Preoperative Intrathecal Morphine is Associated With Reduced Postoperative Pain, Agitation, and Delirium In Living Donor Kidney Transplantation Recipients.

BACKGROUND: Postoperative delirium after organ transplantation can lead to increased length of hospital stay and mortality. Because pain is an important risk factor for delirium, perioperative analgesia with intrathecal morphine (ITM) may mitigate postoperative delirium development. We evaluated if ITM reduces postoperative delirium incidence in living donor kidney transplant (LDKT) recipients. METHODS: Two hundred ninety-six patients who received LDKT between 2014 and 2018 at our hospital were retrospectively analyzed. Recipients who received preoperative ITM (ITM group) were compared with those who did not (control group). The primary outcome was postoperative delirium based on the Confusion Assessment Method for Intensive Care Unit results during the first 4 postoperative days. RESULTS: Delirium occurred in 2.6% (4/154) and 7.0% (10/142) of the ITM and control groups, respectively. Multivariable analysis showed age (odds ratio [OR]: 1.07, 95% CI: 1.01-1.14; P = .031), recent smoking (OR: 7.87, 95% CI: 1.43-43.31; P = .018), preoperative psychotropics (OR: 23.01, 95% CI: 3.22-164.66; P = .002) were risk factors, whereas ITM was a protective factor (OR: 0.23, 95% CI: 0.06-0.89; P = .033). CONCLUSIONS: Preoperative ITM showed an independent association with reduced post-LDKT delirium. Further studies and the development of regional analgesia for delirium prevention may enhance the postoperative recovery of transplant recipients.

Living Donor Liver Transplantation for an Infant Having Tracheostomy and Subglottic Stenosis: A Case Report.

BACKGROUND: It is uncommon to perform liver transplantation for patients with end-stage liver disease having tracheostomy. Usually, the tracheostomy cannula is changed to an oral endotracheal tube (ETT) before operation because ETT is easy to handle during operation. If routine oral ETT insertion is difficult, we should seek other solutions. CASE DESCRIPTION: We report a successful conversion from tracheostomy tube to ETT in a patient with subglottic stenosis. The patient was an 8-month-old infant who was scheduled for living donor liver transplantation due to acute hepatic failure. The original plan was to convert the tracheostomy tube to oral ETT, which failed due to aggravation of subglottic stenosis. An otolaryngologist performed balloon dilatation surgery, and ETT was successfully intubated. Owing to a multidisciplinary approach, the surgery was successfully performed without fatal adverse events, and the patient was later discharged with a tracheostomy. CONCLUSIONS: It is unusual for pediatric patients with tracheostomy tubes to undergo major surgeries like liver transplantation. We hope that this case of successful anesthetic management based on a multidisciplinary approach suggests new ideas to anesthesiologists seeking safe anesthesia.

Second-generation supraglottic airway in laparoscopic donor nephrectomy.

Supraglottic airway (SGA) may have advantages over endotracheal tube (ETT) regarding laryngospasm, coughing, sore throat, and hemodynamic changes; however, studies on the use of SGA in laparoscopic donor nephrectomy (LDN) are lacking. Here, we aimed to confirm the safety and feasibility of second-generation SGA in LDN and compare them with those of ETT. Enrolled adult donors (aged > 18 years) who underwent LDN between August 2018 and November 2021 were divided into two groups-ETT vs. SGA. Airway pressure, lung compliance, desaturation, and hypercapnia were recorded during surgery. After propensity score matching for baseline characteristics and surgical duration, 82 and 152 donors were included in the ETT and SGA groups, respectively, and their outcomes were compared. The peak airway pressure was lower in the SGA group than in the ETT group 5 min after pneumoperitoneum. Dynamic lung compliance was higher in the SGA group than in the ETT group during surgery. There were no cases of intraoperative desaturation, hypercapnia, or postoperative aspiration pneumonitis. The use of second-generation SGA, a safe alternative to ETT for LDN, resulted in reduced airway resistance and increased lung compliance, which suggests its benefits for airway management in kidney donors.

Evaluation of Chylothorax Using Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography After Lung Cancer Surgery.

Background: To determine the role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) in the management of postoperative chylothorax after lung cancer surgery. Methods and Results: Between July 2017 and November 2021, patients who developed postoperative chylothorax following pulmonary resection and mediastinal lymph node dissection were assessed and those who underwent DCMRL for the evaluation of chyle leak were evaluated. The findings of DCMRL and conventional lymphangiography were compared. The incidence of postoperative chylothorax was 0.9% (50/5587). Among the patients with chylothorax, a total of 22 patients (44.0% [22/50]; mean age, 67.6 ± 7.9 years; 15 men) underwent DCMRL. Treatment outcomes were compared between patients with conservative management (n = 10) and those with intervention (n = 12). The patients demonstrated unilateral pleural effusion, ipsilateral to the operation site, and showed right-sided dominance. The most frequent site of thoracic duct injury showing contrast media leakage was visualized at the subcarinal level. No DCMRL-related complication occurred. DCMRL showed comparable performance to conventional lymphangiography in visualizing the central lymphatics, including cisterna chyli (DCMRL vs. conventional lymphangiography, 72.7% vs. 45.5%, p = 0.25) and thoracic duct (90.9% vs. 54.5%, p = 0.13), and in localizing thoracic duct injury (90.9% vs. 54.5%, p = 0.13). On follow-up, the amount of chest tube drainage after lymphatic intervention showed a significant difference over time from that after medical treatment only (p = 0.02). Conclusion: DCMRL can provide detailed information about the leak site and the central lymphatic anatomy in patients with chylothorax after lung cancer surgery. The findings of DCMRL can guide subsequent treatment planning for optimal outcomes.

Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.

Introduction: Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery. Methods: Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO2), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO2), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared. Results: The values of ETCO2, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO2 at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar. Conclusion: During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.

Association between high-sensitivity cardiac troponin I measured at emergency department and complications of emergency coronary artery bypass grafting.

High-sensitivity cardiac troponin I (hs-cTnI) is a widely used biomarker to identify ischemic chest pain in the Emergency Department (ED), but the clinical impact on emergency coronary artery bypass grafting (eCABG) remains undetermined. We aimed to evaluate the clinical impact of hs-cTnI measured at the ED by comparing outcomes of eCABG in patients with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) which comprises unstable angina (UA) and non-ST-segment-elevation myocardial infarction (NSTEMI). From January 2012 to March 2016, 242 patients undergoing eCABG were grouped according to serum hs-cTnI level in the ED. The primary endpoint was major cardiovascular cerebral event (MACCE) defined as a composite of all-cause death, myocardial infarction, repeat revascularization, and stroke. The incidence of each MACCE composite, in addition to postoperative complications such as acute kidney injury, reoperation, atrial fibrillation, and hospital stay duration were also compared. Patients were divided into two groups: UA [<0.04 ng/mL, n = 102] and NSTEMI [≥0.04 ng/mL, n = 140]. The incidence of MACCE did not differ between the two groups. Postoperative acute kidney injury was more frequent in the NSTEMI group after adjusting for confounding factors (6.9% vs. 23.6%; odds ratio, 2.76; 95% confidence interval, 1.09-6.99; p-value = 0.032). In-hospital stay was also longer in the NSTEMI group (9.0 days vs. 15.4 days, p-value = 0.008). ECABG for UA and NSTEMI patients showed comparable outcomes, but hs-cTnI elevation at the ED may be associated with immediate postoperative complications.

Safety and Risk Factors of Pure Laparoscopic Living Donor Right Hepatectomy: Comparison to Open Technique in Propensity Score-matched Analysis.

BACKGROUND: The innovative pure laparoscopic living donor right hepatectomy (LLDRH) procedure for liver transplantation has never been fully compared to open living donor right hepatectomy (OLDRH). We aimed to compare the donor safety and graft results of pure LLDRH to those of OLDRH. METHODS: From May 2013 to July 2017, 288 consecutive donors underwent either OLDRH (n = 197) or pure LLDRH (n = 91). After propensity score matching, 72 donors were included in each group. The primary outcome was postoperative complications during a 90-day follow-up period. Comprehensive complication index, duration of hospital stay, need for additional pain control, readmission, and donor outcomes were also compared. RESULTS: The incidence of major complication during the 90-day follow-up was higher in the LLDRH group than the OLDRH group (6.6% vs 15.4%, P = 0.017) but was not statistically significant in propensity-matched analysis (11.1% vs 13.9%, odds ratio [OR], 1.29; 95% confidence interval [CI], 0.47-3.51; P = 0.62). A right hepatic duct <1 cm was independently associated with complication in the pure LLDRH group (odds ratio, 4.01; 95% confidence interval, 1.08-14.99; P = 0.04). CONCLUSIONS: In the initial 91 pure LLDRH cases, incidence of major complication was higher than in the OLDRH group, but the difference was not significant in propensity-matched analysis. A right hepatic duct verified as <1 cm may be related to increased frequency of complications in pure LLDRH donors. Further analysis is needed.

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.

Volatile sedation in the intensive care unit: A systematic review and meta-analysis.

BACKGROUND: Volatile sedation in the intensive care unit (ICU) may reduce the number of adverse events and improve patient outcomes compared with intravenous (IV) sedation. We performed a systematic review and meta-analysis comparing the effects of volatile and IV sedation in adult ICU patients. METHODS: We searched the PubMed, Embase, Cochrane Central Register, and Web of Science databases for all randomized trials comparing volatile sedation using an anesthetic-conserving device (ACD) with IV sedation in terms of awakening and extubation times, lengths of ICU and hospital stay, and pharmacologic end-organ effects. RESULTS: Thirteen trials with a total of 1027 patients were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time [mean difference (MD), -80.0 minutes; 95% confidence intervals (95% CIs), -134.5 to -25.6; P = .004] and extubation time (MD, -196.0 minutes; 95% CIs, -305.2 to -86.8; P < .001) compared with IV sedation (midazolam or propofol). No differences in the lengths of ICU and hospital stay were noted between the 2 groups. In the analysis of cardiac effects of sedation from 5 studies, patients who received volatile sedation showed lower serum troponin levels 6 hours after ICU admission than patients who received IV sedation (P < .05). The effect size of troponin was largest between 12 and 24 hours after ICU admission (MD, -0.27 µg/L; 95% CIs, -0.44 to -0.09; P = .003). CONCLUSION: Compared with IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times. Considering the difference in serum troponin levels between both arms, volatile anesthetics might have a myocardial protective effect after cardiac surgery even at a subanesthetic dose. Because the included studies used small sample sizes with high heterogeneity, further large, high-quality prospective clinical trials are needed to confirm our findings.