Objective Assessment of Perioperative Anxiety using Functional Near-infrared Spectroscopy in Elderly Patients: A Prospective Randomized Observational Pilot Study.

Background: Assessing and managing patient anxiety is essential to reduce postoperative complications in elderly patients. However, monitoring patient anxiety objectively is impossible. This study aimed to investigate the correlation between the level of fNIRS signals and anxiety in patients aged 65 and older undergoing artificial joint replacement surgery. Material and Methods: Sixty patients aged ≥65 years scheduled for elective total knee arthroplasty under spinal anesthesia were included. To differentiate the degree of anxiety, the patients were randomly divided into three groups, each consisting of 20 patients (group 1: administered normal saline as a placebo; groups 2 and 3: administered dexmedetomidine at a rate of 0.2 and 0.5 µg/kg/h, respectively, for 10 min). Functional near-infrared spectroscopy was measured continuously for 10 min in each session (session 1: pre-anesthetic period; session 2: immediately after the spinal anesthesia period; session 3: normal saline or dexmedetomidine receiving period) in all patients. Vital signs were measured thrice at 5-min intervals during each session. State-Trait Anxiety Inventory -S (STAI-S) and Ramsay Sedation Scale (RSS) scores were assessed at the end of each session. Results: The STAI-S score was significantly correlated with power of bandwidth (p = 0.034). In addition, the RSS score was significantly correlated with BW 1, 2, and 3 (p = 0.010, p < 0.001, and p = 0.003, respectively). Conclusion: The STAI-S score and BW 3 were significantly correlated, suggesting that fNIRS might help objectively and directly monitor anxiety levels.

Impact of Nonselective and Selective α-1 Adrenergic Blockers on the Sedative Efficacy of Dexmedetomidine in Urologic Surgery: A Prospective, Observational Study.

BACKGROUND This study aimed to compare the impact of a-1 adrenergic blockers - nonselective (alfuzosin, doxazosin, and terazosin) and selective (silodosin and tamsulosin) - on the sedative effects of the alpha-2 adrenergic agonist dexmedetomidine (DMT) in patients undergoing urologic surgery. The primary outcome was the sedative effect of DMT as determined by the bispectral index (BIS) and Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale scores. MATERIAL AND METHODS One hundred eighteen patients undergoing elective urologic surgery with spinal anesthesia were recruited. Patients were assigned based on their medication status to group N (no medication; n=33), group NS (nonselective alpha-1 blocker; n=27), or group S (selective alpha-1 blocker; n=58). Mean blood pressure (MBP), heart rate (HR), oxygen saturation (SpO2), BIS, and MOAA/S scale scores were recorded at 5-minute (min) intervals after DMT administration. RESULTS Group NS had significantly higher BIS scores than groups N and S at 25 min (P=0.045) and 30 min (P=0.030) after DMT administration, indicating lower sedation levels. MBP significantly differed between the 3 groups at all time points, with group N experiencing a lower MBP than groups NS and S. No significant differences were found between the groups in MOAA/S scale scores, SpO2, or HR. CONCLUSIONS Nonselective alpha-1 adrenergic blockers can reduce the sedative effects of DMT. Consequently, there may be a need for individualized anesthesia management considering the specific subtype of alpha-1 adrenergic blocker medication.

Perioperative considerations of pyruvate dehydrogenase complex deficiency: a case report of two consecutive anesthesia.

BACKGROUND: Pyruvate dehydrogenase complex (PDHC) deficiency is a rare mitochondrial disorder caused by a genetic mutation affecting the activity of the PDHC enzyme, which plays a major role in the tricarboxylic cycle. Few cases of surgery or anesthesia have been reported. Moreover, there is no recommended anesthetic method. CASE: A 24-month-old child with a PDHC deficiency presented to the emergency room with respiratory failure, mental decline, systemic cyanosis, and lactic acidosis. During hospitalization period, the patient presented with pneumothorax, pneumoperitoneum, and multiple air pockets in the heart. Two surgeries were performed under general anesthesia using an inhalational anesthetic agent. The patient was discharged with home ventilation. CONCLUSIONS: Anesthesiologists should be wary of multiple factors when administering anesthesia to patients with PDHC deficiency, including airway abnormalities, acid-base imbalance, intraoperative fluid management, selection of appropriate anesthetics, and monitoring of lactic acid levels.

A Study of 57 Patients with Prostate Cancer to Compare Outcomes of Estimated Blood Loss and Postoperative Pain Between Robot-Assisted Laparoscopic Radical Prostatectomy and Standard Laparoscopic Radical Prostatectomy.

BACKGROUND Robot-assisted radical prostatectomy (RARP) is becoming an increasingly common method for treatment of prostate cancer. This study aimed to compare outcomes of estimated blood loss and postoperative pain, determined by patient-controlled analgesia (PCA), between RARP and standard laparoscopic radical -prostatectomy (LRP). MATERIAL AND METHODS We enrolled 57 patients who had localized prostate cancer (28 patients in RARP, 29 patients in LRP). Primary outcomes were estimated blood loss (EBL) measured by gravimetric method for gauze and visual estimation for suction bottle, and PCA bolus count that the bolus doses were injected at the 1st, the 6th, the 24th, and the 48th hour after the operation. We recorded anesthesia and operation time, pneumoperitoneum duration, vital signs, fluid volume, and remifentanil use. Using the numeric rating scale (NRS), adverse effects were checked at the 1st, the 6th, the 24th, and the 48th hour and patient satisfaction was assessed at the 48th hour after the operation. RESULTS Anesthesia time, operation time, and gas insufflation time were longer (P=0.001, P=0.003, P=0.021), and patient-controlled analgesia (PCA) bolus counts at the 1st hour after the operation and volumes of administered crystalloid and remifentanil were higher in the RARP group than in the LRP group (P=0.013, P=0.011, P=0.031). There were no significant differences in EBL. CONCLUSIONS The RARP group required longer anesthetic time and more analgesics during the acute postoperative period compared to the LRP group. Regarding anesthesia, LRP is as good a surgical procedure as RARP until the operation time and the number of ports are reduced.

A prospective double-blinded randomized control trial comparing erector spinae plane block to thoracic epidural analgesia for postoperative pain in video-assisted thoracic surgery.

OBJECTIVES: To compare the analgesic efficacies of erector spinae plane (ESP) block and thoracic epidural analgesia (TEA) in video-assisted thoracic surgery (VATS). METHODS: Sixty patients undergoing VATS received patient-controlled TEA with a basal rate of 3 ml/hour (h), a bolus of 3 ml (Group E), or ESP block with programmed intermittent bolus infusions of 15 mL/3 h and a bolus of 5 ml (Group ES) for 2 postoperative days. The primary outcome was to compare pain scores at rest 24 h postoperatively between the 2 groups. Secondary outcomes included NRS score for 48 h, procedural time, dermatomal spread, use of rescue medication, adverse events, and patient satisfaction. RESULTS: Patients with continuous ESP block had a higher NRS score than those with TEA but no statistical difference at a specific time. The dermatomal spread was more extensive in the TEA group than in the ESP block group (p=0.016); cumulative morphine consumption was higher in the ESP block group (p=0.047). The incidence of overall adverse events in the TEA group was higher than in the ESP block group (p=0.045). CONCLUSION: Erector spinae plane block may be inferior to TEA for analgesia following VATS, but it could have tolerable analgesia and a better side effect profile than TEA. Therefore, it could be an alternative to TEA as a component of multimodal analgesia.

Secondary cytoreductive surgery with and without hyperthermic intraperitoneal chemotherapy for recurrent ovarian cancer.

Background: Secondary cytoreductive surgery (CRS) can afford promising results in patients with recurrent ovarian cancer; however, the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains unclear. We compared the outcomes of secondary CRS combined with and without HIPEC in patients with recurrent ovarian cancer. Methods: We retrospectively evaluated patients with recurrent ovarian cancer who underwent secondary CRS, with or without HIPEC (n=46), at the Yonsei Cancer Center between January 2006 and February 2021. Of the 46 included patients, 20 underwent secondary CRS-plus-HIPEC, while 26 underwent secondary CRS without HIPEC (henceforth referred to as secondary CRS-only). Results: Of the 46 patients, 84.8% and 89.1% had undergone optimal surgery and platinum-based chemotherapy, respectively, as the initial treatment before the first relapse. Overall, 32.6% of patients received maintenance therapy, such as bevacizumab or polyadenosine diphosphate ribose polymerase inhibitors. The median follow-up period was 15.9 months. The median progression-free survival (PFS) was 32.7 and 25.1 months in the secondary CRS-plus-HIPEC and secondary CRS-only groups, respectively; however, both groups failed to reach the median overall survival (OS). Based on the Kaplan-Meier analysis, there was no difference in PFS (P=0.587) or OS (P=0.239) between the two groups. We identified patients with epithelial ovarian cancer and found that the median PFS was 25.1 months in the secondary CRS-only group; this was not achieved in the secondary CRS-plus-HIPEC group (P=0.244). Conclusions: In patients with recurrent ovarian cancer, secondary CRS with HIPEC did not improve survival when compared with CRS without HIPEC. However, on subgrouping patients with epithelial ovarian cancer, the addition of HIPEC to secondary CRS tended to improve PFS.

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report.

BACKGROUND: Laparoscopic hepatectomy has recently become popular because it results in less bleeding than open hepatectomy. However, CO2 embolism occurs more frequently. Most CO2 embolisms during laparoscopic surgery are self-resolving and non-symptomatic; however, severe CO2 embolism may cause hypotension, cyanosis, arrhythmia, and cardiovascular collapse. In particular, paradoxical CO2 embolisms are highly likely to cause neurological deficits. We report a case of paradoxical CO2 embolism found on transesophageal echocardiography (TEE) during laparoscopic hepatectomy, although the patient had no intracardiac shunt. CASE SUMMARY: A 71-year-old man was admitted for laparoscopic left hemihepatectomy. During left hepatic vein ligation, the inferior vena cava was accidentally torn. We observed a sudden drop in oxygen saturation to 85%, decrease in systolic blood pressure (SBP) below 90 mmHg, and reduction in end-tidal CO2 to 24 mmHg. A "mill-wheel" murmur was auscultated over the precordium. The fraction of inspired oxygen was increased to 100% with 5 cmH2O of positive end-expiratory pressure (PEEP) and hyperventilation was maintained. Norepinephrine infusion was increased to maintain SBP above 90 mmHg. A TEE probe was inserted, revealing gas bubbles in the right side of the heart, left atrium, left ventricle, and ascending aorta. The surgeon reduced the pneumoperitoneum pressure from 17 to 14 mmHg and repaired the damaged vessel laparoscopically. Thereafter, the patient's hemodynamic status stabilized. The patient was transferred to the intensive care unit, recovering well without complications. CONCLUSION: TEE monitoring is important to quickly determine the presence and extent of embolism in patients undergoing laparoscopic hepatectomy.

Incidental operating room fire from a breathing circuit warmer system: a case report.

BACKGROUND: An airway-associated fire in an operating room can have devastating consequences for patients. Breathing circuit warmers (BCWs) are widely used to provide heated and humidified anesthetic gases and eventually prevent hypothermia during general anesthesia. Herein, we describe a case of a BCW-related airway fire. CASE PRESENTATION: In this case, an electrical short within a BCW wire caused a fire inside the circuit. Simultaneously, the fire was extinguished, ventilation was stopped, and the endotracheal tube was disconnected from the BCW. The patient was exposed to the fire for less than 10 s, resulting in burns to the trachea and bronchi. Immediately after airway burn, bronchoscopy showed no edema or narrowing except for soot in the trachea and both main bronchus. After the inhalation burn event, prophylactic antibiotics, bronchodilator, mucolytics nebulizer, and corticosteroid nebulizer were started. On bronchoscopy 3 days after the inhalation burn, mucosal erythematous edema was observed and the inflammatory reaction worsened. The inflammatory reaction showed aggravation for up to 2 weeks, and then gradually recovered, and the epithelium and mucous membrane of the upper respiratory tract returned to normal after 4 weeks. Eventually, the patient recovered without long-term complications and was successfully discharged. CONCLUSIONS: This is the first report of a fire caused by BCW. We wanted to share our experience of how we responded to an airway-related fire in an OR and treated the patient. It cannot be overemphasized that the electrical medical appliance associated with the airways are fatal to the patient in the event of a fire, so caution should always be exercised.

Sleep quality and emergence delirium in children undergoing strabismus surgery: a comparison between preschool- and school-age patients.

BACKGROUND: Emergence delirium (ED) is common in pediatric patients undergoing general anesthesia with sevoflurane. Preoperative sleep quality is associated with the risk factors for ED. However, research on the relationship between sleep quality and ED is limited. We aimed to investigate the relationship between ED and preoperative sleep quality in pediatric patients undergoing strabismus surgery. METHODS: This clinical trial included pediatric patients aged 4-12 years who underwent elective strabismus surgery. The patients and their parents were questioned about the patients' preoperative sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. For anesthesia induction, thiopental (5 mg/kg) and rocuronium (0.6 mg/kg) were used, and anesthesia was maintained with sevoflurane (minimum alveolar concentration, 1-1.5). After administration of a reversal drug, extubation was performed, and the patients were transferred to a post-anesthesia recovery unit. At 10 min after extubation, the degree of ED was measured using the pediatric anesthesia emergence delirium (PAED) and Watcha scale scores. RESULTS: Of the 62 enrolled patients, three pediatric patients were excluded. The overall incidence of ED was 22%. A total of 59 patients were divided into the two groups. The ED group and the non-ED group comprised 13 and 46 patients. Age, height and weight were significantly lower in the ED group than in the non-ED group. Preoperative PSQI and Watcha scale score were significantly higher in the ED group than in the non-ED group. Multivariate analysis showed that age (adjusted OR [95% CI]: 0.490 [0.290-0.828], p = 0.008) and preoperative PSQI score (adjusted OR [95% CI]: 2.149[1.224-3.771], p = 0.008) was associated with ED. In sub-group analysis, PAED scale and Watcha scale scores showed a moderate correlation with preoperative sleep quality in preschool-age patients. CONCLUSION: In conclusion, the incidence of ED tended to be higher in younger age and poorer preoperative sleep quality in pediatric patients. In particular, the poorer sleep quality score was associated with higher incidence of ED in the preschool-age. Large-scale clinical studies and long-term follow-up studies on ED and sleep quality are required. TRIAL REGISTRATION: This study was registered with Clinicaltrials.gov ( NCT03332407 ) at November 5th 2017.

Comparison of efficacy between palonosetron-midazolam combination and palonosetron alone for prevention of postoperative nausea and vomiting in patients undergoing breast surgery and patient controlled analgesia: A prospective, randomized, double-blind study: A CONSORT-compliant study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complaint in patients following general anesthesia. Various antiemetics, including 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists, are effective but still have limited efficacy. Therefore, combination therapy is preferable to using a single drug alone in high-risk patients. We performed a comparative study on the antiemetic effect of palonosetron, a 5-HT3 receptor antagonist, monotherapy vs palonosetron-midazolam combination therapy for the prevention of PONV. METHODS: A total of 104 female patients scheduled for breast cancer surgery were enrolled. They were randomly divided into 2 groups, a palonosetron monotherapy group (group P) and palonosetron-midazolam combination therapy group (group PM). Both groups received 0.075 mg palonosetron intravenously after induction of anesthesia. Patient-controlled analgesia (PCA) was applied according to the allocated group. Intravenous (IV)-PCA in group P consisted of fentanyl 20 µg/kg plus normal saline (total volume: 100 ml); IV-PCA in group PM consisted of fentanyl 20 µg/kg plus midazolam 4 mg plus normal saline (total volume: 100 ml). Efficacy parameters were collected during 0 to 1, 1 to 6, 6 to 24, and 24 to 48 hours postoperative time intervals. These measures included complete response (defined as no PONV and no rescue anti-emetic use) rate, incidence of PONV, sedation score, rescue antiemetic use, rescue analgesic use, and numerical rating scale (NRS) for pain. The complete response rate during the 0 to 24 hours interval was analyzed as the primary outcome. RESULTS: Although the complete response rate between 0 and 24 hours was higher in group PM (42.3% and 48.1% in group P and PM, respectively), there was no statistically significant difference (P = .55). The complete response rates in other time intervals were not different between the 2 groups as well. The sedation score and NRS score also showed no differences between the 2 groups. CONCLUSIONS: The combination therapy of palonosetron with midazolam did not lead to a greater reduction in the incidence of PONV than monotherapy in patients undergoing breast surgery and receiving IV-PCA containing fentanyl.

The analgesic efficacy of a single injection of ultrasound-guided retrolaminar paravertebral block for breast surgery: a prospective, randomized, double-blinded study.

BACKGROUND: The thoracic paravertebral block is an effective analgesic technique for postoperative pain management after breast surgery. The ultrasound-guided retrolaminar block (RLB) is a safer alternative to conventional paravertebral block. Thus, we assessed the analgesic efficacy of ultrasound-guided RLB for postoperative pain management after breast surgery. METHODS: Patients requiring breast surgery were randomly allocated to group C (retrolaminar injection with saline) and group R (RLB with local anesthetic mixture). The RLB was performed at the level of T3 with local anesthetic mixture (0.75% ropivacaine 20 mL + 2% lidocaine 10 mL) under general anesthesia before the skin incision. The primary outcome was cumulative morphine consumption using intravenous patient-controlled analgesia (IV-PCA) at 24 hour postoperatively. The secondary outcomes were the visual analogue scale (VAS) scores at 1, 6, 24, and 48 hour postoperatively and the occurrence of adverse events and patient satisfaction after the surgery. RESULTS: Forty-six patients were included, 24 in group C and 22 in group R. The cumulative morphine consumption using IV-PCA did not differ between the two groups (P = 0.631). The intraoperative use of remifentanil was higher in group C than in group R (P = 0.025). The resting and coughing VAS scores at 1 hour postoperatively were higher in group R than in group C (P = 0.011, P = 0.004). The incidence of adverse events and patient satisfaction was not significantly different between the two groups. CONCLUSIONS: A single injection of ultrasound-guided RLB did not reduce postoperative analgesic requirements following breast surgery.

The effect of combined Epidural-general Anesthesia on Hemodynamic Instability during Pheochromocytoma and Paraganglioma Surgery: A multicenter retrospective cohort study.

Objectives: The purpose of this study was to compare the effects of combined epidural-general anesthesia with those of general anesthesia alone on hemodynamic instability (intraoperative hypotension and hypertensive crisis) during pheochromocytoma and sympathetic paraganglioma surgery. Methods: A total of 119 patients' medical records were reviewed who were diagnosed as having pheochromocytoma and sympathetic paraganglioma on the basis of histological findings. Intraoperative hypotension was defined as a mean blood pressure < 60 mmHg or a decrease > 30% in baseline systolic blood pressure after adrenal vein ligation. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The predictor variables for intraoperative hypotension and hypertensive crisis were analyzed with logistic regression models. Data were presented as adjusted odds ratio with 95% confidence interval. Results: The independent predictors of intraoperative hypotension were an increased attenuation number on unenhanced computed tomography (1.112 [1.009-1.226], p = 0.033), a high baseline mean blood pressure (1.063 [1.012-1.117], p = 0.015), and the combined epidural-general anesthesia (5.439 [1.410-20.977], p = 0.014). In contrast, an increased attenuation number on unenhanced computed tomography was the only independent predictor of hypertensive crisis (1.087 [1.021-1.158], p = 0.009). Conclusions: The combined epidural-general anesthesia was not effective in attenuating hypertensive responses, but could have exacerbated intraoperative hypotension. These findings should be taken into account before selecting the anesthetic technique in pheochromocytoma and sympathetic paraganglioma surgery.

Concealed congenital long QT syndrome during velopharyngeal dysfunction correction: a case report.

The congenital long QT syndrome (LQTS) is an inherited cardiac disorder characterized by increased QT intervals and a tendency to experience ventricular tachycardia, which can cause fainting, heart failure, or sudden death. A 4-year-old female patient undergoing velopharyngeal correction surgery under general anesthesia suddenly developed Torsades de pointes. Although the patient spontaneously resolved to sinus rhythm without treatment, subsequent QT prolongation persisted. Here, we report a case of concealed LQTS with a literature review.

A prospective pilotstudy comparing the anesthetic effects of an alpha-2 agonist during holmium laser resection of the prostate and transurethral resection for prostate surgery for benign prostatic hyperplasia patients using selective alpha-1 blockers.

BACKGROUND: To examine the response to an α2receptor agonist used as a sedative for patients using long-term selective α1 blockers. METHODS: Sixty-nine consecutive patients undergoing transurethral prostate resection or holmium laser resection of the prostateunder spinal anesthesia were divided into two groups; group N (n = 37), which did not receive α1 blockers, and group T (n = 32), which was administered tamsulosin for at least 1 month before the study. Bispectral index scores, Modified Observer's Assessment of Alertness/Sedation scale scores, heart rate, and mean blood pressure were obtained under sedation using dexmedetomidine for 30 min during surgery. RESULTS: The only significant difference found between the groups were mean bloodpressure 15 min after the first loading dose injection of dexmedetomidine. Differencesbetween both groupswere noted at 15 min(group T: 100.2 ± 12.9 mmHg; group N: 90.0 ± 17.5 mmHg; P = 0.08), 20 min (group T: 99.8 ± 12.3 mmHg; group N: 87.4 ± 15.0 mmHg; P < 0.00), 25 min (group T: 99.3 ± 13.4 mmHg; group N: 85.4 ± 13.8 mmHg; P < 0.00), and 30 min (group T: 98.8 ± 13.1 mmHg; group N: 84.5 ± 13.5 mmHg; P < 0.00). CONCLUSIONS: The use of α2 agonists is appropriate during surgery for benign prostatic hyperplasia patients using tamsulosin, and there is no need to alter the dose. Alertness with anesthesia involving α2 agents was maintained for patients using long-term tamsulosin and patients who did not use tamsulosin. TRIAL REGISTRATION: The study was retrospectively registered with the Clinical Research Informational Service ( KCT0002967 , July 2, 2018).

Propofol attenuates osteoclastogenesis by lowering RANKL/OPG ratio in mouse osteoblasts.

Bone remodeling plays an important role in the bone healing process; for example, following fracture. The relative ratio of the receptor activator of nuclear factor kappa B ligand (RANKL)/ osteoprotegerin (OPG) controls osteoclast differentiation, thereby playing a pivotal role in the regulation of bone remodeling. Propofol, a widely used anesthetic agent in orthopedic procedures, is considered to possess potential antioxidant properties owing to its structural similarity to α-tocopherol. Antioxidants are known to enhance bone healing. Accordingly, in the present study, we aimed to investigate osteoblastic differentiation and RANKL/OPG expression following propofol administration, in order to assess the potentially beneficial effects of this drug on the bone remodeling process, using calvarial primary osteoblasts from newborn mice. Calvarial pre-osteoblast cells were cultured in media containing clinically relevant concentrations of propofol, and cytotoxicity, effects on cell proliferation, osteogenic activity, and osteoclastogenesis were examined. The present findings indicated that propofol did not exert cytotoxic effects or alter cell proliferation in primary calvarial osteoblasts. Further, propofol did not affect osteoblast differentiation. The RANKL/OPG ratio was found to be decreased following propofol administration, and osteoclastogenesis was significantly reduced, indicating that propofol attenuated the osteoclastogenesis-supporting activity of osteoblasts. The results demonstrate that propofol, at clinically relevant concentrations, exerts beneficial effects on bone remodeling by attenuating osteoclastogenesis via suppression of the RANKL/OPG expression axis.

Oxygen insufflation via working channel in a fiberscope is a useful method: A case report and review of literature.

BACKGROUND: Fiberoptic bronchoscopic intubation is the gold standard for endotracheal intubation in difficult or compromised airway situations. However, oxygen insufflation through the working channel of a fiberscope is a controversial method because of the possibility of gastric distention and rupture during an awake fiberoptic bronchoscopic intubation, despite the advantages of preventing fogging of the fiberoptic bronchoscopic lens, blowing oral secretions away, and oxygenation of patients. CASE SUMMARY: Here, we describe a case of cervical instability where we rapidly performed fiberoptic bronchoscopic intubation using oxygen insufflation through working channel of the broncoscopy to administer general anesthesia after two previous failures due to low visibility. A 50-year-old man with a non-specific medical history underwent emergency cervical spine surgery for posterior fusion of the C2 and C3 vertebrae. After two unsuccessful attempts at intubation using the fiberoptic broncoscopy, we performed it successfully using the oxygen insufflation via the working channel, instead of using suction to remove the secretion from the lens. CONCLUSION: Oxygen insufflation via the working channel of the broncoscopy is a useful method for assisting with difficult intubation cases.

Observations on significant hemodynamic changes caused by a high concentration of epidurally administered ropivacaine: correlation and prediction study of stroke volume variation and central venous pressure in thoracic epidural anesthesia.

BACKGROUND: Thoracic epidural anesthesia (TEA) exacerbates hypotension due to peripheral vasodilator effects following the use of general anesthetics. This study aimed to compare the hemodynamic changes caused by three different concentrations of epidural ropivacaine and to evaluate the performance of the stroke-volume variation (SVV) and central venous pressure (CVP) during TEA with general anesthesia. METHODS: A total of 120 patients were administered 8 mL of ropivacaine solution via epidural injection, following randomization into one of three groups based on the concentration of ropivacaine in the study solution: 0.75%, 0.375%, or 0.2%. Hemodynamics were monitored for 30 min after loading. We analyzed the hemodynamic changes in the subgroups according to an age cutoff of 60 years. Receiver operating characteristic (ROC) analysis was performed to characterize the relationship of the SVV, CVP, and a 20% decrease in the mean arterial pressure (MAP) following TEA. RESULTS: Data from 109 patients were analyzed. MAP and systemic vascular resistance index were significantly decreased, and SVV was significantly increased after epidural loading only in the 0.75% ropivacaine group. There was a significant difference in hemodynamics between young and elderly subgroups in the 0.75% ropivacaine group. SVV showed a negative correlation with MAP, whereas CVP showed no correlation. The ROC analysis of SVV demonstrated a weak predictive ability of a 20% decrease in MAP at 10 min after the loading dose, with an area-under-the-curve of 0.687 and a 9.5% optimal cutoff value (sensitivity, 60.6%; specificity, 68.9%). CONCLUSIONS: A high concentration of ropivacaine through TEA caused a significant decrease in the systemic vascular resistance and blood pressure. More significant decreases were shown in the elderly patients. Though the change of SVV showed a negative correlation with hypotension and indicated functional hypovolemia after TEA, the predictability was limited. CLINICAL TRIALS REGISTRATION: Number: NCT01559285 , date: January 24, 2013.

Profuse and acute hemorrhagic gastroesophageal injury after cryotherapy in a cardiac surgery patient.

Upper gastrointestinal injury associated with cryoablation and under placement of transesophageal echocardiography (TEE) during cardiac surgery is a rare complication but potentially fatal. During the cryoablation for the treatment of atrial fibrillation, delivered cryoenergy can adversely affect the esophagus, resulting in gastroesophageal ulceration. The TEE probe itself also can induce adverse effects like esophageal ulceration or perforation. In this case report, we describe a case of emergent gastroesophageal injury with massive bleeding that occurred after manipulation of a TEE probe during cryoablation therapy in a cardiac surgery patient.

The effect of tulobuterol patches on the respiratory system after endotracheal intubation.

BACKGROUND: Endotracheal intubation during anesthesia induction may increase airway resistance (Raw) and decrease dynamic lung compliance (Cdyn). We hypothesized that prophylactic treatment with a transdermal ß2-agonist tulobuterol patch (TP) would help to reduce the risk of bronchospasm after placement of the endotracheal tube. METHODS: Eighty-two American Society of Anesthesiologists (ASA) category I or II adult patients showing obstructive patterns were divided randomly into a control and a TP group (n = 41 each). The night before surgery, a 2-mg TP was applied to patients in the TP group. Standard monitors were recorded, and target controlled infusion (TCI) with propofol and remifentanil was used for anesthesia induction and maintenance. Simultaneously, end-tidal carbon dioxide, Raw, and Cdyn were determined at 5, 10, and 15 min intervals after endotracheal intubation. RESULTS: There was no significant difference in demographic data between the two groups. The TP group was associated with a lower Raw and a higher Cdyn, as compared to the control group. Raw was significantly lower at 10 min (P < 0.05) and 15 min (P < 0.01), and Cdyn was significantly higher at 5 min (P < 0.05) and 15 min (P < 0.01) in the TP group. A trend towards a lower Raw was observed showing a statistically significant difference 5 min after endotracheal intubation (P < 0.01) in each group. CONCLUSIONS: Prophylactic treatment with TP showed a bronchodilatory effect through suppressing an increase in Raw and a decrease in Cdyn after anesthesia induction without severe adverse effects.

Combined spinal-epidural anesthesia for radical hysterectomy in a patient with Sjȍgren syndrome with progressive interstitial lung disease.

INTRODUCTION: Interstitial lung disease (ILD), which is the most common form of respiratory involvement of Sjȍgren syndrome (SS), is highly associated with postoperative pulmonary complications after surgery. We report the successful anesthetic management of a cervical cancer patient with SS and ILD under combined spinal-epidural anesthesia (CSE) to avoid postoperative pulmonary complications. CASE DESCRIPTION: A 41-year-old woman with SS complicated by recently progressive ILD was scheduled for an elective radical hysterectomy under the diagnosis of cervical cancer. We performed CSE with separate needle technique (SNT) using two different interspaces. An epidural catheter was inserted at T11-T12 before administration of spinal medication at L3-L4. We could achieve successful anesthetic management for radical hysterectomy, maintaining stable hemodynamic variables. Postoperative analgesia, using epidural catheter, was effective and devoid of any postoperative pulmonary morbidity. DISCUSSION AND EVALUATION: CSE could offer a high level of sensory blockade, profound muscular blockade, longer duration of surgical anesthesia, excellent postoperative pain control, and reduction in the incidence of pulmonary morbidity. Therefore it would be excellent anesthetic option for the patients with pulmonary impairment. CONCLUSION: CSE with SNT may be particularly advantageous in patients with pulmonary impairment such as progressive ILD when general anesthesia is associated with high risk of postoperative complications.