bupivacaine significantly reduced shoulder pain after gynecologic laparoscopy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01039441.

Effect of Intraoperative Sedation with Dexmedetomidine Versus Propofol on Acute Postoperative Pain Following Major Foot Surgery under Popliteal Sciatic Nerve Block: A Randomized Controlled Trial.

Intravenous (IV) dexmedetomidine is reported to prolong analgesia following peripheral nerve blocks. Popliteal sciatic nerve block provides effective postoperative analgesia, but some patients still experience severe pain during the early postoperative period. We aimed to evaluate the postoperative analgesic effects of IV dexmedetomidine versus propofol in patients undergoing foot surgeries under popliteal sciatic nerve block. Forty patients were enrolled and randomly assigned to receive either IV propofol (n = 20) or IV dexmedetomidine (n = 20) for intraoperative sedation. All the patients received continuous popliteal sciatic nerve block. The corresponding drug infusion rate was adjusted to achieve a modified observer's assessment of alertness/sedation score of 3 or 4. The primary outcome was postoperative cumulative opioid consumption during the first 24 h after surgery. Thirty-nine patients were analyzed. The median (interquartile ranges) postoperative cumulative opioid consumption during the first 24 h after surgery was significantly lower in the dexmedetomidine group (15 (7.5-16.9) mg) than in the propofol group (17.5 (15-25) mg) (p = 0.019). The time to first rescue analgesic request was significantly greater in the dexmedetomidine group than in the propofol group (11.8 ± 2.2 h vs. 10.0 ± 2.7 h, p = 0.030) without the prolonged motor blockade (p = 0.321). Intraoperative sedation with dexmedetomidine reduced postoperative opioid consumption and prolonged analgesic duration after a popliteal sciatic nerve block.

Systemic Oxygen Delivery during One-Lung Ventilation: Comparison between Propofol and Sevoflurane Anaesthesia in a Randomised Controlled Trial.

Systemic oxygen delivery (DO2) is a more comprehensive marker of patient status than arterial oxygen saturation (SaO2), and DO2 in the range of 330-500 mL min-1 is reportedly adequate during anaesthesia. We measured DO2 during one-lung ventilation (OLV) for thoracic surgery-where the risk of pulmonary shunt is significant, and hypoxia occurs frequently-and compared sevoflurane and propofol, the two most commonly used anaesthetics in terms of DO2. Sevoflurane impairs hypoxic pulmonary vasoconstriction. Thus, our hypothesis was that propofol-based anaesthesia would show a higher DO2 value than sevoflurane-based anaesthesia. This was a double-blinded randomised controlled trial conducted at a university hospital from 2017 to 2018. The study population consisted of patients scheduled for lobectomy under OLV (N = 120). Sevoflurane or propofol was titrated to a bispectral index of 40-50. Haemodynamic variables were measured during two-lung ventilation (TLV) and OLV at 15 and 45 min (OLV15 and OLV45, respectively) using oesophageal Doppler monitoring. The mean DO2 (mL min-1) was not different between the sevoflurane and propofol anaesthesia groups (TLV: 680 vs. 706; OLV15: 685 vs. 703; OLV45: 759 vs. 782, respectively). SaO2 was not correlated with DO2 (r = 0.09, p = 0.100). Patients with SaO2 < 94% showed adequate DO2 (641 ± 203 mL min-1), and patients with high SaO2 (> 97%) showed inadequate DO2 (14% of measurements < 500 mL min-1). In conclusion, DO2 did not significantly differ between sevoflurane and propofol. SaO2 was not correlated with DO2 and was not informative regarding whether the patients were receiving an adequate oxygen supply. DO2 may provide additional information on patient status, which may be especially important when patients show a low SaO2.

Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery.

BACKGROUND: Interscalene brachial plexus block of the C5-C6 roots provides highly effective postoperative analgesia after shoulder surgery but usually results in hemidiaphragmatic paresis. Injection around the superior trunk of the brachial plexus is an alternative technique that may reduce this risk. The authors hypothesized that the superior trunk block would provide noninferior postoperative analgesia compared with the interscalene block and reduce hemidiaphragmatic paresis. METHODS: Eighty patients undergoing arthroscopic shoulder surgery were randomized to receive a preoperative injection of 15 ml of 0.5% ropivacaine and 5 µg · ml epinephrine around either (1) the C5-C6 nerve roots (interscalene block group) or (2) the superior trunk (superior trunk block group). The primary outcome was pain intensity 24 h after surgery measured on an 11-point numerical rating score; the prespecified noninferiority limit was 1. Diaphragmatic function was assessed using both ultrasonographic measurement of excursion and incentive spirometry by a blinded investigator before and 30 min after block completion. RESULTS: Seventy-eight patients completed the study. The pain score 24 h postoperatively (means ± SDs) was 1.4 ± 1.0 versus 1.2 ± 1.0 in the superior trunk block (n = 38) and interscalene block (n = 40) groups, respectively. The mean difference in pain scores was 0.1 (95% CI, -0.3 to 0.6), and the upper limit of the 95% CI was lower than the prespecified noninferiority limit. Analgesic requirements and all other pain measurements were similar between groups. Hemidiaphragmatic paresis was observed in 97.5% of the interscalene block group versus 76.3% of the superior trunk block group (P = 0.006); paresis was complete in 72.5% versus 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the interscalene block group. CONCLUSIONS: The superior trunk block provided noninferior analgesia compared with interscalene brachial plexus block for up to 24 h after arthroscopic shoulder surgery and resulted in significantly less hemidiaphragmatic paresis.

Postoperative pain control after the use of dexmedetomidine and propofol to sedate patients undergoing ankle surgery under spinal anesthesia: a randomized controlled trial.

Background: Dexmedetomidine is widely used for conscious sedation in patients undergoing lower-extremity surgery under regional anesthesia. We evaluated the postoperative analgesic effects of intravenous dexmedetomidine given during ankle surgery under spinal anesthesia. Methods: Forty-three participants underwent repair of lateral angle ligaments under spinal anesthesia. For sedation during surgery, participants were allocated to a dexmedetomidine group (n=22) that received a loading dose of 1 mcg.kg-1 over 10 min, followed by a maintenance dose of 0.2-0.7 µg.kg-1.h-1; and a propofol group (n=21) that received an effective site concentration of 0.5-2.0 µg.mL-1 via target-controlled infusion. The primary outcome was the postoperative, cumulative, intravenous (IV) morphine equivalent dose delivered via IV patient-controlled anesthesia (PCA) and rescue analgesic consumption in the first 24 h after surgery. We recorded sensory and motor block durations. Results: The postoperative IV morphine equivalent dose was 14.5 mg (0.75-31.75 mg) in the dexmedetomidine group compared to 48.0 mg (31.5-92.5 mg) in the propofol group (median difference, 33.2 mg; 95% confidence interval, 21.0-54.8 mg; P<0.001). The time to the first complaint of surgical site pain was significantly prolonged in the dexmedetomidine group (P<0.001), but the duration of motor block was comparable between the two groups (P=0.55). Conclusion: IV dexmedetomidine given as a sedative during ankle surgery under spinal anesthesia reduced postoperative opioid consumption in the first 24 h. Thus, intraoperative dexmedetomidine is a versatile sedative adjunct. Level of evidence: Level I, prospective randomized trial.

Increased expression of the Cbl family of E3 ubiquitin ligases decreases Interleukin-2 production in a rat model of peripheral neuropathy.

BACKGROUND: Interleukin 2 (IL-2) influences the development and severity of pain due to its antinociceptive and immunomodulatory effects. Its production is influenced by the increased expression of c-Cbl (Casitas B-lineage lymphoma proto-oncogene) and Cbl-b E3 ubiquitin ligases. We evaluated the effects on IL-2-mediated changes in c-Cbl and Cbl-b expression in a rat model of chronic neuropathic pain. METHODS: Peripheral neuropathy was induced in adult male Sprague-Dawley rats weighing 250-300 g by chronic spinal nerve ligation. Half of the spinal cord ipsilateral to the nerve injury was harvested at 1, 3, and 6 weeks, and the expression levels of IL-2, c-Cbl, Cbl-b, phospholipase C-γ1 (PLC-γ1), ZAP70, and protein kinase Cθ (PKCθ), as well as ubiquitin conjugation, were evaluated. RESULTS: Total IL-2 mRNA levels were significantly decreased at 3 and 6 weeks after nerve injury compared to those in sham-operated rats. The mRNA levels of c-Cbl and Cbl-b, as well as the level of ubiquitin conjugation, were significantly increased at 3 and 6 weeks. In contrast, the levels of phosphorylated ZAP70 and PLC-γ1 were decreased at 3 and 6 weeks after spinal nerve ligation. Ubiquitination of PLC-γ1 and PKCθ was increased at 3 and 6 weeks. CONCLUSIONS: Our results suggest that ubiquitin and the E3 ubiquitin ligases c-Cbl and Cbl-b function as neuroimmune modulators in the subacute phase of neuropathic pain after nerve injury.

Effective Dose of Intravenous Dexmedetomidine to Prolong the Analgesic Duration of Interscalene Brachial Plexus Block: A Single-Center, Prospective, Double-Blind, Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Intravenous (IV) dexmedetomidine (DEX) is reported to prolong the analgesic duration after single-shot interscalene brachial plexus block (ISBPB). However, the effective analgesic dose of IV DEX remains undetermined. Therefore, we aimed to elucidate the clinically relevant dose of IV DEX to prolong the analgesic duration of ISBPB. METHODS: Seventy-two patients scheduled for arthroscopic shoulder surgery received ISBPB with 15 mL of 0.5% ropivacaine with 1:200,000 epinephrine and were randomly assigned to 1 of 4 groups (n = 18, each): (1) IV normal saline (control), (2) IV DEX 0.5 µg/kg (DEX 0.5), (3) IV DEX 1.0 µg/kg (DEX 1.0), and (4) IV DEX 2.0 µg/kg (DEX 2.0). The primary outcome was time to the first pain at surgical site. RESULTS: The median (interquartile range) duration of analgesia was significantly prolonged for the DEX 2.0 (874 minutes [727-1153 minutes]) compared with 656 minutes (590-751 minutes), 703 minutes (644-761 minutes), and 696 minutes (615-814 minutes) for the control, DEX 0.5 and DEX 1.0 groups, respectively (P = 0.001, P = 0.008, and P = 0.003, respectively). Postoperative cumulative IV morphine equivalent consumption at 24 hours was significantly lower in the DEX 2.0 compared with the control, DEX 0.5 and DEX 1.0 groups (P < 0.001, P < 0.001, and P = 0.007, respectively). There were no significant differences in the incidence of intraoperative hypotension and the number of patients who required ephedrine after the pairwise group analysis. Also, there were no significant differences on the durations of motor blockade and sedation and the incidence of bradycardia. CONCLUSIONS: Intravenous DEX at a dose of 2.0 µg/kg significantly increased the duration of ISBPB analgesia without prolonging motor blockade and reduced the cumulative opioid consumption at the first 24 hours in patients undergoing arthroscopic shoulder surgery. CLINICAL TRIAL REGISTRATION: This study was registered at the Clinical Trial Registry of Korea, identifier KCT0002119.

Obesity is independently associated with spinal anesthesia outcomes: a prospective observational study.

The influence of body-mass index (BMI) on spinal anesthesia is still controversial, with discrepant results reported in previous studies. To compare spinal anesthesia in obese and non-obese subjects, the anesthesia profiles in patients who underwent spinal anesthesia using intrathecal hyperbaric bupivacaine were compared. A total of 209 patients undergoing elective total knee replacement arthroplasty (TKRA) surgery under spinal anesthesia were divided into an NO (non-obese) group (BMI < 30 kg/m2, n = 141) and an O (obese) group (BMI ≥ 30 kg/m2, n = 68). Anesthesia was deemed successful if a bilateral T12 sensory block occurred within 15 minutes of intrathecal drug administration, and if the level of sensory block was higher than T12 when the surgery ended. Logistic regression analysis with multiple variables known to influence spinal anesthesia was performed to identify which parameters independently determined the spinal anesthesia outcome. Similar doses of bupivacaine were administered to the NO and O groups. The incidence of anesthesia failure was significantly lower in the O group [n = 43 (30.5%) in the NO group vs. n = 10 (18.9%) in the O group, p = 0.014]. The independent predictors for successful anesthesia in all patients were dose of hyperbaric bupivacaine [odds ratio (OR) 2.12, 95% CI: 1.64-2.73] and obese status (BMI ≥ 30 kg/m2, OR 2.86, 95% CI: 1.25-6.52). Time to first report of postoperative pain and time to first self-void were significantly longer in the O group. These results suggest that the duration of block with hyperbaric bupivacaine is prolonged in obese patients and obesity is independently associated with spinal anesthesia outcomes, as is bupivacaine dosage. A further study enrolling patients with morbid obesity and using a fixed bupivacaine dosage is required to confirm the effect of obesity on spinal anesthesia.

A prospective, randomized, double-blind, multicenter trial to evaluate the therapeutic efficacy and safety of palonosetron in the treatment of postoperative nausea and vomiting over a 72-h period.

PURPOSE: We performed a multicenter, randomized, double-blind trial to assess the efficacy and safety of a single, fixed, intravenous dose of palonosetron (0.075 mg) in the treatment of established postoperative nausea and vomiting (PONV). METHODS: Three hundred and eighty-four patients who had at least one risk factors of PONV and underwent surgery under general anesthesia were screened. Those who developed PONV were randomized to receive either 0.075 mg intravenous palonosetron or a placebo. The incidence of nausea and vomiting, severity of nausea, requirements for rescue anti-emetics, and adverse effects at 2, 24, and 72 h after drug administration were evaluated. Complete response (CR) and complete control (CC) rate were compared for 24 and 72 h. RESULTS: Among the 384 patients, 152 (39.6 %) developed PONV and were randomized to either the palonosetron (n = 75) or placebo (n = 77) group. The number of patients with CR at 24 and 72 h was higher in the palonosetron group than the placebo group [0-24 h: n = 49 (68.1 %) vs. n = 30 (40.5 %), p < 0.001; 0-72 h: n = 47 (65.3 %) vs. n = 28 (37.8 %), p < 0.001]. The incidence of PONV at 2, 24, and 72 h periods was lower in the palonosetron group than the placebo group (29.2, 45.8, and 50.0 % in the palonosetron group vs. 50.0, 62.2, and 66.2 % in the placebo group, p = 0.010, 0.048, 0.047, respectively). The incidence of adverse events was not different between the groups. CONCLUSION: A single 0.075 mg IV dose of palonosetron effectively increased the CR rates at 24 and 72 h in these moderate-risk patients with established PONV.

Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery: randomized controlled trial.

STUDY OBJECTIVE: To compare cosmetic satisfaction with laparoendoscopic single-site surgery (LESS) compared with multi-port surgery. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: University hospital. PATIENTS: Twenty women who underwent laparoscopically-assisted vaginal hysterectomy (LAVH) via LESS or multi-port surgery. INTERVENTIONS: Laparoendoscopic single-site surgery or multi-port surgery. MEASUREMENT AND MAIN RESULTS: Cosmetic satisfaction was assessed using the Body Image Questionnaire at baseline and at 1, 4, and 24 weeks after surgery. Of the 20 LESS procedures, 1 was converted to multi-port surgery because of severe adhesions, and 1 woman assigned to undergo multi-port surgery was lost to follow-up. The 2 surgery groups did not differ in clinical demographic data and surgical results or postoperative pain scores at 12, 24, and 36 hours. Compared with the multi-port group, the LESS group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01). CONCLUSION: Compared with multi-port surgery, LESS is not only a feasible approach with comparable operative outcomes but also has an advantage insofar as cosmetic outcome.

The effect of anesthetic techniques on neutrophil-to-lymphocyte ratio after laparoscopy-assisted vaginal hysterectomy.

BACKGROUND: Surgical stress can induce postoperative systemic leukocytic alterations, including leukocytosis, neutrophilia, or lymphopenia. The present study investigated whether the anesthetic technique could affect the leukocytic alterations, including neutrophil-to-lymphocyte (N/L) ratio, after gynecologic laparoscopy. METHODS: Forty patients scheduled for laparoscopy-assisted vaginal hysterectomy were randomly assigned into two groups: PR group, which received total intravenous anesthesia with propofol and remifentanil, and S group, which received inhalational anesthesia with sevoflurane. Differential counts of leukocytes with N/L ratio of peripheral blood were obtained just before induction (T1), at the end of surgery (T2), 2 hours after surgery (T3), and 24 hours (T4) after surgery. RESULTS: Significant increase in total leukocytic count, neutrophil count, and N/L ratio, and decrease in lymphocytic count were observed at all time points after surgery in both groups. N/L ratio was significantly lower in group PR compared with group S at T3. The increase of N/L ratio in contrast to the value at T1 was significantly lower at T2 and T3 in group PR compared with that of group S. CONCLUSION: Total intravenous anesthesia with propofol and remifentanil resulted in transient but salient leukocytic alterations in the peripheral blood in terms of N/L ratio compared with inhalational anesthesia with sevoflurane in laparoscopy-assisted vaginal hysterectomy.