Impact of Hepatic Portal Venous Gas on the Prognosis of Traumatic Out-of-Hospital Cardiac Arrest: A Reason to Consider Terminating Cardiopulmonary Resuscitation.

Background: We evaluated the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) by assessing the presence of hepatic portal vein gas (HPVG) observed in ultrasound (US) or point-of-care ultrasonography (POCUS) performed during CPR. Furthermore, we aimed to understand the role of HPVG in decision-making regarding CPR discontinuation or withholding in traumatic OHCA. Methods: The retrospective study was conducted at the level 1 trauma center of urban academic medical centers in South Korea. We included adult trauma OHCA patients who underwent CPR between January 1, 2020, and June 30, 2022. Data on traumatic OHCA patients who presented to the level I trauma center during this period were extracted from the hospital's electronic medical record system. The arrest data were separately managed through the hospital's electronic medical record system for quality control, specifically the arrest registry. US images or clips of the hepatic portal vasculature (HPV) during CPR were used to assess the presence of HPVG. These images were independently reviewed by two emergency medicine physicians with several years of US examination experience who were blinded to all clinical details and outcomes. We evaluated the prognosis of traumatic OHCA by assessing the presence of HPVG using the US. In addition, we analyzed the general characteristics and assessed the impact on the ROSC in traumatic OHCA. Results: Among the 383 cardiac arrest patients, 318 traumatic OHCA patients were included. The mean age was 54.9 ± 19.4 years, and most patients were male. The initial rhythm was mainly asystole, and falls were the most frequent cause of injury. The overall ROSC rate was 18.8%, with a survival rate of 7.2% at hospital discharge. Among the 50 patients who underwent a US examination of HPV, 40 showed HPVG. The HPVG group had a significantly lower ROSC rate and survival rate at ED discharge and hospital discharge compared to the group without HPVG. Conclusion: Traumatic OHCA with HPVG presents a significantly worse prognosis. This suggests that early consideration of termination or withholding of CPR may be appropriate in such cases.

Hemodynamic changes in the prone position according to fluid loading after anaesthesia induction in patients undergoing lumbar spine surgery: a randomized, assessor-blind, prospective study.

INTRODUCTION: A change from the supine to prone position causes hemodynamic alterations. We aimed to evaluate the effect of fluid preloading in the supine position, the subsequent hemodynamic changes in the prone position and postoperative outcomes. PATIENTS AND METHODS: This prospective, assessor-blind, randomized controlled trial was conducted between March and June 2023. Adults scheduled for elective orthopaedic lumbar surgery under general anaesthesia were enrolled. In total, 80 participants were randomly assigned to fluid maintenance (M) or loading (L) groups. Both groups were administered intravenous fluid at a rate of 2 ml/kg/h until surgical incision; Group L was loaded with an additional 5 ml/kg intravenous fluid for 10 min after anaesthesia induction. The primary outcome was incidence of hypotension before surgical incision. Secondary outcomes included differences in the mean blood pressure (mBP), heart rate, pleth variability index (PVi), stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index and cardiac index before surgical incision between the two groups. Additionally, postoperative complications until postoperative day 2 and postoperative hospital length of stay were investigated. RESULTS: Hypotension was prevalent in Group M before surgical incision and could be predicted by a baseline PVi >16. The mBP was significantly higher in Group L immediately after fluid loading. The PVi, SVV and PPV were lower in Group L after fluid loading, with continued differences at 2-3 time points for SVV and PPV. Other outcomes did not differ between the two groups. CONCLUSION: Fluid loading after inducing general anaesthesia could reduce the occurrence of hypotension until surgical incision in patients scheduled for surgery in the prone position. Additionally, hypotension could be predicted in patients with a baseline PVi >16. Therefore, intravenous fluid loading is strongly recommended in patients with high baseline PVi to prevent hypotension after anaesthesia induction and in the prone position. TRIAL NUMBER: KCT0008294 (date of registration: 16 March 2023).

Fluid preloading could reduce the occurrence of hypotension in the prone position. Hypotension could be predicted in patients with a baseline PVi >16. Intravenous fluid preloading is strongly recommended in patients with high baseline PVi to prevent hypotension after anaesthesia induction and in the prone position.

Norepinephrine prevents hypotension in older patients under spinal anesthesia with intravenous propofol sedation: a randomized controlled trial.

Reducing hypotension is crucial as hypotension is the most common side effect of spinal anesthesia, and in older patients with various comorbidities, it can lead to fatality. We hypothesized that continuous infusion of norepinephrine could effectively prevent hypotension in older patients undergoing hip surgery under spinal anesthesia with propofol sedation. The study randomly assigned patients aged ≥ 70 years to either a control (Group C, n = 35) or a norepinephrine group (Group N, n = 35). After spinal anesthesia, continuous infusion of propofol and normal saline or norepinephrine was initiated. The number of hypotensive episodes, the primary outcome, as well as other intraoperative hemodynamic events and postoperative complications were compared. In total, 67 patients were included in the final analysis. The number of hypotensive episodes was significantly higher in Group C than in Group N (p < 0.001). Furthermore, Group C required a greater amount of fluid to maintain normovolemia (p = 0.008) and showed less urine output (p = 0.019). However, there was no difference in postoperative complications between the two groups. Continuous intravenous infusion of prophylactic norepinephrine prevented hypotensive episodes, reduced the requirement of fluid, and increased the urine output in older patients undergoing unilateral hip surgery under spinal anesthesia with propofol sedation.Clinical trial registration number: KCT0005046 ( https://cris.nih.go.kr ). IRB number: 2020-0533 (Institutional Review Board of Asan Medical Center, approval date: 13/APR/2020).

Etomidate versus propofol for sedation in gastrointestinal endoscopy: A systematic review and meta-analysis of outcomes.

BACKGROUND: Propofol is increasingly being used for sedation in gastrointestinal endoscopy; however, owing to its side effects, an alternative drug is needed. We aimed to compare the safety, satisfaction, and efficacy outcomes of etomidate versus propofol in patients undergoing gastrointestinal endoscopy, including advanced endoscopic procedures. METHODS: We systematically searched Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL (via EBSCO), China National Knowledge Infrastructure, and Web of Science (1946-April 2020) databases for randomized controlled trials of gastrointestinal endoscopy (upper gastrointestinal endoscopy, colonoscopy, and advanced endoscopy) using etomidate or propofol as sedatives. We pooled odds ratios (ORs) for the safety profile and patient and anesthesiologist satisfaction using mixed-effects conditional logistic models and standardized mean differences for efficiency outcomes using random-effects models. RESULTS: Twenty-four studies involving 3875 patients were included. Compared with propofol, etomidate resulted in significantly reduced apnea (OR: 0.22; 95% confidence interval [CI]: 0.13-0.37; P < .001), hypoxemia (OR: 0.43; 95% CI: 0.35-0.54; P < .001), hypotension (OR: 0.20; 95% CI: 0.11-0.36; P < .001), and bradycardia (OR: 0.52; 95% CI: 0.30-0.91; P = .02) but led to increased myoclonus (OR: 8.54; 95% CI: 5.20-14.01; P < .001) and lowered anesthesiologist satisfaction (OR: 0.60; 95% CI: 0.39-0.91; P = .02). CONCLUSION: Etomidate may be a good alternative to propofol for gastrointestinal endoscopy, especially advanced endoscopy. Etomidate appears to be safe as an inducer for hemodynamically unstable patients or older adult patients undergoing gastrointestinal endoscopy.

Application of the New Preoperative Frailty Risk Score in Elderly Patients Undergoing Emergency Surgery.

BACKGROUND: Predicting preoperative frailty risk in emergency surgery is difficult with limited information because preoperative evaluation is not commonly performed properly. A recent study attempted to predict preoperative frailty risk using only diagnostic and surgical codes that can be extracted from the electronic medical records system. OBJECTIVE: This study aimed to validate whether the prediction model of preoperative frailty risk presented in the previous study is well applied to other medical hospitals' data. METHODS: This is a retrospective cohort study including 1,557 patients (≥75 years old) who were admitted to a single institution for emergency operations between January 1, 2010, and December 31, 2019, for study analysis. The Charlson comorbidity index, Hospital Frailty Risk Score, and the recently developed Operation Frailty Risk Score (OFRS) were calculated using the patient's diagnostic and operation codes. The predictive performances of these calculated risk scores and the American Society of Anesthesiologists-Physical Status classification for postoperative 90-day mortality were compared by using the receiver operating characteristic curve analysis. FINDINGS: The predictive performance of the OFRS, Charlson comorbidity index, American Society of Anesthesiologists-Physical Status, and Hospital Frailty Risk Score for postoperative 90-day mortality was 0.81, 0.630, 0.699, and 0.549 on a c-statistics basis, respectively. CONCLUSIONS: The OFRS using diagnostic and operation codes may show the best predictive performance for 90-day mortality compared to other risk scores, and it can be the clinically applicable model to evaluate the preoperative frailty risk in elderly patients undergoing emergency surgery.

Subretinal versus intravitreal administration of human CD34+ bone marrow-derived stem cells in a rat model of inherited retinal degeneration.

BACKGROUND: To evaluate whether subretinal or intravitreal injection of human CD34+ bone marrow-derived stem cells (BMSC) can have protective effects on retinal degeneration that may be enhanced by coadministration of exosomes harvested from human bone marrow mesenchymal stem cells (MSCs). METHODS: Human CD34+ cells were harvested from the mononuclear cell fraction of bone marrow using magnetic beads and labeled with EGFP. Exosomes were harvested from cultured human MSCs under hypoxic conditions. Royal College of Surgeons (RCS) 3-weeks-old rats, immunosuppressed with cyclosporine A, received subretinal or intravitreal injection of CD34+ cells (50,000 cells), CD34+ cells with exosomes (50,000 cells+10 µg), exosomes alone (10 µg), or PBS. Retinal function was examined using electroretinography (ERG), and the eyes were harvested for histologic and immunohistochemical analysis. RESULTS: The b-wave amplitude of ERG at 2 weeks after injection was significantly higher in eyes with subretinal or intravitreal CD34+ BMSC alone or in combination with exosomes when compared to PBS injected eyes or untreated contralateral eyes. At 4 weeks after injection, the ERG signal decreased in all groups but eyes with subretinal CD34+ BMSCs alone or combined with exosomes showed partially preserved ERG signal and preservation of the outer nuclear layer of the retina near the injection site on histology when compared to eyes with PBS injection. Immunohistochemical analysis identified the human cells in the outer retina. Subretinal or intravitreal exosome injection had no effect on retinal degeneration when administered alone or in combination with CD34+ cells. CONCLUSIONS: Both subretinal and intravitreal injection of human CD34+ BMSCs can provide functional rescue of degenerating retina, although the effects were attenuated over time in this rat model. Regional preservation of the outer retina can occur near the subretinal injection site of CD34+ cells. These results suggest that CD34+ cells may have therapeutic potential in retinal degeneration.

Correlation between the Perfusion Index and Intraoperative Hypothermia: A Prospective Observational Pilot Study.

Background and Objectives: We examined the association between the baseline perfusion index (PI) and changes in intraoperative body temperature during general anesthesia. The PI reflects the peripheral perfusion state. The PI may be associated with changes in body temperature during general anesthesia because the degree of redistribution of body heat from the central to the peripheral compartment varies depending on the peripheral perfusion state. Materials and Methods: Thirty-eight patients who underwent brain surgery were enrolled in this study. The baseline PI and body temperature of the patients were measured on entering the operating room. Body temperature was recorded every 15 min after induction of anesthesia using an esophageal temperature probe. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for intraoperative hypothermia. Results: Eighteen patients (47 %) developed hypothermia intraoperatively. The baseline PI was significantly lower among patients in the hypothermia group (1.8 ± 0.7) than among those in the normothermia group (3.0 ± 1.2) (P < 0.001). The baseline PI and body temperature were independently associated with intraoperative hypothermia (PI: odds ratio [OR], 0.270; 95% confidence interval [CI], 0.105-0.697; P = 0.007, baseline body temperature: OR, 0.061; 95% CI, 0.005-0.743; P = 0.028). Conclusions: This study showed that low baseline PI was the factor most related to the development of intraoperative hypothermia. Future studies should consider the PI as a predictor of intraoperative hypothermia.

Long-term Prognosis of Localized Lymphoid Hyperplasia of the Rectum.

Background/Aims: Although localized lymphoid hyperplasia (LLH) of the rectum is occasionally observed, its clinical implications are unclear. This study aimed to investigate the clinical course and significance of LLH of the rectum. Methods: We identified 65 patients diagnosed with LLH of the rectum using a histopathologic examination and who received follow-up endoscopies between January 2009 and June 2015. Patients with a history of inflammatory bowel disease, lymphoma, familial adenomatous polyposis, or uncontrolled malignancy and patients who underwent scar biopsy after endoscopic resection or surgery were excluded. Endoscopic findings and clinical courses were analyzed. Results: During the median follow-up of 31 months (interquartile range, 19 to 40 months), 81.5% (53/65) of LLHs of the rectum were resolved. Clinically significant diseases, including ulcerative colitis (UC, n=5) and mucosa-associated lymphoid tissue (MALT) lymphoma (n=1), were diagnosed in 9.2% of patients (6/65). The other six patients showed no significant changes in the lesion (n=3) or a waxing and waning appearance (n=3). According to endoscopic findings, all of the 47 polypoid types showed resolution or waxing and waning patterns. Five of the 11 nodular types (45.5%) developed into UC. One of the seven submucosal tumor (SMT)-like types (14.3%) developed into MALT lymphoma. Conclusions: LLH of the rectum with persistent symptoms or the endoscopic appearance of the nodular or SMT-like type may lead to clinically significant disease. Risk stratification according to endoscopic findings and careful surveillance are required for these lesions.

Transforaminal Epiduroscopic Laser Ablation for Removal of a Postlaminectomy Synovial Cyst: A Case Report.

Background: Synovial cysts rarely occur after a laminectomy and are difficult to detect if there are no symptoms; however, they can cause lower back pain or symptoms of radiculopathy. Various methods are used to treat synovial cysts. Here, we will introduce the first case with treatment using the transforaminal epiduroscopic laser annuloplasty (TELA) system. Case report: A 64-year-old female patient visited the pain clinic with lower back pain and pain radiating from the left lower extremity. An MRI T2 image showed a synovial cyst of facet joint origin at the L4-L5 level; the patient had undergone a laminectomy 10 years ago at the same spinal level. The patient rated the pain an 8 on the numerical rating scale (NRS), and pain was reduced after epidural steroid injection, but symptoms recurred a month later. The cyst ablation was performed using the TELA system with a 1414 nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, and after the procedure, pain decreased to 4 points immediately and was reduced to 2 points on the NRS after 1 week. Six months after the procedure, the pain level was measured on NRS 2 and cyst was not recurred in the additional MRI. Conclusion: We introduced the TELA system as a noninvasive therapy for treating synovial cysts. Ablation of cystic necks using a 1414 nm Nd:YAG laser could be a method to prevent cyst recurrence, but long-term follow-up and large scale control studies will be needed to verify the effectiveness of this method.

Efficacy and Tolerability of Prucalopride in Bowel Preparation for Colonoscopy: A Systematic Review and Meta-Analysis.

INTRODUCTION: Adequate bowel preparation is a vital determinant for the success of colonoscopy. However, individuals who undergo bowel preparation for colonoscopy can experience major discomfort. To solve this problem, adding prucalopride to the prepared solution may reduce intake volume, decreasing discomfort and side effects. We performed meta-analyses and systematic review of available randomized controlled trials. METHODS: Meta-analyses were conducted to evaluate the overall relative risk and 95% confidence intervals in the combined studies for the assessment of primary outcome, which is the efficacy of bowel preparation with the addition of prucalopride. RESULTS: Four randomized controlled trials involving 581 patients were included. When data were pooled for all patients in two non-inferiority studies, no significant difference in the quality of bowel preparation was observed between patients receiving prucalopride plus bowel preparation solution at a lower volume and those receiving the existing solution (relative risk: 0.94; 95% confidence interval: 0.86-1.03). The effects of prucalopride on acceptability, adverse events, adenoma detection rate, and polyp detection rate did not significantly differ from those of traditional solutions. CONCLUSIONS: The combination of prucalopride and bowel preparation solution at a lower volume has similar effects on bowel preparation, and its use did not increase the occurrence of adverse effects.

Genome-wide analysis of RopGEF gene family to identify genes contributing to pollen tube growth in rice (Oryza sativa).

BACKGROUND: In plants, the key roles played by RopGEF-mediated ROP signaling in diverse processes, including polar tip growth, have been identified. Despite their important roles in reproduction, a comprehensive analysis of RopGEF members has not yet been performed in rice (Oryza sativa). To determine whether RopGEF regulators are involved in rice pollen tube growth, we performed genome-wide analysis of this family in rice. RESULTS: Phylogenomic and meta-expression analysis of eleven RopGEFs in rice showed that four genes were preferentially expressed in mature pollen. These four genes contain the plant-specific Rop nucleotide exchanger (PRONE) domain and possible phosphorylated residues, suggesting a conserved role in polar tip growth with Arabidopsis thaliana. In subcellular localization analysis of the four RopGEFs through tobacco (Nicotiana benthamiana) infiltration, four proteins were predominantly identified in plasma membrane. Moreover, double mutants of RopGEF2/8 exhibited reduced pollen germination, causing partial male sterility. These genes possess unique cis-acting elements in their promoters compared with the other RopGEF genes. CONCLUSIONS: In this study, four RopGEF genes were identified as pollen-specific gene in eleven members of rice, and the expression pattern, promoter analysis, and evolutionary relationship of the RopGEF family were studied compared with Arabidopsis. Our study indicated that four RopGEF genes might function during pollen germination in distinct subcellular localization. Our study could provide valuable information on the functional study of RopGEF in rice.

Intraocular pressure (IOP) after intravitreal dexamethasone implant (Ozurdex) amongst different geographic populations-GEODEX-IOP study.

PURPOSE: To analyse the intraocular pressure rise after intravitreal dexamethasone implant (Ozurdex) amongst different geographic populations. METHODS: The medical charts of 294 dexamethasone implants between February 2011 and 2017 were reviewed retrospectively. South Asian (India), White (Europe, US and Israel) Latino (Argentina and Brazil) patient data was included in the study. Ocular hypertension (OHT) was defined as intraocular pressure of >25 mmHg or an increase of at least 10 mmHg from baseline. The main indications for treatment were diabetic macular edema (ME) (65.6%), retinal vein occlusion (26.5%), uveitis (7.8%). RESULTS: Amongst 294 intravitreal implants, ocular hypertension (>25 mmHg) was recorded in 0, 8 and 9.5% in White, Latino, and South Asian groups, respectively. However, IOP > 20 mmHg was recorded in 14%, 28% and 27% in White, Latino, and South Asian groups, respectively. Incidence of very high IOP (>35 mmHg) was lower in all geographical groups. It was 3% in Latino followed by 2% in South Asian group. CONCLUSION: Latino and South Asian groups have higher IOP rise compared to White population. Most patients with elevated IOP fluctuate between 20-25 mmHg.

CRISPR-Cas9-mediated therapeutic editing of Rpe65 ameliorates the disease phenotypes in a mouse model of Leber congenital amaurosis.

Leber congenital amaurosis (LCA), one of the leading causes of childhood-onset blindness, is caused by autosomal recessive mutations in several genes including RPE65. In this study, we performed CRISPR-Cas9-mediated therapeutic correction of a disease-associated nonsense mutation in Rpe65 in rd12 mice, a model of human LCA. Subretinal injection of adeno-associated virus carrying CRISPR-Cas9 and donor DNA resulted in >1% homology-directed repair and ~1.6% deletion of the pathogenic stop codon in Rpe65 in retinal pigment epithelial tissues of rd12 mice. The a- and b-waves of electroretinograms were recovered to levels up to 21.2 ± 4.1% and 39.8 ± 3.2% of their wild-type mice counterparts upon bright stimuli after dark adaptation 7 months after injection. There was no definite evidence of histologic perturbation or tumorigenesis during 7 months of observation. Collectively, we present the first therapeutic correction of an Rpe65 nonsense mutation using CRISPR-Cas9, providing new insight for developing therapeutics for LCA.

A new regulatory mechanism for Raf kinase activation, retinoic acid-bound Crabp1.

The rapidly accelerated fibrosarcoma (Raf) kinase is canonically activated by growth factors that regulate multiple cellular processes. In this kinase cascade Raf activation ultimately results in extracellular regulated kinase 1/2 (Erk1/2) activation, which requires Ras binding to the Ras binding domain (RBD) of Raf. We recently reported that all-trans retinoic acid (atRA) rapidly (within minutes) activates Erk1/2 to modulate cell cycle progression in stem cells, which is mediated by cellular retinoic acid binding protein 1 (Crabp1). But how atRA-bound Crabp1 regulated Erk1/2 activity remained unclear. We now report Raf kinase as the direct target of atRA-Crabp1. Molecularly, Crabp1 acts as a novel atRA-inducible scaffold protein for Raf/Mek/Erk in cells without growth factor stimulation. However, Crabp1 can also compete with Ras for direct interaction with the RBD of Raf, thereby negatively modulating growth factor-stimulated Raf activation, which can be enhanced by atRA binding to Crabp1. NMR heteronuclear single quantum coherence (HSQC) analyses reveal the 6-strand ß-sheet face of Crabp1 as its Raf-interaction surface. We identify a new atRA-mimicking and Crabp1-selective compound, C3, that can also elicit such an activity. This study uncovers a new signal crosstalk between endocrine (atRA-Crabp1) and growth factor (Ras-Raf) pathways, providing evidence for atRA-Crabp1 as a novel modulator of cell growth. The study also suggests a new therapeutic strategy by employing Crabp1-selective compounds to dampen growth factor stimulation while circumventing RAR-mediated retinoid toxicity.

An Unusual Delayed Onset of Systemic Toxicity After Fluoroscopy-Guided Cervical Epidural Steroid Injection With Levobupivacaine: A Case Report.

BACKGROUND: Cervical epidural steroid injection (CESI) with local anesthetics is commonly used to treat neck pain and radicular pain of the upper extremity. Local anesthetic systemic toxicity (LAST) occurs shortly after injection as a complication; however, delayed onset is a very rare event, especially in central nervous system (CNS) block. CASE REPORT: We present a case in which delayed onset of LAST occurred in a patient who received CESI for cervical and arm radiating pain due to a cervical disc protrusion. We performed the interlaminar approach for CESI using fluoroscopic guidance. After confirming the location of the epidural space using the loss of resistance technique and spreading of contrast agent (Telebrix® 30), a mixture of 0.25% levobupivacaine 12.5 mg (5 mL in volume), hyaluronidase 1,500 IU (1 mL), dexamethasone 5 mg (1 mL), and normal saline 3 mL was administrated. After 50 minutes of injection, the patient showed CNS toxicity (unconsciousness, seizure) with normal blood pressure and tachycardia; therefore, she was immediately sedated with intravenous midazolam (3 mg), and 15 L/min of oxygen was administered. The patient fully recovered after 30 minutes of sedation without any sequelae. CONCLUSION: Delayed onset of LAST is a rare complication of a common procedure in CESI, so it is important to be aware of this complication and the presentation of toxicity.

Life-threatening massive empyema: A novel complication of intrathoracic omental herniation.

Intrathoracic omental herniation (ITOH) is the herniation of the omentum through the esophageal hiatus without herniation of the stomach. It is a rare disease and serious complications due to ITOH have not been reported in the literature. Here, we reported the case of 47-year old man who presented to the emergency department with dyspnea and chest pain. Enhanced computed tomography (CT) demonstrated a large retrocardiac mass and ITOH was suspected. During the observation period in the emergency department, the patient's condition rapidly deteriorated. Follow-up CT showed large parapneumonic effusion and empyema. Emergency surgery was performed and the omental sac was removed. The patient's vital signs were restored and his symptoms were relieved. He was discharged on hospital day 15 without complications. Emergency physicians should be aware that severe complications of ITOH could develop and that if the patient's symptoms and vital signs worsen, emergency surgery should be considered.

Comparison of analgesic efficacy of oxycodone and fentanyl after total hip replacement surgery: A randomized controlled trial.

BACKGROUND: Total hip replacement (THR) is often accompanied by severe postoperative pain. We aimed to study whether oxycodone can be an effective alternative for fentanyl in the management of early postoperative pain after total hip replacement. METHODS: We conducted a randomized controlled trial on 46 patients scheduled to undergo THR. We followed a standard general anesthetic technique, with endotracheal intubation. Twenty minutes before the end of surgery, single bolus injection of fentanyl, 50 µg (fentanyl group [group F], n = 23) or oxycodone, 4 mg (oxycodone group [group O], n = 23) was administered intravenously. Numeric rating scale (NRS) was used to assess pain in the post-anesthesia care unit (PACU). All patients had intravenous patient-controlled analgesia (PCA) with 10 µg/kg of fentanyl for 48 hours. Intravenous boluses of 50 µg were administered for breakthrough pain. The cumulative opioid dose administered at 6, 12, 24, and 48 h after surgery were recorded. A P value of less than .05 was considered statistically significant. RESULTS: The NRS of group O in the PACU was significantly lower (P <.05); fewer patients in group O required additional fentanyl boluses in the PACU (P <.05). The cumulative opioid requirement was significantly less in group O at 6, 12, 24, and 48 hours after surgery. (P <.05) CONCLUSIONS:: A single bolus injection of oxycodone is more effective than that of fentanyl in the acute phase of postoperative pain after THR. It may be used as an alternative drug for fentanyl in pain control after orthopedic surgery.

Transthoracic radiofrequency ablation for hepatic tumor located beneath the diaphragm under one-lung ventilation: A case report.

RATIONALE: Radiofrequency ablation (RFA) has become the reliable, effective, and less invasive treatment for small primary or metastatic hepatic tumors. Hepatic tumors that located immediately beneath the diaphragm are difficult to treat with percutaneous RFA due to poor visualization by percutaneous ultrasonography and the close location of the heart or lung. A transthoracic approach has been proposed to be an alternative for hepatic tumors located beneath the diaphragm that are difficult to access by conventional percutaneous or laparoscopic approaches. There has been no report regarding the anesthetic management of the transthoracic RFA for hepatic tumor. PATIENT CONCERNS: A 69-year-old female had undergone segmentectomy due to hepatocellular carcinoma 4 years ago. DIAGNOSES: Newly developed hepatic tumor located in the liver dome and beneath the diaphragm was diagnosed by follow-up imaging study. INTERVENTIONS: Because the tumor could not be identified by transabdominal ultrasonography (US), transthoracic approach for RFA under one-lung ventilation was planned. General anesthesia was induced with propofol and remifentanil via target-controlled infusion system and rocuronium was administered. Orotracheal intubation with double-lumen endotracheal tube was performed and position of the tube in the trachea was confirmed by bronchoscope. The RFA electrode was introduced percutaneously into the right pleural cavity, guided by visualization through the thoracoscope and inserted into the tumor after visualizing the tumor by US. Radiofrequency waves can be successfully administered through the needle. OUTCOMES: We performed successfully RFA of the hepatic tumor through one-lung ventilation and transthoracic approach. At 5 days postoperatively, she was discharged in a stable condition without any complication. LESSONS: Transthoracic RFA can be successfully performed under one-lung ventilation, optimal analgesia, and vigilant monitoring.

Effect of prophylactic palonosetron and sugammadex on postoperative nausea and vomiting in patients undergoing microvascular decompression under propofol-maintained anesthesia: A retrospective observational study.

Microvascular decompression (MVD) is associated with a particularly high risk of postoperative nausea and vomiting (PONV) among craniotomy patients. However, there is no information regarding the effect of prophylactic palonosetron and sugammadex on PONV in patients undergoing MVD under propofol-maintained anesthesia.Medical records of 274 adults who had undergone MVD under propofol-maintained anesthesia were reviewed. Patients were classified into 4 groups, based on the reversal agent used (sugammadex/pyridostigmine) and whether or not prophylactic palonosetron was used. The PONV incidence and risk factors were analyzed according to the use of these agents.The overall incidence of PONV was 30.7% during the first 24 hours postoperatively. The incidence of PONV was lower in the group using combination of prophylactic palonosetron and sugammadex (19.3%) compared with the group not using both agents (37.2%). The combined use of the prophylactic palonosetron and sugammadex was identified as a factor affecting the occurrence of PONV in both univariable (OR = 0.40, 95% CI: 0.21-0.77, P = .006) and multivariable (OR = 0.38, 95% CI: 0.20-0.75, P = .005) logistic regression analyses. In multivariable logistic regression analysis, female sex was also significant independent risk factor in PONV (OR = 2.62, 95% CI: 1.35-5.08, P = .004).In this retrospective observational study, the combined use of prophylactic palonosetron before anesthetic induction and sugammadex as a reversal of neuromuscular blockade are associated with a reduction in the incidence of PONV in patients undergoing MVD under propofol-maintained anesthesia.

Replacement of dexmedetomidine loading with midazolam for sedation in elderly patients with spinal anesthesia.

BACKGROUND: Dexmedetomidine is an effective sedative during spinal anesthesia. However, it requires a loading dose, which can result in transient hypertension, hypotension, bradycardia, and/or sinus arrest. In addition, the time required to reach an appropriate depth of sedation may cause anxiety to the patients. Therefore, we examined whether an intravenous bolus of midazolam could replace the loading dose of dexmedetomidine for sedation during surgery in elderly patients who received spinal anesthesia. METHODS: Patients aged over 60 years who scheduled to undergo total knee arthroplasty under spinal anesthesia were enrolled in this study. The patients were randomized into 2 groups. Patients in dexmedetomidine group (group D) (n = 20) were administered a loading dose of dexmedetomidine (1.0 µg/kg over 10 min) intravenously followed by dexmedetomidine maintenance (0.5 µg/kg/h). Patients in group MD (n = 20) were administered an intravenous midazolam (0.05 mg/kg) followed by dexmedetomidine maintenance (0.5 µg/kg/h) intravenously. Heart rate (HR), mean arterial blood pressure (MBP), peripheral oxygen saturation (SpO2), and patient state index (PSI) were recorded. Ramsay sedation scale (RSS) scores were evaluated at 10 minutes after drug administration and the end of surgery. RESULTS: A total of 40 subjects were enrolled in the present study. At baseline, there was no between-group difference in HR. Ten minutes after drug administration, group D had lower HR than group MD (62.1 ±â€Š9.4 versus 69.6 ±â€Š13.4, P = .047). PSI was significantly lower in group MD at 10 minutes after drug administration (82.8 ±â€Š13.0 versus 72.0 ±â€Š16.0, P = .024); there was no between-group difference at 30 and 60 minutes, and lower values in group D at the end of surgery (70.2 ±â€Š22.6 versus 79.7 ±â€Š10.9, P = .011). The RSS score showed statistically significantly deeper sedation in group MD 10 minutes after drug administration, but no difference at the end of surgery. CONCLUSIONS: An intravenous bolus of midazolam is a viable alternative to dexmedetomidine loading for sedation during surgery in elderly patients who received spinal anesthesia. This is especially effective for patients who are at high risk for bradycardia or who want a faster sedation.