Evaluating the Efficacy of the Erector Spinae Plane Block as a Supplementary Approach to Cardiac Anesthesia during Off-Pump Coronary Bypass Graft Surgery via Median Sternotomy: A Randomized Clinical Trial.

Background: Pain control after off-pump coronary artery bypass graft (OPCAB) facilitates mobilization and improves outcomes. The efficacy of the erector spinae plane block (ESPB) after cardiac surgery remains controversial. Methods: We aimed to investigate the analgesic effects of ESPB after OPCAB. Precisely 56 patients receiving OPCAB were randomly divided into ESPB and control groups. The primary outcome was visual analog scale (VAS) pain scores at 6, 12, 24, and 48 h postoperatively. Secondary outcomes were the dose of rescue analgesics in terms of oral morphine milligram equivalents, the dose of antiemetics, the length of intubation time, and the length of stay in the intensive care unit (ICU). Results: The VAS scores were similar at all time points in both groups. The incidence of severe pain (VAS score > 7) was significantly lower in the ESPB group (50% vs. 15.4%; p = 0.008). The dose of rescue analgesics was also lower in the ESPB group (19.04 ± 18.76, 9.83 ± 12.84, p = 0.044) compared with the control group. The other secondary outcomes did not differ significantly between the two groups. Conclusions: ESPB provides analgesic efficacy by reducing the incidence of severe pain and opioid use after OPCAB.

Incidence of intraoperative hypotension in older patients undergoing total intravenous anesthesia by remimazolam versus propofol: A randomized controlled trial.

BACKGROUND: An increase in the frequency of surgeries among older individuals is observed in some countries. Hypotension is common and exaggerated in older patients and can lead to increased morbidity and mortality. Total intravenous anesthesia is commonly administered with propofol, while remimazolam has been suggested as an alternative to propofol because of advantages such as a more stable hemodynamic profile and less respiratory suppression. We conducted a single-blind, parallel-group randomized controlled trial to compare the incidence of intraoperative hypotension between patients administered with remimazolam and propofol. METHODS: A total of 132 patients, aged between 65 to 80 years and undergoing laparoscopic cholecystectomy or transurethral resection of bladder tumors were randomly assigned to the propofol or remimazolam group with a permuted block system while being blinded to the hypnotic agent. Remifentanil was administered via target-controlled infusion in both groups, with an initial effect-site concentration of 3.0 ng/mL and titration range of 1.5 to 4.0 ng/mL intraoperatively. The primary outcome of this study was the overall incidence of hypotension during general anesthesia. RESULTS: Patients in the propofol group experienced higher intraoperative hypotension than those in the remimazolam group (59.7% vs 33.3%, P = .006). Multivariate logistic regression analysis showed that remimazolam administration was associated with reduced hypotension (adjusted odds ratio, 0.34; 95% CI, 0.16-0.73). Secondary outcomes such as recovery time, delirium, and postoperative nausea and vomiting were comparable in both groups. CONCLUSION: Total intravenous anesthesia with remimazolam was associated with less intraoperative hypotension than propofol in older patients, with a comparable recovery profile.

Massive pulmonary embolism after caesarean section managed with surgical thrombectomy bridged with extracorporeal membrane oxygenation: A case report.

INTRODUCTION: Pulmonary embolism (PE) is a rare but fatal complication in postpartum women. Mortality is as high as 65% in massive PE, in which systemic hypotension persists or circulatory collapse occurs. This case report describes a patient who underwent a caesarean section complicated by massive PE. The patient was managed with early surgical embolectomy and bridged with extracorporeal membrane oxygenation (ECMO). PRESENTATION OF CASE: A 36 years old postpartum patient with an unremarkable medical history had sudden cardiac arrest due to PE on the day after a caesarean section. The patient recovered spontaneous cardiac rhythm after cardiopulmonary resuscitation; however, hypoxia and shock persisted. Cardiac arrest and spontaneous circulation recovery were repeated twice per hour. Veno-arterial (VA) ECMO rapidly improved the patient's condition. Surgical embolectomy was conducted 6 h after the initial collapse by the experienced cardiovascular surgeon. The patient's condition improved rapidly, and was weaned from ECMO on postoperative day three. The patient recovered normal heart function and no pulmonary hypertension was observed on follow-up echocardiography performed 15 months later. DISCUSSION: Timely intervention is important in the management of PE because of its rapid progression. VA ECMO is a useful bridge therapy to prevent derangement and severe organ failure. Surgical embolectomy is appropriate following the use of ECMO in postpartum patients because of the risk of major haemorrhagic complications or intracranial haemorrhage. CONCLUSION: In patients who have undergone caesarean section complicated by massive PE, surgical embolectomy is preferred because of the risk of haemorrhagic complications and their relatively young age.

Post-induction hypotension with remimazolam versus propofol in patients routinely administered angiotensin axis blockades: a randomized control trial.

BACKGROUND: Certain routine medication could result in post-induction hypotension (PIH), such as angiotensin axis blockades, which are frequently administered as a first-line therapy against hypertension. Remimazolam is reportedly associated with lesser intraoperative hypotension than propofol. This study compared the overall incidence of PIH following remimazolam or propofol administration in patients managed by angiotensin axis blockades. METHODS: This single-blind, parallel-group, randomized control trial was conducted in a tertiary university hospital in South Korea. Patients undergoing surgery with general anesthesia were considered for enrollment if the inclusion criteria were met: administration of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 19 to 65 years old, American Society of Anesthesiologists physical status classification ≤ III, and no involvement in other clinical trials. The primary outcome was the overall incidence of PIH, defined as a mean blood pressure (MBP) < 65 mmHg or decrease by ≥ 30% of the baseline MBP. The time points of measurement were baseline, just before the initial intubation attempt, and 1, 5, 10, and 15 min following intubation. The heart rate, systolic and diastolic blood pressures, and bispectral index were also recorded. Groups P and R included patients administered propofol and remimazolam, respectively, as an induction agent. RESULTS: A total of 81 patients were analyzed, of the 82 randomized patients. PIH was less frequent in group R than group P (62.5% versus 82.9%; t value 4.27, P = 0.04, adjusted odds ratio = 0.32 [95% confidence interval 0.10-0.99]). The decrease in the MBP from baseline was 9.6 mmHg lesser in group R than in group P before the initial intubation attempt (95% confidence interval 3.3-15.9). A similar trend was observed for systolic and diastolic blood pressures. No severe adverse events were observed in either group. CONCLUSION: Remimazolam results in less frequent PIH than propofol in patients undergoing routine administration of angiotensin axis blockades. TRIAL REGISTRATION: This trial was retrospectively registered on Clinical Research Information Service (CRIS), Republic of Korea (KCT0007488). Registration date: 30/06/2022.

The Analgesic Efficacy of the Single Erector Spinae Plane Block with Intercostal Nerve Block Is Not Inferior to That of the Thoracic Paravertebral Block with Intercostal Nerve Block in Video-Assisted Thoracic Surgery.

This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain (0-10, where 10 = worst imaginable pain) in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction (1-5, where 5 = extremely satisfied) and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups (PACU: 2.0 (1.8, 5.3) vs. 2.0 (2.0, 4.0), p = 0.970; 24 h: 2.0 (0.8, 3.0) vs. 2.0 (1.0, 3.5), p = 0.993; 48 h: 1.0 (0.0, 3.5) vs. 1.0 (0.0, 5.0), p = 0.985). The upper limit of the 95% CI for the differences (PACU: 1.428, 24 h: 1.052, 48 h: 1.176) was within the predefined noninferiority margin of 2. Total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, p = 0.767) and satisfaction scores (3.5 (3.0, 4.0) vs. 4.0 (3.0, 5.0), p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.

Quality of recovery in patients administered remimazolam versus those administered an inhalant agent for the maintenance of general anesthesia: a randomized control trial.

BACKGROUND: Remimazolam is a novel intravenous benzodiazepine that is appropriate for the maintenance of anesthesia. Quality of recovery is an important component of health care quality, but there is no published randomized control trial focused on the quality of recovery in patients undergoing total intravenous anesthesia with remimazolam. METHODS: This parallel-group, single-blind randomized control trial at a tertiary care medical center in South Korea was conducted to determine the difference in the quality of recovery between the patients administered remimazolam and those administered an inhalant anesthetic agent. A total of 168 patients aged 19-65 years who underwent elective laparoscopic cholecystectomy or robotic gynecologic surgery were considered for enrollment. Randomization was performed using sealed envelopes containing computer-generated random allocation sequences. Remimazolam was administered for the maintenance of anesthesia in the remimazolam group (Group R), and desflurane was administered in the desflurane group (Group D). The induction protocol and the target value of the bispectral index were identical in both groups. Patients were blinded to the drug that was administered until they finished the postoperative questionnaire. The main outcome measure was the decrement of the QoR-40 score on postoperative day 1 compared to the QoR-40 score on the day before surgery. RESULTS: A total of 165 patients were analyzed. The preoperative and postoperative global QoR-40 scores were 183 and 152 (IQR 173-192 and 136-169), respectively. The perioperative decrement of the global QoR-40 score was 29.96 ± 22.49. The decrement of the QoR-40 score was smaller in Group R than in Group D (26.99 versus 32.90, respectively; mean difference 5.91, 95% confidence interval -0.96-12.79). After adjustment for sex, the type of surgery and surgical time, the administration of remimazolam resulted in a 7.03-point (95% CI 0.35-13.72) less decrement of the QoR-40 score than desflurane. There were no severe adverse events in either group. CONCLUSION: Total intravenous anesthesia maintained with remimazolam provides a better quality of recovery than anesthesia maintained with an inhalant agent in patients undergoing laparoscopic surgery. Additionally, postoperative nausea and vomiting were largely reduced with remimazolam. TRIAL REGISTRATION: KCT0006288 , Clinical Research Information Service (CRIS), Republic of Korea Registration date: 23/06/2021.

Effect of intramuscular midazolam premedication on patient satisfaction in women undergoing general anaesthesia: a randomised control trial.

OBJECTIVE: To determine the effect of premedication with intramuscular midazolam on patient satisfaction in women undergoing general anaesthesia. TRIAL DESIGN, SETTING AND PARTICIPANTS: Double-blind, parallel randomised control trial at a tertiary care medical centre in South Korea. Initially, 140 women aged 20-65 years who underwent general anaesthesia and had an American Society of Anesthesiology physical status classification of I or II were randomly assigned to the intervention group or the control group, and 134 patients (intervention n=65; control n=69) completed the study. INTERVENTION: Intramuscular administration of midazolam (0.05 mg/kg) or placebo (normal saline 0.01 mL/kg) on arrival at the preoperative holding area. MAIN OUTCOMES: The primary outcome was the patient's overall satisfaction with the anaesthesia experience as determined by questionnaire responses on the day after surgery. Satisfaction was defined as a response of 3 or 4 on a five-point scale (0-4). The secondary outcomes included blood pressure, heart rate, oxygen desaturation, recovery duration and postoperative pain. RESULTS: Patients who received midazolam were more satisfied than those who received placebo (percentage difference: 21.0%, OR 3.56, 95% CI 1.46 to 8.70). A subgroup analysis revealed that this difference was greater in patients with anxiety, defined as those whose Amsterdam Preoperative Anxiety and Information Scale anxiety score was ≥11, than that for the whole sample population (percentage difference: 24.0%, OR 4.33, 95% CI 1.25 to 14.96). Both groups had similar heart rates, blood pressure and oxygen desaturation. CONCLUSION: Intramuscular administration of midazolam in women before general anaesthesia in the preoperative holding area improved self-reported satisfaction with the anaesthesia experience, with an acceptable safety profile. TRIAL REGISTRATION NUMBER: KCT0006002.

A case report of arthroscopic surgery under extended spinal anesthesia for 402 minutes, assisted by monitored anesthesia care.

INTRODUCTION: Surgical spinal anesthesia is usually maintained for approximately 3 h with bupivacaine, but it is difficult to accurately predict the duration of surgery for each case. When an operation continues for an extended duration, regression of spinal anesthesia often leads to general anesthesia. Here we present a case of extended spinal anesthesia assisted by monitored anesthesia care. CASE PRESENTATION: A 32-year-old male who suffered from persistent pain of the right knee was diagnosed with rupture of the right anterior cruciate ligament. Arthroscopic surgery of the right knee was conducted with spinal anesthesia. A local anesthetic mixture of 0.5% hyperbaric bupivacaine 12 mg with 50 µg of epinephrine was used. The surgery took longer than expected with a total anesthesia time of 402 minutes. In the final 30 minutes of surgery, spinal anesthesia regressed and the procedure was completed under monitored anesthesia care (MAC). CLINICAL DISCUSSION: When spinal anesthesia is on regression during the final stage of surgery, the application of MAC safely secures additional operation time. By adopting MAC, the patient avoided general anesthesia and had minimal physiological distress and a rapid recovery. Another benefit of MAC is the reduced consumption of resources. Further, by avoiding endotracheal intubation and mechanical ventilation, the risk of transmission of infectious agents is minimized. CONCLUSION: In situations where spinal anesthesia is regressing close to the end of a surgical procedure, the application of MAC has potential benefits over general anesthesia. These benefits are particularly relevant during the current COVID-19 pandemic.

Deep learning models for the prediction of intraoperative hypotension.

BACKGROUND: Intraoperative hypotension is associated with a risk of postoperative organ dysfunction. In this study, we aimed to present deep learning algorithms for real-time predictions 5, 10, and 15 min before a hypotensive event. METHODS: In this retrospective observational study, deep learning algorithms were developed and validated using biosignal waveforms acquired from patient monitoring of noncardiac surgery. The classification model was a binary classifier of a hypotensive event (MAP <65 mm Hg) or a non-hypotensive event by analysing biosignal waveforms. The regression model was developed to directly estimate the MAP. The primary outcome was area under the receiver operating characteristic (AUROC) curve and the mean absolute error (MAE). RESULTS: In total, 3301 patients were included. For invasive models, the multichannel model with an arterial pressure waveform, electrocardiography, photoplethysmography, and capnography showed greater AUROC than the arterial-pressure-only models (AUROC15-min, 0.897 [95% confidence interval {CI}: 0.894-0.900] vs 0.891 [95% CI: 0.888-0.894]) and lesser MAE (MAE15-min, 7.76 mm Hg [95% CI: 7.64-7.87 mm Hg] vs 8.12 mm Hg [95% CI: 8.02-8.21 mm Hg]). For the noninvasive models, the multichannel model showed greater AUROCs than that of the photoplethysmography-only models (AUROC15-min, 0.762 [95% CI: 0.756-0.767] vs 0.694 [95% CI: 0.686-0.702]) and lesser MAEs (MAE15-min, 11.68 mm Hg [95% CI: 11.57-11.80 mm Hg] vs 12.67 [95% CI: 12.56-12.79 mm Hg]). CONCLUSIONS: Deep learning models can predict hypotensive events based on biosignals acquired using invasive and noninvasive patient monitoring. In addition, the model shows better performance when using combined rather than single signals.

Symptoms and Characteristics Which Require Attention During COVID-19 Screening at a Port of Entry.

BACKGROUND: The quarantine process at a country's port of entry has an important role in preventing an influx of coronavirus disease 2019 (COVID-19) cases from abroad and further minimizing the national healthcare burden of COVID-19. However, there has been little published on the process of COVID-19 screening among travelers entering into a country. Identifying the characteristics of COVID-19 infected travelers could help attenuate the further spread of the disease. METHODS: The authors analyzed epidemiological investigation forms and real-time polymerase chain reaction (PCR) results for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) of entrants to Incheon International Airport between March 11 to April 30, 2020. We performed univariate and multivariate logistic regression analysis to determine the odds of positive SARS-CoV-2 result. RESULTS: A total of 11,074 entrants underwent reverse-transcription PCR for SARS-CoV-2, resulting 388 confirmed cases of COVID-19 infection. COVID-19 had a strong association with the reported loss of smell or taste and association with self-reported fever, chill, cough, and vomiting. If a traveler reported contact with an individual with either respiratory symptoms or confirmed COVID-19 in the last two weeks directly prior to landing, the probability of a positive result was increased. CONCLUSION: If overseas travelers experience loss of smell or taste in the two weeks prior to arrival, they may require an immediate examination to rule out COVID-19 at a port of entry. As to measure body temperature upon arrival at a port of entry, it is important to screen for any occurrence of fever within the two weeks prior to travel. Also, information with epidemiological relevance, such as recent contact with an individual suffering from any respiratory symptoms or with confirmed COVID-19, should be included in COVID-19 screening questionnaires for international travelers.

Transient Oliguria during Anesthesia in Cerebral Salt Wasting Syndrome.

Cerebral salt wasting syndrome is a hyponatremic and hypovolemic condition caused by intracranial disorders, such as head injury, subarachnoid hemorrhage, brain tumor, and brain operations. We report a case of a 5-year-old girl that had cerebral salt wasting syndrome with marked polyuria who showed transient oliguria during general anesthesia. The patient had undergone an operation for traumatic intracranial hemorrhage three months prior and has had marked polyuria and hyponatremia since then. After induction of anesthesia for cranioplasty, the patient had oliguria during surgery and then resumed polyuria in the post-operative period.

Difficult Intubation in Pediatric Patient with a Large Lymphangioma at the Tongue Base.

Lymphangioma is a congenital malformation of lymphatic system and often involves the oral cavity. When lymphangioma is located on the mouth floor and enlarges, it can compress the airway and make intubation difficult. The GlideScope(®) video laryngoscope is sometimes used in routine intubation, but is most commonly used in difficult or failed intubation. We report a pediatric patient with a difficult intubation due to a large tongue base mass. The airway was compromised due to limited intraoral space, large mass at the tongue base, and glottis distortion. Oral approach was not successful with the Macintosh laryngoscope. In this case, a rigid stylet was made to match the GlideScope(®) curve and the endo-tracheal tube was inserted through the glottis under GlideScope(®) guidance. We believe that, even in pediatric patients, a rigid stylet is necessary when intubation at a sharp posterior angulation to the trachea is difficult during GlideScope(®) approach.