Effects of argon and nitrogen plasma pulses on the skin and skin appendages in an in vivo animal model.

BACKGROUND: For medical purposes, plasma can be generated from inert gaseous sources in a device by ultra-high-frequency generators and emitted to target tissue at a pulse duration in the milliseconds. OBJECTIVE: To evaluate argon and nitrogen plasma pulse-induced tissue reactions in the skin and skin appendages of an in vivo animal model. METHODS: Argon and nitrogen plasma pulses were non-invasively delivered to in vivo rat skin at various experimental settings. Specimens were histologically evaluated following hematoxylin and eosin and Masson's trichrome staining. RESULTS: At low-energy settings of 1.0, 1.5, and 2.0 J, nitrogen plasma treatments generated noticeable tissue coagulation at the depths of 31.5 ± 8.3, 94.9 ± 16.9, and 171.6 ± 19.7 µm, respectively, at Day 0. At high-energy settings of 2.5 and 3.0 J, nitrogen plasma treatments generated marked tissue coagulation at the depths of 381.7 ± 33.6 µm and 456.3 ± 75.7 µm, respectively, at Day 0. CONCLUSIONS: Treatment with argon plasma induces microscopic changes in the epidermis, dermis, and sebaceous glands without generating excessive thermal injury, whereas that with nitrogen plasma elicits energy-dependent thermal coagulation in the epidermis and dermis with remarkable neocollagenesis.

Interactive tissue reactions of 1064-nm focused picosecond-domain laser and dermal cohesive polydensified matrix hyaluronic acid treatment in in vivo rat skin.

BACKGROUND: Picosecond-domain laser treatment using a microlens array (MLA) or a diffractive optical element (DOE) generates micro-injury zones in the epidermis and upper dermis. OBJECTIVE: To investigate interactive tissue reactions between MLA-type picosecond laser pulses and cohesive polydensified matrix hyaluronic acid (CPMHA) filler in the dermis. METHODS: In vivo rats with or without CPMHA pretreatment were treated with a 1064-nm picosecond-domain neodymium:yttrium-aluminum-garnet (Nd:YAG) laser using an MLA or DOE. Skin samples were obtained at post-treatment days 1, 10, and 21 and histologically and immunohistochemically analyzed. RESULTS: Picosecond-domain Nd:YAG laser treatment with an MLA-type or a DOE-type handpiece generated fractionated zones of pseudo-cystic cavitation along the lower epidermis and/or upper papillary dermis at Day 1. At Day 21, epidermal thickness, dermal fibroblasts, and collagen fibers had increased. Compared to CPMHA-untreated rats, rats pretreated with CPMHA showed marked increases in fibroblasts and collagen fibers in the papillary dermis. Immunohistochemical staining for the hyaluronic acid receptor CD44 revealed that MLA-type picosecond laser treatment upregulated CD44 expression in the basilar epidermis and dermal fibroblasts. CONCLUSIONS: We suggest that the hyaluronic acid-rich environment associated with CPMHA treatment may enhance MLA-type picosecond-domain laser-induced tissue reactions in the epidermis and upper dermis.

Systematic review and meta-analysis: Effect of Helicobacter pylori eradication on chronic spontaneous urticaria.

BACKGROUND: Helicobacter pylori (HP) infection is considered to play a role in the pathogenesis of chronic spontaneous urticaria (CSU). However, the efficacy of HP eradication therapy on CSU symptom improvement has not been well established. This meta-analysis was conducted to estimate the association between HP infection and CSU and to evaluate whether HP eradication therapy benefits patients with CSU. MATERIAL AND METHODS: In October 2018, we searched databases for studies investigating the efficacy of HP eradication therapy for patients with CSU. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using random effects models. RESULTS: The meta-analysis included 22 studies with a total of 1385 patients with CSU. When comparing the spontaneous remission of urticarial symptom in patients with HP-positive to HP-negative patients, HP-negative patients showed significantly higher spontaneous remission of urticarial symptoms. (risk ratio 0.39; 95% confidence interval: 0.19-0.81). Among HP-positive CSU patients, remission of CSU was more likely shown in HP eradication therapy group compared to untreated group, aside from achieving HP elimination (risk ratio 2.10; 95% confidence interval: 1.20-3.68). However, there was no significant difference in the remission of CSU whether antibiotic therapy was successful in eradication of HP or not (risk ratio 1.00; 95% confidence interval: 0.65-1.54). CONCLUSIONS: The results of this meta-analysis show that HP might be associated with the occurrence and persistence of CSU. The effectiveness of HP eradication therapy in suppressing CSU symptoms was significant. Interestingly, we found that resolution of CSU was not associated with successful eradication of HP infection. CSU Patients who were undergone antibiotic therapy for HP eradication showed significant higher CSU remission with or without HP eradication. Further studies are recommended to evaluate the mechanisms associated with relation of HP with CSU.

Extracellular C1qbp inhibits myogenesis by suppressing NFATc1.

Aging and lack of exercise are the most important etiological factors for muscle loss. We hypothesized that new factors that contribute to muscle loss could be identified from ones commonly altered in expression in aged and exercise-limited skeletal muscles. Mouse gastrocnemius muscles were subjected to mass spectrometry-based proteomic analysis. The muscle proteomes of hindlimb-unloaded and aged mice were compared to those of exercised and young mice, respectively. C1qbp expression was significantly upregulated in the muscles of both hindlimb-unloaded and aged mice. In vitro myogenic differentiation was not affected by altering intracellular C1qbp expression but was significantly suppressed upon recombinant C1qbp treatment. Additionally, recombinant C1qbp repressed the protein level but not the mRNA level of NFATc1. NFATc1 recruited the transcriptional coactivator p300, leading to the upregulation of acetylated histone H3 levels. Furthermore, NFATc1 silencing inhibited p300 recruitment, downregulated acetylated histone H3 levels, and consequently suppressed myogenic differentiation. The expression of C1qbp was inversely correlated with that of NFATc1 in the gastrocnemius muscles of exercised or hindlimb-unloaded, and young or aged mice. These findings demonstrate a novel role of extracellular C1qbp in suppressing myogenesis by inhibiting the NFATc1/p300 complex. Thus, C1qbp can serve as a novel therapeutic target for muscle loss.

Polyhexamethylene guanidine aerosol causes irreversible changes in blood proteins that associated with the severity of lung injury.

Polyhexamethylene guanidine (PHMG) is a positively charged polymer used as a disinfectant that kills microbes but can cause pulmonary fibrosis if inhaled. After the long-term risks were confirmed in South Korea, it became crucial to measure toxicity through diverse surrogate biomarkers, not only proteins, especially after these hazardous chemicals had cleared from the body. These biomarkers, identified by their biological functions rather than simple numerical calculations, effectively explained the imbalance of pulmonary surfactant caused by fibrosis from PHMG exposure. These long-term studies on children exposed to PHMG has shown that blood protein indicators, primarily related to apolipoproteins and extracellular matrix, can distinguish the degree of exposure to humidifier disinfectants (HDs). We defined the extreme gradient boosting models and computed reflection scores based on just ten selected proteins, which were also verified in adult women exposed to HD. The reflection scores successfully discriminated between the HD-exposed and unexposed groups in both children and adult females (AUROC: 0.957 and 0.974, respectively) and had a strong negative correlation with lung function indicators. Even after an average of more than 10 years, blood is still considered a meaningful specimen for assessing the impact of environmental exposure to toxic substances, with proteins providing in identifying the pathological severity of such conditions.

Intraoperative infusion of 0.6-0.9 µg·kg(-1)·min(-1) remifentanil induces acute tolerance in young children after laparoscopic ureteroneocystostomy.

BACKGROUND: Intraoperative infusion of opioids has been associated with increased postoperative pain and analgesic requirements, but the development of tolerance in young children is less clear. This prospective, randomized, double-blinded study was designed to test the hypothesis that the intraoperative administration of remifentanil results in postoperative opioid tolerance in a dose-related manner in young children. METHODS: We enrolled 60 children (aged 1-5 yr) who were undergoing elective laparoscopic ureteroneocystostomy. Patients were randomized and received an intraoperative infusion of 0, 0.3, 0.6, or 0.9 µg·kg·min remifentanil. Postoperative pain was managed by a parent/nurse-controlled analgesia pump using fentanyl. The primary outcome included the total fentanyl consumptions at 24 and 48 h postsurgery. Secondary outcomes were the postoperative pain scores and adverse effects. RESULTS: The children who received 0.6 and 0.9 µg·kg·min remifentanil required more postoperative fentanyl than the children who received saline or 0.3 µg·kg·min remifentanil (all P < 0.001) for 24 h after surgery. The children who received 0.3-0.9 µg·kg·min intraoperative remifentanil reported higher pain scores at 1 h after surgery than the children who received saline (P = 0.002, P = 0.023, and P = 0.006, respectively). No significant intergroup differences in recovery variables were observed, but vomiting was more frequent in the 0.9 µg·kg·min remifentanil group than in the other groups (P = 0.027). CONCLUSIONS: The intraoperative use of 0.3 µg·kg·min remifentanil for approximately 3 h (range: 140-265 min) did not induce acute tolerance, but the administration of 0.6 and 0.9 µg·kg·min remifentanil to young children resulted in acute tolerance for 24 h after surgery in an apparently dose-related manner.

Systemic antibiotics cause deterioration of emphysema associated with exaggerated inflammation and autophagy.

The interaction between the microbial environment and the host is important for immune homeostasis. Recent research suggests that microbiota dysbiosis can be involved in respiratory diseases. Emphysema is a chronic inflammatory disease, but it is unclear whether dysbiosis caused by antibiotics can affect disease progression. Here, we tried to elucidate the effect of systemic antibiotics on smoking-exposed emphysema models. In this study, the antibiotic mixture caused more alveolar destruction and airspace expansion in the smoking group than in the smoking only or control groups. This emphysema aggravation as a result of antibiotic exposure was associated with increased levels of inflammatory cells, IL-6, IFNγ and protein concentrations in bronchoalveolar lavage fluid. Proteomics analysis indicated that autophagy could be involved in antibiotic-associated emphysema aggravation, and increased protein levels of LC3B, atg3, and atg7 were identified by Western blotting. In microbiome and metabolome analyses, the composition of the gut microbiota was different with smoking and antibiotic exposure, and the levels of short-chain fatty acids (SCFAs), including acetate and propionate, were reduced by antibiotic exposure. SCFA administration restored emphysema development with reduced inflammatory cells, IL-6, and IFNγ and decreased LC3B, atg3, and atg7 levels. In conclusion, antibiotics can aggravate emphysema, and inflammation and autophagy may be associated with this aggravation. This study provides important insight into the systemic impact of microbial dysbiosis and the therapeutic potential of utilizing the gut microbiota in emphysema.

Effect of anesthetic methods on cerebral oxygen saturation in elderly surgical patients: prospective, randomized, observational study.

BACKGROUND: Intraoperative cerebral oxygen desaturation was reported to be associated with postoperative cognitive dysfunction in elderly patients. The effect of the anesthesia method on regional cerebral oxygen saturation (rSO(2)) is still a question under debate. The purpose of this study was to compare the effects of three common anesthesia methods on intraoperative rSO(2) changes in elderly patients. METHODS: In this prospective randomized clinical trial, 87 patients scheduled for elective transurethral prostatectomy were allocated to receive general inhalational anesthesia (GA group, n = 30), spinal anesthesia (SA group, n = 28), or spinal anesthesia plus sedation with midazolam (SA+S group, n = 29). RESULTS: The numbers of patients showing a decrease in rSO(2) below the baseline value were higher in the SA (92.9 %) and SA+S (100 %) groups than in the GA group (33.3 %). The number of patients with a ≥ 50 % decrease in rSO(2) below baseline was greater in the SA+S (31.0 %) group than in the GA (0 %) or SA (3.6 %) group. During surgery, patients subjected to general anesthesia had higher rSO(2) than those with spinal anesthesia. Blood pressures and heart rates were similar in three groups except 5 and 10 min after anesthesia. Intraoperative SpO(2) was higher in the GA group than in the two spinal anesthesia groups. CONCLUSIONS: Spinal anesthesia is associated with more frequent cerebral desaturation than general anesthesia; and it was aggravated when combined with midazolam sedation. The cerebral effects of anesthesia should be considered when managing high-risk elderly patients.

Preoperative comorbidities and relationship of comorbidities with postoperative complications in patients undergoing transurethral prostate resection.

PURPOSE: We retrospectively identified preoperative comorbidities and analyzed the relationship of the comorbidities to postoperative complications in patients treated with transurethral prostate resection. MATERIALS AND METHODS: We reviewed the surgical and clinical records of 1,878 patients who underwent transurethral prostate resection at a single university hospital between January 2006 and December 2009. Variables included preoperative comorbidities, intraoperative data and postoperative complications, including mortality. RESULTS: Only 32.6% of the patients had no observed preoperative comorbidity and the other 67.4% had at least 1. The incidence of comorbidities increased with age (p <0.001). The overall postoperative complication rate was 5.8%. There were 3 deaths for an overall 0.16% 30-day mortality rate. The postoperative complication rate was significantly higher in patients who had a comorbidity preoperatively and were 50 to 59 (p = 0.043), 60 to 69 (p = 0.028) and 70 to 79 years old (p = 0.017). The Charlson comorbidity index was significantly associated with postoperative complications (r(2) = 0.221, p = 0.012). CONCLUSIONS: Almost two-thirds of the patients who underwent transurethral prostate resection had various preoperative comorbidities. The fact that the preoperative comorbidity was significantly related to postoperative complications after transurethral prostate resection should be considered in perioperative management in this population.

Changes of dorsalis pedis artery flow pattern after caudal block in children: observational study using a duplex sonography.

OBJECTIVE: To evaluate the changes of the flow velocity, the volume flow, and the diameter of dorsalis pedis artery using a duplex ultrasonography after caudal block with sevoflurane anesthesia in children. AIM: To know the acute change in peripheral arterial flow patterns of sympathetically blocked lower limbs in anesthetized children. BACKGROUND: Caudal analgesia in combination with general anesthesia may affect the circulatory hemodynamics due to sympatholytic vasodilating effects. METHODS: After approval by the Ethics Committee, we evaluated the changes of peripheral hemodynamics using a duplex ultrasonography before and after a caudal block in sevoflurane-anesthetized children. RESULTS: A caudal block using 0.15% ropivacaine 1.5 ml·kg(-1) significantly altered the arterial flow patterns; increased peak velocity (24%) and volume flow (76%), and the diameter of the dorsalis pedis artery (20%) in children. However, blood pressures and heart rates were not affected significantly by caudal block. CONCLUSIONS: Duplex sonographic measurements indicate that a caudal block changes the flow patterns of the dorsalis pedis artery significantly in the anesthetized children.

Fentanyl sparing effects of combined ketorolac and acetaminophen for outpatient inguinal hernia repair in children.

PURPOSE: In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair. MATERIALS AND METHODS: We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 microg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects. RESULTS: Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 microg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls. CONCLUSIONS: Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.

Fentanyl-sparing effect of acetaminophen as a mixture of fentanyl in intravenous parent-/nurse-controlled analgesia after pediatric ureteroneocystostomy.

BACKGROUND: Although acetaminophen has been used widely and is well tolerated in children, its efficacy and safety have not been clarified when combined with an opioid in intravenous parent-/nurse-controlled postoperative analgesia. METHODS: Sixty-three children (aged 6-24 months) who had undergone elective ureteroneocystostomies were enrolled in this prospective, randomized, double-blinded study. After the surgery, an analgesic pump was programmed to deliver fentanyl at a basal infusion rate of 0.25 microg.kg(-1).h(-1) and 0.25 microg/kg bolus after a loading dose of 0.5 microg/kg(-1). In the fentanyl-acetaminophen group, acetaminophen was coadministered as a solution mixture at a basal infusion rate of 1.5 mg.kg(-1).h(-1) and 1.5 mg/kg bolus after a loading dose of 15 mg/kg, whereas saline was administered to the fentanyl group. RESULTS: Postoperative pain scores were similar between the two groups. The total dose (micrograms per kilogram per day, mean+/-SD) of fentanyl at postoperative days 1 (8.3+/-3.7 vs. 18.1+/-4.6, P=0.021) and 2 (7.0+/-2.4 vs. 16.6, P=0.042) was significantly less in the fentanyl-acetaminophen group compared with that in the fentanyl group. The incidences of vomiting (16.1 vs. 56.3%, P=0.011) and sedation (9.7 vs. 46.9%, P=0.019) were significantly lower in the fentanyl-acetaminophen group than those in the fentanyl group. CONCLUSIONS: Acetaminophen has significant fentanyl-sparing effects and reduces side effects when combined with fentanyl in intravenous parent-/nurse-controlled analgesia for postoperative pediatric pain management.

Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach.

BACKGROUND: Postoperative pain following endoscopic thyroidectomy, although less severe than after open methods, is still a source of marked discomfort and surgical stress. This clinical trial was conducted to determine if repeated intravenous paracetamol could decrease postoperative pain and rescue analgesic requirements after robot-assisted endoscopic thyroidectomy via the transaxillary approach. MATERIALS AND METHODS: This prospective, randomized, double-blinded, and placebo-controlled study enrolled 124 women 21-60 years of age who were scheduled for elective gasless robot-assisted endoscopic thyroidectomy via the transaxillary approach. The patients were given placebo or 1 g of paracetamol as a 100 ml solution infused over 15 min 1 h before the induction of anesthesia, and then at 6-h intervals for the following 24 h. RESULTS: Postoperative pain scores were significantly lower at 1, 3, 6, and 24 h after surgery in the paracetamol group than in the placebo group. Significantly fewer patients in the paracetamol group received rescue analgesics compared to the placebo group (9.5% vs. 65.6%, respectively). First analgesic time was similar in the two groups. Postoperative nausea (44.3% vs. 22.2%) and vomiting (21.3% vs. 6.3%) were more frequent in the placebo group than in the paracetamol group. Other postoperative side effects, including sedation, confusion, and pruritus, were similar in the two groups. CONCLUSIONS: We concluded that repeated administration of 1 g of intravenous paracetamol over 24 h is easy, effective, safe, and well tolerated for pain management in patients with moderate to severe postoperative pain after gasless robot-assisted endoscopic thyroidectomy performed via the transaxillary approach.

Effects of epidural fentanyl on speed and quality of block for emergency cesarean section in extending continuous epidural labor analgesia using ropivacaine and fentanyl.

We performed a prospective, randomized, and double-blind study comparing the top-up effects of 2% lidocaine/100 microg fentanyl/epinephrine (n=31) and 2% lidocaine/saline/epinephrine (n=30) when extending an epidural labor analgesia using low-dose ropivacaine and fentanyl. Survival analysis for the sensory blocks to the T4 level showed no statistically significant differences in onset time to T4 between the 2 groups. Onset times (min) to T4-sensory blocks for cold and pinprick were not different between the two groups. However, median maximum sensory level in the lidocaine-fentanyl group (T1 for cold and T2 for pinprick) was significantly higher than that in the lidocaine-saline group (T3 and T4, respectively). The lidocaine-fentanyl group exhibited less visceral pain (6.5% vs. 36.7%), less supplementation of lidocaine (6.5% vs. 43.3%), and less nausea (6.5% vs. 26.7%) compared with the lidocaine-saline group during the intraoperative period. It is concluded that adding fentanyl to 2% lidocaine does not speed up the onset of the block when the onset is tested with cold or sharp pinprick but improves the quality of analgesia with fewer side effects in emergency top-up for cesarean section.

Autophagy Suppresses Toll-Like Receptor 3-Mediated Inflammatory Reaction in Human Epidermal Keratinocytes.

Autophagy, one mechanism of programmed cell death, is fundamental to cellular homeostasis. Previous studies have identified autophagy as a novel mechanism by which cytokines control the immune response. However, its precise role in immune-related inflammatory skin diseases such as psoriasis remains unclear. Thus, this study explored the functional role of autophagy in psoriatic inflammation of epidermal keratinocytes. Strong light chain 3 immunoreactivity was observed in epidermal keratinocytes of both human psoriatic lesions and imiquimod-induced mice psoriatic model, and it was readily induced by polycytidylic acid (poly (I:C)), which stimulates Toll-like receptor 3 (TLR3), in human epidermal keratinocytes in vitro. Rapamycin-induced activation of autophagy significantly reduced poly (I:C)-induced inflammatory reaction, whereas, inhibition of autophagy by 3-methyladeine increased that. Our results indicate that the induction of autophagy may attenuate TLR3-mediated immune responses in human epidermal keratinocytes, thus providing novel insights into the mechanisms underlying the development of inflammatory skin diseases including psoriasis.

Ultrasound evaluation of the sacral area and comparison of sacral interspinous and hiatal approach for caudal block in children.

BACKGROUND: Although caudal block via the sacral hiatus is a common regional technique in children, it is sometimes difficult to identify the hiatus. A needle approach via the S2-3 interspace can be used as an alternative to the conventional approach. The authors compared the feasibility and clinical characteristics between the S2-3 approach and hiatal approach, in addition to ultrasound study. METHODS: Sacral space depth, dural sac end level, and caudal space depth were evaluated using ultrasound with high-frequency linear probe in the lateral decubitus position in 317 anesthetized children (study 1). In another 162 children who underwent ambulatory urological surgeries, success rate, drug spread, and clinical characteristics were compared between the hiatal and S2-3 approaches (study 2). RESULTS: The dural sac end level was S2U (S3M-L5M). The median depth of the sacral space at the S2-3 level was 7.3 mm, whereas the caudal space depth at the hiatus was 2.9 mm. The overall success rate was 96.3% in both groups. The success rates at the first puncture attempt were 96.2% in the S2-3 group and 77.5% in the hiatus group. Drug spread level and clinical characteristics were similar between the two groups. CONCLUSIONS: The S2-3 approach can be applied as a useful fallback method to the conventional landmark approach in children, especially in those older than 36 months who present with difficult identification of the sacral hiatus.

A comparison of high volume/low concentration and low volume/high concentration ropivacaine in caudal analgesia for pediatric orchiopexy.

BACKGROUND: It is unclear whether the volume or concentration of local anesthetic influences its spread and quality of caudal analgesia when the total drug dose is fixed. METHODS: We performed this study in a prospective, randomized, observer-blind manner. Children aged 1-5 yr received a constant dose of 2.25 mg/kg of ropivacaine prepared as either 1.0 mL/kg of 0.225% (low volume/high concentration [LVHC], n = 37) or 1.5 mL/kg of 0.15% solution (high volume/low concentration [HVLC], n = 36). Both solutions contained radiopaque dye. RESULTS: The median spread levels with ranges in the HVLC group (confirmed by fluoroscopic examination) were significantly higher (T6, T3-11) than in the LVHC group (T11, T8-L2). There were no significant differences in recovery times, postoperative pain scores, or side effects between the two groups. After discharge, fewer children in the HVLC group required rescue oral acetaminophen compared with the LVHC group (50.0% vs 75.7%). First oral acetaminophen time was found to be significantly longer with HVLC patients than LVHC patients (363.0 min vs 554.5 min). CONCLUSIONS: We confirmed (with fluoroscopy) that a caudal block with 1 mL/kg ropivacaine spreads to T11 and to T6 with 1.5 mL/kg. If the total dose is fixed, caudal analgesia with a larger volume of diluted ropivacaine (0.15%) provides better quality and longer duration after discharge than a smaller volume of more concentrated ropivacaine (0.225%) in children undergoing day-case orchiopexy. The spread level of ropivacaine correlated significantly with the first oral acetaminophen time after discharge.

Effective dose of dobutamine in augmenting free flap blood flow during reconstructive surgery of the lower extremity.

Success of surgical free flap transfer depends on achieving and maintaining adequate perfusion across the microvascular anastomosis. The purpose of this prospective study was to determine the optimal infusion rate of dobutamine to augment duplex ultrasound measured blood flow to the tissue flap during surgery.Twenty-one patients undergoing general anesthesia for lower limb reconstructive surgery were recruited. The optimal dobutamine dose was evaluated using the modified Dixon's up-and-down method, starting at 6 µg·kg·min, and then titrated in increments of 1 µg·kg·min.The optimal dose of dobutamine for improving blood flow to the tissue flap was 3.50 ±â€Š0.57 µg·kg·min in 50% of patients. The 95% effective dose of dobutamine calculated by probit analysis was 4.46 µg·kg·min (95% confidence interval: 3.99-7.00 µg·kg·min).The results of our study suggest that a dobutamine infusion rate less than 5 µg·kg·minprovides significant improvement of blood flow to the tissue flap, while minimizing cardiovascular side effects.

Effect of preemptive epidural analgesia on cytokine response and postoperative pain in laparoscopic radical hysterectomy for cervical cancer.

BACKGROUND AND OBJECTIVE: Surgical stress and general anesthesia suppress immune function. Preemptive epidural analgesia can affect the perioperative immune responses, and influence cancer management. METHODS: Forty women undergoing elective laparoscopic radical hysterectomy for cervical cancer were allocated to this prospective, randomized, double-blind trial. Before inducing anesthesia, 2 mg morphine dissolved in 15 mL of 1% lidocaine (preemptive group) or the same volume of normal saline (control group) was administered into the epidural space through a prepared catheter in a double-blind manner, using sealed syringes. After peritoneal closure, the other drugs in the remaining sealed syringe were administered in the reverse manner. All patients were then administered lidocaine plus morphine over a 72-hour period, using a patient-controlled epidural analgesia pump. RESULTS: The interleukin-6 levels in both groups increased significantly after surgery. These elevations were significantly less pronounced in the preemptive group than in the control group. The interleukin-2 level in both groups decreased significantly after surgery. Seventy-two hours after surgery, the interleukin-2 level returned to its baseline value in the preemptive group but not in the control group. The number of lymphocytes in both groups decreased significantly after surgery. The pain scores at 6 and 12 hours after surgery in the preemptive group were significantly lower than in the control group. CONCLUSIONS: Preemptive epidural analgesia is a reasonable approach for potentially controlling perioperative immune function and preventing postoperative pain in patients undergoing cancer surgery.