The impact of electrosurgical devices on electromyography-based neuromuscular monitoring during abdominal laparotomy: a case series.

The present study aimed to evaluate the effect of electrosurgical devices on neuromuscular monitoring using an electromyography (EMG)-based neuromuscular monitor during abdominal laparotomy. Seventeen women (aged 32-64 years) undergoing gynecological laparotomy under total intravenous general anesthesia were enrolled in the study. A TetraGraph™ was placed to stimulate the ulnar nerve and to monitor the abductor digiti minimi muscle. After device calibration, train-of-four (TOF) measurements were repeated at intervals of 20 s. Rocuronium 0.6 to 0.9 mg/kg was administered for induction, and additional doses of 0.1 to 0.2 mg/kg were administered to maintain TOF counts ≤ 2 during the surgery. The primary outcome of the study was the ratio of measurement failure. The secondary outcomes of the study were the total number of measurements, the number of measurement failures, and the most extended consecutive number of measurement failures. The data are expressed as median (range). Of the 3091 (1480-8134) measurements, the number of measurement failures was 94 (60-200), resulting in a failure ratio of 3.5% (1.4-6.5%). The most extended consecutive number of measurement failures was 8 (4-13). All attending anesthesiologists were able to maintain and reverse neuromuscular blocks under EMG guidance. This prospective observational study demonstrated that the use of EMG-based neuromuscular monitoring does not seem to be heavily affected by electrical interference during lower abdominal laparotomic surgery. Trial registration This trial was registered in the University Hospital Medical Information Network under registration number UMIN000048138 (registration date; June 23, 2022).

Comparing Conscious Sedation With Regional Anesthesia Versus General Anesthesia in Minimally Invasive Mitral Valve Surgery With Right-Sided Minithoracotomy: A Retrospective Study.

OBJECTIVES: The aims of the present study were to evaluate and compare the safety and feasibility, including hospitalization, intensive care unit (ICU) stay, frequency of conversion to general anesthesia (GA), pH, PaCO2, and PaO2, of selected patients who underwent minimally invasive mitral valve surgery (MIMVS) via a right minithoracotomy under conscious sedation (CS) to avoid GA. The authors also aimed to evaluate the perioperative management of spontaneous breathing. DESIGN: A retrospective, observational study. SETTING: Single-center. PARTICIPANTS: This study enrolled 101 patients who underwent MIMVS under CS or GA. INTERVENTIONS: The patients who underwent MIMVS were managed under CS or GA according to indication criteria. MEASUREMENTS AND MAIN RESULTS: ICU stay (p = 0.010), postoperative time until first fluid intake (p < 0.0001), and duration of mechanical ventilation (p = 0.004) were shorter in the CS group than in the GA group. No patients converted to GA from CS. PaCO2 during cardiopulmonary bypass (CPB) in the CS group was significantly lower than that in the GA group. However, PaCO2 at the termination of CPB in the CS group was significantly higher than that in the GA group. CONCLUSIONS: In the CS group, advanced-age patients with comorbidities underwent mitral surgery without postoperative complications. The authors' findings suggested that MIMVS under CS could be a potentially less-invasive method, providing a quicker recovery than MIMVS under GA.

Target-controlled infusion and population pharmacokinetics of landiolol hydrochloride in gynecologic patients.

PURPOSE: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers. In this study, we evaluated the usefulness of target-controlled infusion (TCI) of landiolol hydrochloride and determined PK parameters of landiolol in gynecologic patients. METHODS: Nine patients who were scheduled to undergo gynecologic surgery were enrolled. After inducing anesthesia, landiolol hydrochloride was administered at the target plasma concentrations of 500 and 1,000 ng/mL for each 30 min. A total of 126 data points of plasma concentration were collected from the patients and used for the population PK analysis. Furthermore, a population PK model was developed using the nonlinear mixed-effect modeling software. RESULTS: The patients had markedly decreased heart rates (HRs) at 2 min after the initiation of landiolol hydrochloride administration; however, their blood pressures did not markedly change from the baseline value. The concentration time course of landiolol was best described by a 2-compartment model with lag time. The estimate of PK parameters were total body clearance (CL) 34.0 mL/min/kg, distribution volume of the central compartment (V 1) 74.9 mL/kg, inter-compartmental clearance (Q) 70.9 mL/min/kg, distribution volume of the peripheral compartment (V 2) 38.9 mL/kg, and lag time (ALAG) 0.634 min. The predictive performance of this model was better than that of the previous model. CONCLUSION: TCI of landiolol hydrochloride is useful for controlling HR, and the PK parameters of landiolol in gynecologic patients were similar to those in healthy male volunteers and best described by a 2-compartment model with lag time.

Effects of Marine Sand on the Microbial Degradation of Biodegradable Plastics in Seawater and Biofilm Communities that Formed on Plastic Surfaces.

Four types of biodegradable plastics were evaluated for their biodegradability in seawater collected at Ajigaura coast, Japan, in the presence or absence of marine sand. One of the plastics, poly(3-hydroxybutyrate-co-3-hydroxyhexanoate) (PHBH), showed a degree of biodegradation in a seawater sample, and the addition of marine sand markedly accelerated its biodegradation. The addition of marine sand did not affect the bacterial composition of the biofilm that formed on PHBH, and the family Rhodobacteraceae, which was predicted to contribute to the degradation of PHBH, was dominant in biofilm communities regardless of the addition of marine sand. Marine sand may serve as a bacterial source, resulting in the accelerated degradation of PHBH.

Awake intubation for thoracic aortic aneurysm causing esophageal stenosis with food residues and compression of the pulmonary artery and left bronchi: a case report.

BACKGROUND: Anesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi. CASE PRESENTATION: An 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred. CONCLUSIONS: Performing awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture.

[Administration of sugammadex to a patient with myasthenia gravis with fade of the train-of-four ratio].

A 50-year-old man (weight 87 kg, height 171 cm) with myasthenia gravis (MG) was scheduled for extended thymectomy under general anesthesia. His preanesthetic train-of-four ratio (T4/T1) was 59%. The first twitch of the train-of-four (T1) was 130% after calibration. We administered rocuronium 10 mg (0.11 mg x kg(-1)) for tracheal intubation. Maximal suppression was achieved in 50 seconds. During the operation, we did continuous infusion of rocuronium to maintain T1 at 10%. We discontinued rocuronium infusion before the end of surgery. In patients with MG, deep levels of neuromuscular block can be achieved with less rocuronium. We hypothesized that the requirement of sugammadex in a patient with MG is less than that in normal patients. Therefore, we administered 0.5 mg x kg(-1) of sugammadex. After 5 min, T4/T1 had reached 54%, but T1 had not reached the control value; therefore, we administered additional 1.5 m x kg(-1) of sugammadex. Subsequently, T1 reached 120%. Patients with MG with fade on T4/T1 require a full dose of sugammadex, identical to the dose administered to normal patients.

[Intubation training survey using four types of laryngoscopes among medical students: a comparison of the Macintosh laryngoscopes, Miller laryngoscopes, Airtraq, and Pentax-AWS Airwayscope].

BACKGROUND: Recently, rigid indirect laryngoscopes with integrated tube guidance such as Pentax-AWS (AWS) and Airtraq (ATQ) are clinically available. They are known to improve the laryngeal view and facilitate intubation compared to the Macintosh laryngoscope (MAC). However, whether these new devices are easy to learn for novice laryngoscopists is not well understood. We surveyed medical students regarding their usefulness in intubation procedure on mannequin. METHODS: Sixty-six medical students with no intubation experience were enrolled. A short instruction including practice for four devices (MAC, Miller laryngoscope (MIL), AWS, and ATQ) was given. Four intubation procedures (one for each device) to the mannequin (Laerdal airway trainer) were performed. The time to place the tube, percentage of glottic opening (POGO), incidence of esophageal intubation and teeth click were recorded. Participants were asked to choose the best device for their use. For statistical analyses, ANOVA and Chi-square tests were used where appropriate, and P < 0.01 considered significant. RESULTS: Time for intubation was significantly longer in ATQ (P < 0.01). POGO was significantly higher in AWS, but lower in MAC (P < 0.01). Complications were fewer in AWS (P < 0.01), and 70% of the participants chose AWS as the best device. CONCLUSION: With minimal instruction including practice, the AWS seemed to achieve safer intubation with better laryngeal view for novice laryngoscopists.

Early Graft Dysfunction Following Heart Transplant: Prevention and Management.

Heart transplant can be considered as the "gold standard" treatment for end-stage heart failure, with nearly 5.7 million adults in the United States carrying a diagnosis of heart failure. According to the International Society for Heart and Lung Transplantation registry, nearly 3300 orthotopic heart transplants were performed in 2016 in North America. In spite of significant improvements in overall perioperative care of heart transplant recipients for the past few decades, the risk of 30-day mortality remains 5% to 10%, primarily related to early failure of the allograft. Early graft dysfunction (EGD) occurs within 24 hours after transplant, manifesting as left ventricular dysfunction, right ventricular dysfunction, or biventricular dysfunction. EGD is further classified into primary and secondary graft dysfunction. This review focus on describing overall incidences of EGD, potential risk factors associated with EGD, perioperative preventive measures, and various management options.

Minimally Invasive Awake Mitral Valve Surgery and Cardiopulmonary Bypass Without General Anesthesia.

Herein, we report the case of a 49-year-old man with a potentially fatal allergy to propofol and remifentanil who underwent awake minimally invasive mitral valve surgery with cardiopulmonary bypass using thoracic epidural anesthesia, without the need for endotracheal general anesthesia. The aim was the management of spontaneous respiration during cardiopulmonary bypass surgery in an awake patient.

Detection of dexmedetomidine in human breast milk using liquid chromatography-tandem mass spectrometry: Application to a study of drug safety in breastfeeding after Cesarean section.

Several analytical methods for dexmedetomidine (DEX) in human plasma have been published, but quantification of DEX in human breast milk has not been described. In this article, we describe a high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method suitable for quantification of DEX in human breast milk. DEX and an internal standard were extracted in a single liquid-liquid extraction step with diethyl ether from 200µL of human breast milk. HPLC was performed on a TSK-gel ODS-100V column with isocratic elution at a flow rate of 0.3mL/min using a mobile phase of 5mM ammonium formate:0.1% formic acid in acetonitrile (60:40, v/v). Detection was performed using an API4000 mass spectrometer with positive electrospray ionization. The method was validated in the concentration range of 10pg/mL (lower limit of quantification) to 2000pg/mL. The intra- and inter-day accuracy were within ±5.8% and precision was <6.31% based on the coefficient of variation. The recoveries of DEX in human breast milk were 82.4-87.9%. Recovery and matrix effects were consistent and reproducible for human breast milk. The method is robust and was successfully used in a study of drug safety in breastfeeding in patients after administration of DEX.

Target-controlled infusion and population pharmacokinetics of landiolol hydrochloride in patients with peripheral arterial disease.

PURPOSE: We previously determined the pharmacokinetic (PK) parameters of landiolol in healthy male volunteers and gynecological patients. In this study, we determined the PK parameters of landiolol in patients with peripheral arterial disease. METHODS: Eight patients scheduled to undergo peripheral arterial surgery were enrolled in the study. After inducing anesthesia, landiolol hydrochloride was administered at target plasma concentrations of 500 and 1,000 ng/mL for 30 minutes each. A total of 112 data points of plasma concentration were collected from the patients and used for the population PK analysis. A population PK model was developed using a nonlinear mixed-effect modeling software program (NONMEM). RESULTS: The patients had markedly decreased heart rates at 2 minutes after initiation of landiolol hydrochloride administration; however, systolic blood pressures were lower than the baseline values at only five time points. The concentration time course of landiolol was best described by a two-compartment model with lag time. The estimates of PK parameters were as follows: total body clearance, 30.7 mL/min/kg; distribution volume of the central compartment, 65.0 mL/kg; intercompartmental clearance, 48.3 mL/min/kg; distribution volume of the peripheral compartment, 54.4 mL/kg; and lag time, 0.633 minutes. The predictive performance of this model was better than that of the previous model. CONCLUSION: The PK parameters of landiolol were best described by a two-compartment model with lag time. Distribution volume of the central compartment and total body clearance of landiolol in patients with peripheral arterial disease were approximately 64% and 84% of those in healthy volunteers, respectively.

Population pharmacokinetics of olprinone in healthy male volunteers.

BACKGROUND: Olprinone decreases the cardiac preload and/or afterload because of its vasodilatory effect and increases myocardial contractility by inhibiting phosphodiesterase III. PURPOSE: The objective of this study was to characterize the population pharmacokinetics of olprinone after a single continuous infusion in healthy male volunteers. METHODS: We used 500 plasma concentration data points collected from nine healthy male volunteers for the study. The population pharmacokinetic analysis was performed using the nonlinear mixed effect model (NONMEM®) software. RESULTS: The time course of plasma concentration of olprinone was best described using a two-compartment model. The final pharmacokinetic parameters were total clearance (7.37 mL/minute/kg), distribution volume of the central compartment (134 mL/kg), intercompartmental clearance (7.75 mL/minute/kg), and distribution volume of the peripheral compartment (275 mL/kg). The interindividual variability in the total clearance was 12.4%, and the residual error variability (exponential and additive) were 22.2% and 0.129 (standard deviation). The final pharmacokinetic model was assessed using a bootstrap method and visual predictive check. CONCLUSION: We developed a population pharmacokinetic model of olprinone in healthy male adults. The bootstrap method and visual predictive check showed that this model was appropriate. Our results might be used to develop the population pharmacokinetic model in patients.