Effect of Sevoflurane Anesthesia on Diastolic Function: A Prospective Observational Study.

BACKGROUND: The effect of sevoflurane on left ventricular diastolic function is not well understood. We hypothesized that parameters of diastolic function may improve under sevoflurane anesthesia in patients with preexisting diastolic dysfunction compared to patients with normal diastolic function. METHODS: This observational study included 60 patients undergoing breast surgery or laparoscopic cholecystectomy. Patients were assigned to diastolic dysfunction (n = 34) or normal (n = 26) groups of septal e' < 8 or ≥ 8.0 cm/s on the first thoracic echocardiography (TTE) performed before anesthesia. During anesthesia, sevoflurane was maintained at 1 to 2 minimum alveolar concentration (MAC) to maintain the bispectral index at 40 to 50. At the end of surgery, the second TTE was performed under 0.8 to 1 MAC of sevoflurane with the patient breathing spontaneously without ventilator support. Primary end point was the percentage change (Δ) of e' on 2 TTEs (Δe'). Secondary end points were ΔE/e', Δleft atrial volume index (ΔLAVI), and Δtricuspid regurgitation maximum velocity (ΔTR Vmax). These percentage changes (Δ) were compared between diastolic dysfunction and normal groups. RESULTS: e' (Δe': 30 [6, 64] vs 0 [-18, 11]%; P < .001), mitral inflow E wave velocity (E), mitral inflow E/A ratio (E/A), and mitral E velocity deceleration time (DT) improved significantly in diastolic dysfunction group compared to normal group. LAVI decreased in diastolic dysfunction group but did not reach statistical significance between the 2 groups (ΔLAVI:-15 [-31, -3] vs -4 [-20, 10]%, P = .091). ΔE/e' was not different between the 2 groups (11 [-16, 26] vs 12 [-9, 22]%, P = .853) (all: median [interquartile range, IQR]). TR was minimal in both groups. CONCLUSIONS: In this study, echocardiographic parameters of diastolic function, including septal e', E, E/A, and DT, improved with sevoflurane anesthesia in patients with preexisting diastolic dysfunction, but remained unchanged in patients with normal diastolic function.

Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices.

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.

Comparison of Early and Late Surgeries after Coronary Stent Implantation in Patients with Normal Preoperative Troponin Level: A Retrospective Study.

Current guidelines recommend delaying noncardiac surgery for 6 months after drug eluting stent implantation. However, this recommendation is largely based on limited evidence and various event definitions. Whether early surgery within 6 months of coronary stent implantation increases myocardial injury in patients with normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) has not yet been investigated. This retrospective study assessed patients who received coronary stent implantation and underwent noncardiac surgery (vascular, abdominal, or thoracic) between 2010 and 2017 with normal preoperative hs-cTnI (n = 186). Patients were divided into early (within 6 months of PCI) and late (after 6 months of PCI) groups. The primary endpoint was the incidence of myocardial injury as diagnosed by hs-cTnI within 3 days post-operation. The secondary outcomes were myocardial infarction, stent thrombosis, emergent coronary revascularization, major bleeding (bleeding requiring transfusion or intracranial bleeding), stroke, renal failure, heart failure, or death within 30 days post-operation. Inverse probability treatment weighting (IPTW) was carried out to adjust for the intergroup baseline differences. Myocardial injury occurred in 28.6% (8/28) and 27.8% (44/158) of the early and late groups, respectively, with no difference between groups (odds ratio [OR] 1.067, 95% confidence interval [CI] 0.404, 2.482; p = 0.886). Secondary outcomes did not differ between the groups. IPTW analysis also showed no differences in myocardial injury and secondary outcomes between the groups. In conclusion, early surgery within 6 months after coronary stent implantation did not increase the incidence of myocardial injury in patients with normal preoperative hs-cTnI.

Infection Prevention Measures for Surgical Procedures during a Middle East Respiratory Syndrome Outbreak in a Tertiary Care Hospital in South Korea.

In 2015, we experienced the largest in-hospital Middle East respiratory syndrome (MERS) outbreak outside the Arabian Peninsula. We share the infection prevention measures for surgical procedures during the unexpected outbreak at our hospital. We reviewed all forms of related documents and collected information through interviews with healthcare workers of our hospital. After the onset of outbreak, a multidisciplinary team devised institutional MERS-control guidelines. Two standard operating rooms were converted to temporary negative-pressure rooms by physically decreasing the inflow air volume (-4.7 Pa in the main room and -1.2 Pa in the anteroom). Healthcare workers were equipped with standard or enhanced personal protective equipment according to the MERS-related patient's profile and symptoms. Six MERS-related patients underwent emergency surgery, including four MERS-exposed and two MERS-confirmed patients. Negative conversion of MERS-CoV polymerase chain reaction tests was noticed for MERS-confirmed patients before surgery. MERS-exposed patients were also tested twice preoperatively, all of which were negative. All operative procedures in MERS-related patients were performed without specific adverse events or perioperative MERS transmission. Our experience with setting up a temporary negative-pressure operation room and our conservative approach for managing MERS-related patients can be referred in cases of future unexpected MERS outbreaks in non-endemic countries.

Non-intubated video-assisted thoracoscopic lung biopsy for interstitial lung disease: a single-center experience.

BACKGROUND: The mortality and morbidity associated with video-assisted thoracoscopic (VATS) lung biopsy for interstitial lung disease (ILD) are not negligible. We evaluated whether non-intubated VATS lung biopsy, which avoids intubation and general anesthesia, can be safely performed in ILD subjects. METHODS: This retrospective study compared the incidence of complications and surgical mortality between 25 consecutive intubated subjects and 10 non-intubated subjects (a total of 35 consecutive subjects) at a single institution. RESULTS: No major surgical complications or deaths were reported in either group, and non-intubated VATS biopsies were safely performed in subjects with relatively low carbon monoxide diffusing capacity (P=0.08) or poor American Society of Anesthesiologists physical status scores (ASA) (P=0.02). CONCLUSIONS: These preliminary results suggest that non-intubated VATS lung biopsy is a safe and feasible option in patients with ILD.

Preoperative depressed mood and perioperative heart rate variability in patients with hepatic cancer.

STUDY OBJECTIVE: How perioperative heart rate variability (HRV) indices differ according to the anxiety or depressed mood of patients scheduled to undergo a major surgical procedure for cancer. DESIGN: Prospective observational study. SETTING: Operating room. PATIENTS: Forty-one male patients between 40 and 70 years of age with hepatocellular carcinoma were included in the final analysis. INTERVENTIONS: HRV was measured on the day before surgery (T1), impending anesthesia (T2), and after anesthetic induction (T3). Preoperative anxiety and depressed mood of all patients were evaluated using the State-Trait Anxiety Inventory and Self-Rating Depression Scale (SDS). MEASUREMENTS AND RESULTS: HRV was significantly different among T1, T2, and T3. At T2, high frequency (HF) (normalized units of HF [nuHF]) was decreased and low frequency (LF) (normalized units of LF) and LF/HF were increased compared with those at T1 and T3. In the subgroup analysis between high and low SDS groups, high SDS group showed significantly decreased nuHF (P = .035), increased nuLF (P = .039), and increased LF/HF (P = .020) compared to low SDS group at T1. However, these values at T2 and T3 were not different between 2 groups. In analysis within the groups, low SDS group showed significant differences in nuHF, nuLF, and LF/HF among T1, T2, and T3 (P < .05, respectively), but no changes in these values were observed in high SDS group among the 3 different time points. CONCLUSIONS: HRV decreased significantly immediately before anesthesia and recovered to baseline with anesthetic induction. Preoperative, more depressed patients showed increased sympathetic tone at baseline and blunted response to impending anesthesia on the HRV measurements.

The Fast and Easy Way for Double-Lumen Tube Intubation: Individual Angle-Modification.

UNLABELLED: To find the faster and easier way than the existing intubating technique for double-lumen tube, we modified the angle of double-lumen tube according to an individual's upper airway anatomy and compared the time needed and the number of attempts for successful intubation between individually angle-modified and non-modified double-lumen tubes. Adult patients undergoing elective thoracic surgery were randomly allocated in either non-angle-modified (Group N, n = 54) or angle-modified (Group M, n = 54) groups. During mask ventilation in the sniffing position, angle-modification was performed in Group M as follows: the distal tip of the tube was placed at the level of the cricoid cartilage and the shaft was bent at the intersection of the oral and pharyngeal axes estimated from the patient's surface anatomy. The time needed and the number of attempts for successful intubation and Cormack and Lehane (C-L) grade were recorded. Overall median intubation time (sec) was significantly shorter in Group M than in Group N [10.2 vs. 15.1, P<0.001]. In addition, Group M showed the shorter median intubation time (sec) in C-L grades I-III [8.2 vs. 11.1 in C-L grade I, (P = 0.003), 10.3 vs. 15.3 in II, (P = 0.001), and 11.8 vs. 27.9 in III, (P<0.001), respectively]. Moreover, all intubation was successfully performed at the first attempt in patients with C-L grades I-III in Group M (P = 0.027). Our study showed an individual angle-modification would be useful for the fast and easy intubation of double-lumen tube in patients with C-L grades I-III. TRIAL REGISTRATION: ClinicalTrials.gov NCT02190032.

Comparison Between Phenylephrine and Dopamine in Maintaining Cerebral Oxygen Saturation in Thoracic Surgery: A Randomized Controlled Trial.

Fluid is usually restricted during thoracic surgery, and vasoactive agents are often administered to maintain blood pressure. One-lung ventilation (OLV) decreases arterial oxygenation; thus oxygen delivery to the brain can be decreased. In this study, we compared phenylephrine and dopamine with respect to maintaining cerebral oxygenation during OLV in major thoracic surgery.Sixty-three patients undergoing lobectomies were randomly assigned to the dopamine (D) or phenylephrine (P) group. The patients' mean arterial pressure was maintained within 20% of baseline by a continuous infusion of dopamine or phenylephrine. Maintenance fluid was kept at 5 mL/kg/h. The depth of anesthesia was maintained with desflurane 1MAC and remifentanil infusion under bispectral index guidance. Regional cerebral oxygen saturation (rScO2) and hemodynamic variables were recorded using near-infrared spectroscopy and esophageal cardiac Doppler.The rScO2 was higher in the D group than the P group during OLV (OLV 60 min: 71 ±â€Š6% vs 63 ±â€Š12%; P = 0.03). The number of patients whose rScO2 dropped more than 20% from baseline was 0 and 6 in the D and P groups, respectively (P = 0.02). The D group showed higher cardiac output, but lower mean arterial pressure than the P group (4.7 ±â€Š1.0 vs 3.9 ±â€Š1.2 L/min; 76.7 ±â€Š8.1 vs 84.5 ±â€Š7.5 mm Hg; P = 0.02, P = 0.02). Among the variables, age, hemoglobin concentration, and cardiac output were associated with rScO2 by correlation analysis.Dopamine was superior to phenylephrine in maintaining cerebral oxygenation during OLV in thoracic surgery.

Is Preoperative Biochemical Testing for Pheochromocytoma Necessary for All Adrenal Incidentalomas?

This study examined whether imaging phenotypes obtained from computed tomography (CT) can replace biochemical tests to exclude pheochromocytoma among adrenal incidentalomas (AIs) in the preoperative setting.We retrospectively reviewed the medical records of all patients (n = 251) who were admitted for operations and underwent adrenal-protocol CT for an incidentally discovered adrenal mass from January 2011 to December 2012. Various imaging phenotypes were assessed for their screening power for pheochromocytoma. Final diagnosis was confirmed by biopsy, biochemical tests, and follow-up CT.Pheochromocytomas showed similar imaging phenotypes as malignancies, but were significantly different from adenomas. Unenhanced attenuation values ≤10 Hounsfield units (HU) showed the highest specificity (97%) for excluding pheochromocytoma as a single phenotype. A combination of size ≤3 cm, unenhanced attenuation values ≤ 10 HU, and absence of suspicious morphology showed 100% specificity for excluding pheochromocytoma.Routine noncontrast CT can be used as a screening tool for pheochromocytoma by combining 3 imaging phenotypes: size ≤3 cm, unenhanced attenuation values ≤10 HU, and absence of suspicious morphology, and may substitute for biochemical testing in the preoperative setting.

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.

Potentially modifiable risk factors for acute kidney injury after surgery on the thoracic aorta: a propensity score matched case-control study.

Perioperative risk factors were identified for acute kidney injury (AKI) defined by the RIFLE criteria (RIFLE = risk, injury, failure, loss, end stage) after surgery on the thoracic aorta with cardiopulmonary bypass (CPB) in this case-control study. A retrospective review was completed for 702 patients who underwent surgery on the thoracic aorta with CPB. A total of 183 patients with AKI were matched 1:1 with patients without AKI by a propensity score. Matched variables included age, gender, body-mass index, preoperative creatinine levels, estimated glomerular filtration rate, a history of hypertension, diabetes mellitus, cerebrovascular accident, smoking history, or chronic obstructive pulmonary disease to exclude the influence of patient demographics, preoperative medical status, and baseline renal function. Multivariate logistic regression analysis was used to evaluate for independent risk factors in the matched sample of 366 patients. The incidence of AKI was 28.6% and 5.9% of patients from the entire sample required renal replacement therapy. AKI was associated with a prolonged postoperative hospital stay and a higher one-month and one-year mortality both in the entire and matched sample set. Independent risk factors for AKI were a left ventricular ejection fraction <55%, preoperative hemoglobin level <10 g/dL, albumin <4.0 g/dL, diagnosis of dissection, operation time >7 hours, deep hypothermic circulatory arrest (DHCA) time >30 min, pRBC transfusion >1000 mL, and FFP transfusion >500 mL. Although the incidence of poor glucose control (blood glucose >180 mg/dL) was higher in patients with AKI in matched sample, it was not an independent risk factor.AKI was still associated with a poor clinical outcome in the matched sample. Potentially modifiable risk factors included preoperative anemia and hypoalbuminemia. Efforts to minimize operation time and DHCA time along with transfusion amount may protect patients undergoing aortic surgery against AKI.

Effect of pre-warmed intravenous fluids on perioperative hypothermia and shivering after ambulatory surgery under monitored anesthesia care.

PURPOSE: The aim of this study was to evaluate the effects of pre-warmed (approximately 41 °C) intravenous fluids (IV) on perioperative hypothermia and postoperative shivering in female patients undergoing short, ambulatory urological surgery under monitored anesthesia care (MAC). METHODS: Patients between the ages of 35 and 80 years were randomly assigned to either the pre-warmed (n = 27) or the room temperature (n = 26) group. According to group allocation, either pre-warmed IV fluids that had been stored in a warming cabinet for at least 8 h or room temperature IV fluids were administered intraoperatively up to approximately 600-700 ml, including a bolus infusion of 10 ml/kg within 20 min. Perioperative core temperatures at the tympanic membrane, postoperative shivering, subjective thermal comfort, and the use of forced-air warming interventions in the post-anesthesia care unit (PACU) were recorded. RESULTS: Mean core temperatures were significantly higher in the pre-warmed group than they were in the room temperature group after 10 ml/kg preload fluid was administered, at the end of the operation, and on admission to the PACU (p = 0.004, p = 0.02, and p = 0.008, respectively). The incidence of hypothermia (<36 °C) was significantly lower in the pre-warmed group (n = 4) than in the room temperature group (n = 11, p = 0.035) upon PACU admission. The postoperative shivering incidence was also significantly lower in the pre-warmed group (n = 2) than in the room temperature group (n = 8, p = 0.039). CONCLUSIONS: Infusion of pre-warmed IV fluid improved the postoperative recovery profile by decreasing hypothermia and shivering in female patients undergoing short, ambulatory urological surgery under MAC.

Fibrinogen recovery and changes in fibrin-based clot firmness after cryoprecipitate administration in patients undergoing aortic surgery involving deep hypothermic circulatory arrest.

BACKGROUND: Cryoprecipitate may be used to treat bleeding in cardiac surgery. Its effects on plasma fibrinogen and fibrin clotting in this setting are poorly defined. STUDY DESIGN AND METHODS: Patients undergoing on-pump aortic surgery with deep hypothermic circulatory arrest (DHCA) were recruited prospectively. After protamine reversal, cryoprecipitate was administered to patients with bleeding, and fibrin deficit was indicated by thromboelastometry (ROTEM)-based FIBTEM test. Coagulation was assessed using ROTEM-based tests and standard laboratory tests before and after cryoprecipitate. RESULTS: Thirteen patients were included. Cryoprecipitate significantly elevated EXTEM A10 from (mean ± standard deviation) 29.4 ± 5.8 to 34.8 ± 5.9 mm (p = 0.01), FIBTEM A10 from 3.5 ± 0.9 to 5.8 ± 1.7 mm (p = 0.04), and plasma fibrinogen concentration from 154.2 ± 25.6 to 193.4 ± 30.5 mg/dL (p = 0.01). EXTEM clot elasticity at 10 minutes (CE10) increased from 42.5 ± 12.0 to 54.7 ± 14.9 mm after cryoprecipitate (30.0% increase). FIBTEM CE10 increased from 3.7 ± 0.9 to 6.2 ± 2.0 mm (53.0% increase). A fibrinogen dose of 13.2 ± 5.2 mg/kg was required to increase FIBTEM A10 by 1 mm. In vivo recovery of fibrinogen was 61.6 ± 31.2%. CONCLUSIONS: Cryoprecipitate increased plasma fibrinogen levels and fibrin-based clotting in bleeding patients undergoing aortic surgery with DHCA. In vivo recovery of fibrinogen was considerably below 100% and fibrinogen content varied between cryoprecipitate units. Trials are needed to assess whether cryoprecipitate impacts clinical outcomes and to evaluate its safety.

Simplified clinical risk score to predict acute kidney injury after aortic surgery.

OBJECTIVE: The authors identified risk factors for acute kidney injury (AKI) defined by risk, injury, failure, loss, end-stage (RIFLE) criteria after aortic surgery with cardiopulmonary bypass and constructed a simplified risk score for the prediction of AKI. DESIGN: Retrospective and observational. SETTING: Single large university hospital. PARTICIPANTS: Patients (737) who underwent aortic surgery with cardiopulmonary bypass between 1997 and 2010. MAIN RESULTS: Multivariate logistic regression analysis was used to evaluate risk factors. A scoring model was developed in a randomly selected derivation cohort (n = 417), and was validated on the remaining patients. The scoring model was developed with a score based on regression ß-coefficient, and was compared with previous indices as measured by the area under the receiver operating characteristic curve (AUC). The incidence of AKI was 29.0%, and 5.8% required renal replacement therapy. Independent risk factors for AKI were age older than 60 years, preoperative glomerular filtration rate <60 mL/min/1.73 m(2), left ventricular ejection fraction <55%, operation time >7 hours, intraoperative urine output <0.5 mL/kg/h, and intraoperative furosemide use. The authors made a score by weighting them at 1 point each. The risk score was valid in predicting AKI, and the AUC was 0.74 [95% confidence interval (CI): 0.69 to 0.79], which was similar to that in the validation cohort: 0.74 (95% CI: 0.69 to 0.80; p = 0.97). The risk-scoring model showed a better performance compared with previously reported indices. CONCLUSIONS: The model would provide a simplified clinical score stratifying the risk of postoperative AKI in patients undergoing aortic surgery.

The effect of passive leg elevation and/or trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children undergoing surgery for congenital heart disease.

BACKGROUND: In this study we evaluated the effect of passive leg elevation (LE) and Trendelenburg (T) position on the cross-sectional area (CSA) of the internal jugular vein (IJV) in infants and young children undergoing surgery for congenital heart disease. A secondary aim was to compare the CSA of the IJV between subjects with right-to-left (RL) shunt and left-to-right (LR) shunt. METHODS: Ninety infants and small children from 10 days to 31 months old weighing from 1.5 to 9.7 kg were assigned to group RL (n = 48) or LR (n = 42). In both groups, the CSA, transverse, and vertical diameters of the IJV on both sides of the neck were measured using a 2-dimensional ultrasound transducer in the following positions: supine position, 15° of T position, supine position with 50° of LE, and 15° of Trendelenburg position with 50° of LE (TLE). A more than 25% increase in mean CSA of the IJV was considered clinically significant. RESULTS: In group LR, T, LE, and TLE significantly increased CSA of both right (at least 12.3%, 10.3%, and 18.3%, respectively, "at least" refers to the lower 95% confidence limits) and left (at least 15.8%, 15.0%, and 18.9%, respectively) IJVs, whereas only TLE increased the CSA of both IJVs significantly in group RL (at least 8.2% and 7.7% in the right and left, respectively). The increase in the CSA of the right IJV related to T and TLE was larger in group LR than in group RL (at least 12.3% vs 1.2% for T and at least 18.3% vs 8.2% for TLE, respectively). A clinically significant increase in CSA was achieved in both right and left IJVs with TLE in group LR (mean 28.6% and 26.3%, respectively). The CSA of the right IJV was larger than that of the left IJV in most (at least 69.2%) patients. CONCLUSIONS: Passive LE was as effective as T position to increase the CSA of the IJV, but there was no clinically significant increase in the CSA with any single maneuver. Only T position with passive LE achieved a clinically significant increase in the CSA of both IJVs in infants and young children with LR shunt, but not in the same age group with RL shunt.

The effect of patient-controlled intravenous analgesia on postoperative hypokalemia in patients undergoing laparoscopic cholecystectomy.

PURPOSE: We investigated whether hypokalemia developed during the postoperative period and whether the use of intravenous patient-controlled analgesia (IV-PCA) could decrease the incidence of postoperative hypokalemia in patients who underwent laparoscopic cholecystectomy. METHODS: Sixty patients undergoing laparoscopic cholecystectomy were randomly assigned to either IV-PCA (n = 30) or control (n = 30) groups. We measured serum potassium concentration at the outpatient department (T1), at 8:00 a.m. on the day of surgery (T2), at 6 h after the end of surgery (T3), and at 8:00 a.m. on the first (T4), second (T5), and third (T6) postoperative days. Serum potassium concentration, incidence of hypokalemia, mean blood pressure, heart rate, respiratory rate, and the patient-reported visual analogue scale score were compared within each group and between groups at each time point. RESULTS: Serum potassium concentrations in all patients showed a significant decrease at T2-T4 compared to the preoperative concentration (T1). Serum potassium concentrations at T3 and T4 in the IV-PCA group were significantly higher than those in the control group. Also, the incidence of hypokalemia at T3 and T4 was significantly lower in the IV-PCA group. Mean blood pressure and heart rate were significantly lower in the IV-PCA group than in controls at T3 and T4. CONCLUSIONS: The results show that hypokalemia developed during the perioperative period and the use of IV-PCA in patients undergoing laparoscopic cholecystectomy effectively decreased the degree and incidence of postoperative hypokalemia on the day of the operation and postoperative day one.

Use of fibrin-based thromboelastometry for cryoprecipitate transfusion in cardiac surgery involving deep hypothermic circulatory arrest during cardiopulmonary bypass.

We aimed to assess the predictive value of fibrin-based thromboelastometry performed before weaning from cardiopulmonary bypass (CPB) for cryoprecipitate administered to correct the bleeding diathesis after CPB involving deep hypothermic circulatory arrest. Eleven patients undergoing aortic surgery were enrolled. The arterial blood was withdrawn before skin incision, 30 min before CPB weaning (Cweaning), 5 min after protamine reversal (Preversal) and at closure of the sternum to run intrinsically activated INTEM, heparinase-treated HEPTEM, extrinsically activated EXTEM and platelet-inhibited FIBTEM analysis, platelet count, fibrinogen, prothrombin time (international normalized ratio) and activated partial thromboplastin time. The predicted value of FIBTEM A10 obtained during CPB for cryoprecipitate transfusion at Preversal was calculated. The cut-off points for FIBTEM A10 to reflect fibrinogen of 200 mg/dl at Preversal were 5 mm (P = 0.15). FIBTEM A10 at Preversal and Cweaning showed correlations as follows: FIBTEM A10 at Preversal = 0.02 + 1.42 × FIBTEM A10 at Cweaning (r² = 0.80). The cut-off value for FIBTEM A10 at Cweaning to determine whether to prepare cryoprecipitate in advance during CPB was calculated to be 3 mm, and the positive and negative predictability for FIBTEM A10 of 3 or less versus more than 3 at Cweaning for the necessity of cryoprecipitate transfusion at Preversal (A10 ≤ 5 versus > 5) were 100 and 80%, respectively. This study showed that fibrinogen reflected in FIBTEM during pump can be used to estimate FIBTEM after Preversal and the amount of cryoprecipitate needed for replacing mainly the fibrinogen could be predicted with high sensitivity and specificity.

Hemostatic and electrolyte effects of hydroxyethyl starches in patients undergoing posterior lumbar interbody fusion using pedicle screws and cages.

STUDY DESIGN: Prospective, randomized, double blind, clinical study. OBJECTIVE: To compare the hemostatic and electrolyte effects of 2 commonly administered hydroxyethyl starches (HES) in patients undergoing posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND DATA: HES are commonly administered colloid solutions to restore and maintain intravascular volume before transfusion is initiated. However, infusion of HES itself can impair coagulation. HES-induced coagulopathy could be a serious problem in PLIF which involves continuous bone bleeding and oozing. Voluven (Fresenius Kabi, Germany), previously regarded as the least coagulopathic due to its low molecular weight (MW) and degree of substitution (DS), is a saline-based HES. Hextend (Biotime, United States) is a new type of HES with physiologic pH and balanced electrolytes, including calcium, which is beneficial to coagulation. Studies comparing the coagulopathy of Hextend and Voluven are rare. Therefore, coagulation, pH/electrolyte changes, and blood loss using Hextend and Voluven in patients undergoing PLIF were compared. METHODS.: Fifty-four patients scheduled for PLIF involving 3 vertebrae or less were randomly assigned to the Voluven or the Hextend group. Of each solution 15 mL/kg was administered during surgery. Blood loss, coagulation, and electrolyte profiles were checked before infusion and 5 minutes, 3 hours, and 24 hours after the end of infusion. RESULTS: The Hextend group showed slightly better electrolyte balance, however, more coagulation impairment and postoperative transfusion (37% vs. 11%) compared with the Voluven group. The effect of Hextend on coagulation lasted until 24 hours after infusion. CONCLUSION: If coagulopathy is a concern during PLIF, then, a HES with low MW/DS in a saline-based medium (Voluven) may be a better alternative than a HES with high MW/DS in a balanced salt medium (Hextend).

Transesophageal echocardiography (TEE)-induced Mallory-Weiss laceration in a patient who underwent aortic and mitral valve replacement -A case report-.

Transesophageal echocardiography (TEE) is a relatively noninvasive and highly valuable diagnostic modality to monitor cardiac surgery. TEE is utilized to estimate the results of the surgical correction or the cardiac function on a real time basis. Accordingly, the frequency of TEE usage is increasing. Previous studies have shown low risk of TEE-associated complications; nonetheless, major gastrointestinal trauma can occur on a rare occasion. We herein present a case of Mallory-Weiss laceration after an intraoperative TEE examination.

Protective effects of gabapentin on allodynia and alpha 2 delta 1-subunit of voltage-dependent calcium channel in spinal nerve-ligated rats.

This study was designed to determine whether early gabapentin treatment has a protective analgesic effect on neuropathic pain and compared its effect to the late treatment in a rat neuropathic model, and as the potential mechanism of protective action, the alpha(2)delta(1)-subunit of the voltage-dependent calcium channel (alpha(2)delta(1)-subunit) was evaluated in both sides of the L5 dorsal root ganglia (DRG). Neuropathic pain was induced in male Sprague-Dawley rats by a surgical ligation of left L5 nerve. For the early treatment group, rats were injected with gabapentin (100 mg/kg) intraperitoneally 15 min prior to surgery and then every 24 hr during postoperative day (POD) 1-4. For the late treatment group, the same dose of gabapentin was injected every 24 hr during POD 8-12. For the control group, L5 nerve was ligated but no gabapentin was administered. In the early treatment group, the development of allodynia was delayed up to POD 10, whereas allodynia was developed on POD 2 in the control and the late treatment group (p<0.05). The alpha(2)delta(1)-subunit was up-regulated in all groups, however, there was no difference in the level of the alpha(2)delta(1)-subunit among the three groups. These results suggest that early treatment with gabapentin offers some protection against neuropathic pain but it is unlikely that this action is mediated through modulation of the alpha(2)delta(1)-subunit in DRG.