Association between intraoperative hyperglycemia and postoperative end-organ dysfunctions after cardiac surgery: a retrospective observational study.

PURPOSE: Hyperglycemia has been associated with postoperative morbidity in patients who undergo cardiac surgery. However, it remains unclear whether the duration of hyperglycemia is as important as its magnitude in the development of postoperative end-organ dysfunction (PEOD). This retrospective study investigated the hypothesis that the intraoperative blood glucose (BG) exposure index (GE index), calculated by the product of the magnitude and duration of BG concentration ≥ 180 mg/dL, which is an integration of the severity and duration of hyperglycemia, is associated with the incidence of PEOD in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: The primary outcome in this study was PEOD within 72 h of surgery, which was defined as a composite of postoperative acute kidney injury, delirium, myocardial injury, and prolonged mechanical ventilation. The GE index (the magnitude of BG concentration deviation ≥ 180 mg/dL [Formula: see text] duration of BG concentration ≥ 180 mg/dL) of each patient was calculated based on the intraoperative BG concentration. The relationship between the GE index and the primary outcome was examined via logistic regression model with adjustment for potential confounders. RESULTS: Within 72 h of surgery, 301 patients (54.5%) developed PEOD. PEOD was more common in patients with greater GE index quartiles (first versus third quartile; adjusted odds ratio, 5.65, 95% confidence interval (95% CI), 2.94-10.90; P < 0.001; first versus forth quartile, adjusted odds ratio, 20.80; 95% CI, 8.01-54.00; P < 0.001). CONCLUSION: In patients undergoing cardiac surgery with cardiopulmonary bypass, the GE index was an independent predictor of PEOD.

[Intra-occular pressure during robotic-assisted laparoscopic radical prostectomy].

BACKGROUND: Aeroperitoneum increases intra-occular pressure (IOP). We measured IOP during robotic-assisted laparoscopic radical prostectomy (RALP) that requires steeper Trenderenburg position. METHODS: Fourteen patients with no ocular diseases were candidates. We measured their IOP during robotic operation from beginning to end. RESULTS: Our date shows that IOP continues to increase over the time of steep Trenderenburg position. CONCLUSIONS: Long time RALP might be risky for IOP.

[Effectiveness of local cooling and lidocaine administration for prevention of pain upon injection of propofol].

BACKGROUND: Propofol is commonly used for induction and maintenance of anesthesia, but pain at the site of intravenous injection is a clinical problem. We studied the effectiveness of local cooling and pretreatment with lidocaine for prevention of injection pain of propofol. METHODS: A total of 226 adult patients scheduled to receive general anesthesia were assigned randomly to four groups: a control group receiving no prophylactic intervention, a cooling group receiving topical cooling, a lidocaine group receiving 1 mg x kg(-1) lidocaine, and a lidocaine plus cooling group receiving topical cooling and 1 mg x kg(-1) lidocaine. A 20 gauge intravenous catheter was inserted into the peripheral vein at the radial side of the forearm. After prophylactic intervention had been performed, 1-2 mg x kg(-1) MCT/LCT propofol was injected. Patients were asked to grade the pain as none, mild, moderate, or severe. RESULTS: The incidence of propofol-induced pain was significantly higher in the control group (39%) than in the other three groups (17% in the cooling group, 16% in the lidocaine group and 8% in the lidocaine plus cooling group). However, there were no significant differences between the three groups with different prophylactic interventions. CONCLUSIONS: The results suggest that cooling and pretreatment with lidocaine reduce the incidence of pain upon propofol injection.

[A case of intracranial subdural hematoma after thoracic epidural anesthesia].

Intracranial subdural hematoma (SDH) occurred in a 58-year-old female after laparoscopy-assisted distal gastrectomy under general and thoracic epidural anesthesia. On postoperative day 2, she complained of headache in sitting position, but there were no remarkable neurological defect and nausea. On postoperative day 5, her headache subsided and she could walk by herself. But on postoperative day 10, she felt heavy-headed again, and complained sensory abnormality of her right leg. Magnetic resonance imaging of the head showed small acute subdural hematoma in bilateral parietal regions with no mass effect. She was managed conservatively with bed rest and intravenous fluids. Her condition improved and was discharged on postoperative day 17 without subsequent complications. SDH after epidural anesthesia is rare, but diagnosis in early stage has a decisive influence on its prognosis. It is crucial to exclude the possibility of SDH and observe closely if the patient complains of severe headache or another unexplained symptom only with postdural puncture headache.

Left Stellate Ganglion Blockade for Refractory Ventricular Arrhythmias With Aconitine Poisoning: A Case Report.

Aconitine poisoning causes refractory ventricular arrhythmias (VAs). In a 20-year-old man, VAs of unknown etiology did not respond to drugs and electrical defibrillation. However, left stellate ganglion blockade (SGB) dramatically decreased arrhythmias without complications. At a later date, we found that refractory VAs were caused by aconitine poisoning. Left SGB is effective for treating refractory VAs with aconitine poisoning and can be easily performed with few complications for VAs of unknown etiology even if patients are receiving anticoagulant therapy. Also, left SGB can be performed to diagnose refractory VAs.

Effects of propofol on left ventricular mechanoenergetics in the excised cross-circulated canine heart.

Although propofol is commonly used for general anesthesia, its direct effects on left ventricular (LV) contractility and energetics remain unknown. Accordingly, we studied the effects of intracoronary propofol on excised cross-circulated canine hearts using the framework of the Emax (a contractility index)-PVA (systolic pressure-volume area, a measure of total mechanical energy)-V(O2) (myocardial oxygen consumption per beat) relationship. We obtained 1) the V(O2)-PVA relationship of isovolumic contractions with varied LV volumes at a constant Emax, 2) the V(O2)-PVA relationship with varied LV volumes at a constant intracoronary concentration of propofol, and 3) the V(O2)-PVA relationship under increased intracoronary concentrations of either propofol or CaCl(2) at a constant LV volume to assess the cardiac mechanoenergetic effects of propofol. We found that propofol decreased Emax dose-dependently. The slope of the linear V(O2)-PVA relationship (oxygen cost of PVA) remained unchanged by propofol. The PVA-independent V(O2)-Emax relationship (oxygen cost of Emax) was the same for propofol and Ca(2+). In conclusion, propofol showed a direct negative inotropic effect on LV. At its clinical concentrations, decreases in contractility by propofol were relatively small. Propofol shows mechanoenergetic effects on the LV that are similar to those of Ca(2+) blockers or ß-antagonists-i.e., it exerts negative inotropic effects without changing the oxygen costs of Emax and PVA.

[Effectiveness of gum elastic bougie for tracheal intubation with Airtraq optical laryngoscope].

BACKGROUND: Although Airtraq (ATQ) is well accepted as a useful device for tracheal intubation especially in cases of difficult airway management, we sometimes encounter difficulty in insertion of a tracheal tube along the blade of ATQ across the vocal cord in spite of ATQ assistance. Gum Elastic Bougie (GEB) is well known as a practical device for intubation assistance with Macintosh laryngoscope. We studied the efficacy of GEB for intubation with ATQ. METHODS: One-hundred-forty one patients scheduled for general anesthesia, ASA physical status 1 or 2, were allocated into two groups randomly; patients intubated with ATQ without GEB (n = 70), and those with ATQ with GEB (n = 71). Twenty anesthegiologists were assinged to them evenly according to their experience. We measured the time they needed for intubation. RESULTS: The combinational advantage of ATQ and GEB was not significantly proved among board certified anesthesiologist. However, among non-board-certified anesthesiologist group, the time needed for successful intubation was significantly shorter with combined use of ATQ and GEB. CONCLUSIONS: For the people with less experience of intubation, GEB is useful assistance for intubation with ATQ. It was concluded that the combined use of ATQ and GEB is a simple and effective process for ordinary doctors or paramedics.

[Use of sugammadex in a patient with amyotrophic lateral sclerosis].

Amyotrophic lateral sclerosis (ALS) is a degenerative disease involving motor neurons. The anesthetic problem is increased susceptibility to non-depolarizing muscle relaxants and the feasibility of spinal and epidural anesthesia. An 86-year-old man with ALS underwent colostomy to the ileus. We chose general anesthesia with propofol, remifentanil, rocuronium and sugammadex. We administered 30 mg (0.52 mg . kg-1) of rocuronium only for induction. TOF-count was 2 at the end of operation. At spontaneous neuromuscular recovery to TOF-count 3, we administered sugammadex 2.1 mg . kg-1. The patient emerged from general anesthesia smoothly, and was extubated. Post-operative course was uneventful. Our anesthetic management of ALS patient using sugammadex was successful. Further evidence is required to establish appropriate use of sugammadex for ALS patients.

[A case of caesarean section in a patient with myasthenia gravis: crisis was successfully avoided by preoperative plasmapheresis].

Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and fatigability. Women with MG have increased risk of pregnancy-related complications and an adverse pregnancy outcome. Maternal changes in pregnancy can also affect MG. The course of the disease in pregnancy is unpredictable. Delivery via caesarean section is very stressful and may cause severe myasthenic crisis. Therefore, if caesarean section is selected, coordinated management by a gynecologist, a neurologist and an anesthesiologist is necessary. We describe a 30-year-old woman with MG diagnosed during pregnancy. She was hospitalized on 33rd gestational week and was planned for delivery via caesarian section at 37th gestational week. In addition to her usual medications, we performed plasmapheresis to improve her condition for the operation not with fresh frozen plasma but with albumin solution just before the operation. No obvious abnormality of coagulation system was observed, and combined spinal and epidural anesthesia was performed with no adverse outcome. We managed her perioperative period free from myasthenic crisis.

Celsior preserves cardiac mechano-energetics better than University of Wisconsin solution by preventing oxidative stress.

OBJECTIVES: Identity of the optimal heart preservation solution remains unknown. Because oxidative stress contributes to contractile failure in the ischaemic/reperfused myocardium and the main characteristic of Celsior is its antioxidant effect, it is important to elucidate the relationship between the inhibitory effect on oxidative stress and cardiac mechano-energetics. We therefore evaluated the efficacy of Celsior from both aspects by comparison with the University of Wisconsin solution (UWS). METHODS: We used 18 excised cross-circulated canine hearts. Excised hearts were preserved with UWS (n = 6) or Celsior (n = 6) for 3 h at 4 °C; the remaining six served as controls. Hearts were then cross-circulated and rewarmed. The end-systolic pressure-volume ratio (LV Emax) and the ventricular pressure-volume area, which is a measure of total mechanical energy, were assessed after reperfusion. Biopsies were taken from the endocardium after excising the heart, before reperfusion, after reperfusion and 4 h after reperfusion to assess the inhibitory effect of each agent on oxidative stress. Endo-myocardial biopsy samples were studied immunohistochemically for expression of 4-hydroxy-2-nonenal (HNE)-modified protein, which is a major lipid peroxidation product. RESULTS: Emax in the UWS group was significantly smaller than in the control group, whereas the Emax in the Celsior group was preserved. Oxygen cost of Emax in the UWS group was significantly higher than in the Celsior group. Myocardial HNE-modified protein levels increased gradually, both under preservation and after reperfusion in the UWS group. Myocardial HNE-modified protein levels in the Celsior group were lower, mainly before and 4 h after reperfusion compared with the UWS group. CONCLUSIONS: Celsior may maintain cardiac contractility and conserve oxygen cost by inhibiting oxidative stress.

[Acute myocardial infarction due to coronary artery spasm after caesarean section].

We experienced acute myocardial infarction due to coronary artery spasm after caesarean section. A 41-year-old multigravida woman with no previous cardiac history or coronary risk factor developed acute myocardial infarction after caesarean section, and was successfully resuscitated with emergency percutaneous transluminal coronary angioplasty. Acute myocardial infarction during pregnancy and postpartum period is a rare event, but could be associated with high mortality if it occurs. It is necessary to consider the possibility of acute myocardial infarction and provide early diagnosis and treatment by multidisciplinary team when a pregnant woman complains of retrosternal chest pain.

Exponential fitting of postextrasystolic potentiation may underestimate the cardiac Ca2+ recirculation fraction: a theoretical analysis.

The recirculation fraction of intramyocardial Ca(2+) (RF) has conventionally been obtained from the monotonic decay of postextrasystolic potentiation (PESP). The used assumption is that the decay is exponential. However, we have found that PESP usually decays in alternans even at spontaneous heart rates (>100 beats/min) in excised, cross-circulated canine heart preparations under normal coronary perfusion and normothermia. We have already devised a means of extracting the exponential decay component for RF calculation by subtracting the oscillatory component from the alternans PESP decay by a curve-fitting method. Using mathematics, we assessed the possible error in estimated RF when an exponential curve was naively fit to the alternans PESP decay. We obtained results showing that the exponential assumption may considerably underestimate RF even when the alternans is trivial with the oscillatory component of only 10% of the exponential component.

Energy for myocardial Ca2+ handling per beat increases with heart rate in excised cross-circulated canine heart.

OBJECTIVE: Although tachycardia is well known to increase cardiac oxygen consumption (Vo2) per min, the relationship between Vo2 for excitation-contraction (E-C) coupling per beat and heart rate change over its full working range still remains controversial. METHODS: To elucidate this relationship, we varied heart rate over a reasonably wide range (60-180 beat/min) and studied the relationship between left ventricular (LV) Emax (load-independent contractility index), PVA (pressure-volume area)-independent Vo2, and basal metabolic Vo2 in nine excised, cross-circulated canine hearts. RESULTS: PVA-independent Vo2 per min significantly increased linearly with increasing heart rate while Emax remained unchanged. Basal metabolic Vo2 per min was measured under KCl arrest. E-C coupling Vo2 per min obtained by subtracting the constant basal metabolic Vo2 from the PVA-independent Vo2 also significantly increased linearly with increasing heart rate. However, PVA-independent Vo2 per beat significantly decreased with increasing heart rate. In contrast, E-C coupling Vo2 per beat, as well as that normalized to Emax, slightly but significantly increased with increasing heart rate. CONCLUSION: The E-C coupling energy for myocardial Ca2+ handling increases with heart rate despite constant contractility in the left ventricle of the excised cross-circulated canine heart.

Celsior preserved cardiac mechanoenergetics better than popular solutions in canine hearts.

BACKGROUND: Better protective effects of Celsior on cardiac function than the other conventional solutions have been reported in acute experiments and in clinical trials for at-risk patients. However, no study has yet precisely elucidated how these preservation solutions affect cardiac mechanoenergetics. Therefore, we evaluated the effects of St. Thomas' Hospital solution No. 2, University of Wisconsin solution, and Celsior on left ventricular contractility (Emax: end-systolic pressure-volume ratio) and oxygen consumption. METHODS: We used 32 canine excised cross-circulated hearts. Twenty-three hearts served as donor hearts after hypothermic ischemia with one of the three solutions, and the remaining 9 served as controls. After arrest with each solution, the hearts were preserved for 4 hours at 4 degrees C. Then, we measured left ventricular pressure, volume, and oxygen consumption to obtain Emax and the relation between ventricular pressure-volume area (a measure of total mechanical energy) and oxygen consumption. We also evaluated the oxygen cost of Emax by changing Emax with calcium administration. RESULTS: Celsior did not significantly affect E(max) (6.3 +/- 2.4 in control versus 5.3 +/- 1.3 mm Hg.mL(-1).100 g with Celsior) nor the oxygen cost of Emax (1.2 +/- 0.6 versus 1.6 +/- 0.5 mL O2.mL.mm Hg(-1).beat(-1).100 g(-2), respectively). In contrast, St. Thomas' Hospital and University of Wisconsin solutions significantly decreased Emax (4.5 +/- 1.1 and 3.5 +/- 0.9 mm Hg.mL(-1).100 g, respectively) and increased the oxygen cost of Emax (2.5 +/- 0.8 and 2.4 +/- 0.9 mL O2.mL.mm Hg(-1).beat(-1).100 g(-2), respectively) compared with control and Celsior-preserved hearts. The slope and intercept of the oxygen consumption versus pressure-volume area relation showed no significant difference among the four groups. CONCLUSIONS: Celsior showed better protective effects on cardiac mechanoenergetics than St. Thomas' Hospital and University of Wisconsin solutions in the acute phase of heart transplantation.