Comparison of remimazolam-based and propofol-based total intravenous anesthesia on hemodynamics during anesthesia induction in patients undergoing transcatheter aortic valve replacement: a randomized controlled trial.

PURPOSE: This study aimed to compare the hemodynamic effects of remimazolam- and propofol-based total intravenous anesthesia in patients who underwent transcatheter aortic valve replacement. METHODS: This was a single-center, single-blind, randomized controlled trial set at Nara Medical University, Kashihara, Japan. We included 36 patients aged ≥ 20 years scheduled to undergo elective transfemoral transcatheter aortic valve replacement (TAVR) under general anesthesia. The participants were randomly assigned to the remimazolam and propofol groups (n = 18 each). Remimazolam- or propofol-based total intravenous anesthesia was initiated at 12 mg/kg/min or 2.5 mcg/mL via target-controlled infusion, respectively, along with remifentanil. After confirming the loss of consciousness, the administration rate was adjusted using electroencephalographic monitoring. The primary outcome was the rate of arterial hypotension, defined as a mean arterial pressure < 60 mmHg, from anesthesia induction until the beginning of the surgical incision. The total doses of ephedrine and phenylephrine were also assessed. RESULTS: During anesthesia induction, the arterial hypotension rates were 11.9% and 21.6% in the remimazolam and propofol groups, respectively (P = 0.01). The total dose of ephedrine was higher in the propofol group (14.4 mg) than in the remimazolam group (1.6 mg) (P < 0.001); however, the total dose of phenylephrine was not significantly different between the two groups (propofol 0.31 mg vs. remimazolam: 0.17 mg, P = 0.10). CONCLUSION: Remimazolam-based total intravenous anesthesia resulted in a lower hypotension rate than propofol-based total intravenous anesthesia during induction in patients undergoing TAVR. Remimazolam-based total intravenous anesthesia can be used safely during anesthetic induction in patients with severe aortic stenosis.

Deep Dissecting Hematoma Requiring Surgical Removal During Veno-Venous Extracorporeal Membrane Oxygenation Management: A Case Report.

Deep dissecting hematoma (DDH) is a disease in which minor trauma leads to the formation of an extensive hematoma. If left untreated, this can result in significant skin necrosis. Therefore, early treatment following a precise diagnosis is essential. However, the complexity of the disease may require differentiating it from soft tissue infections. A 58-year-old man with severe coronavirus disease 2019 (COVID-19) pneumonia developed skin complications such as purpura and blisters on his right upper extremity while undergoing veno-venous extracorporeal membrane oxygenation (VV-ECMO). We initially suspected a soft tissue infection or venous perfusion defect caused by the VV-ECMO cannula; however, these conditions were not observed. After making an exploratory incision, we diagnosed the patient with DDH and performed hematoma removal and skin grafting. The initial symptoms of DDH include erythema, swelling, and pain. It is important to differentiate DDH from soft tissue infections, especially necrotizing fasciitis, which is a more urgent condition. Because a surgical incision is necessary for the diagnosis and treatment of DDH, we do not hesitate to perform an exploratory incision to prevent skin necrosis, thereby contributing to early healing.

[A case of thoracic endovascular aortic repair using a transapical approach through the left ventricular apex for an ascending aortic pseudoaneurysm].

We report a case of a patient with two previous histories of resection of thymoma using median sternotomy and repair for an ascending aortic pseudoaneurysm using median thoracotomy undergoing endovascular aortic repair of the recurrence of pseudoaneurysm in the same site. Due to severe adhesion and calcification in the tissue after two histories of thoracotomy, we expected it impossible to repair the pseudoaneurysm with open thracotomy. We concluded that endovascular aortic repair was the best way for the case. Only problem was the limitation of the characters of current devices for thoracic endovascular aortic repair. If the procedure is done in the ordinary way, the tips of stent graft delivery systems are so long that there may be a danger of damaging the aortic valve, coronary artery, and left ventricle. This is why we decided to use a transapical approach through the left ventricular apex by using left thoracotomy. For the operation, an arterial line and central venous line were secured and one-lung ventilation was performed. We used femoral-femoral bypass to prepare for unexpected bleeding. During the deployment of the stent graft, ventricular fibrillation was produced by the fibrillator to locate in the appreciate site. In the end, the operation was successful.

Relationship between estimated and observed heparin sensitivity indices in cardiac and thoracic aortic surgery.

BACKGROUND: Little evidence exists on the relationship between the estimated heparin sensitivity index (HSI) based on commonly available clinical and laboratory data and observed HSI in the adult population. This retrospective study assessed the relationship between the observed and estimated HSIs. METHODS: This study was conducted in an academic, single-institution setting. Patients aged ≥ 20 years who underwent cardiac and thoracic aortic surgery and requiring cardiopulmonary bypass were included. Clinical and laboratory data, including age, sex, and platelet count, were collected. The fibrinogen-albumin ratio index was calculated by dividing the fibrinogen value by the albumin value, multiplied by 10.The HSI was calculated using the formula: (activated clotting time after initial heparin administration-baseline activated clotting time)/initial heparin dose (IU/kg). The estimated HSI was based on the results of multiple regression analysis that included clinically relevant factors. The intraclass correlation coefficient between the observed and estimated HSIs was used to assess. RESULTS: In total, 560 patients with valid activated clotting time (ACT) values after initial heparin administration were included in the final analysis to explore associated factors using the estimated HSI. Multiple regression analysis revealed that hemodialysis, platelet count, fibrinogen-to-albumin ratio index, baseline activated clotting time, and initial heparin dose were significantly associated with the HSI. The mean (standard deviation) observed and estimated HSIs were 1.38 (0.43) and 1.55 (0.13), respectively, with an intra-class correlation coefficient of 0.10. CONCLUSIONS: The correlation between the observed and estimated HSIs was low, and a formula with high accuracy for estimating the HSI is needed.

Association between Preoperative Hand Grip Strength and Postoperative Delirium after Cardiovascular Surgery: A Retrospective Study.

The association of frailty with postoperative delirium has not been fully investigated in patients undergoing cardiovascular surgery. Therefore, this study aimed to investigate whether preoperative hand grip strength is associated with postoperative delirium. This retrospective study included patients aged >65 years who had undergone elective cardiovascular surgery using cardiopulmonary bypass at a Japanese university hospital between April 2020 and February 2022. We defined low hand grip strength as hand grip values of <275 n and <177 n for men and women, respectively. Postoperative delirium was assessed using the confusion assessment method during patients' intensive care unit stay. The odds ratio of low hand grip strength for postoperative delirium was estimated using multiple logistic analysis, which was adjusted for prominent clinical factors. Ninety-five patients with a median age of 74 years were included in the final analysis, and 31.5% of them had low hand grip strength. Postoperative delirium occurred in 37% of patients, and the odds ratio of low preoperative hand grip strength for postoperative delirium was 4.58 (95% confidence interval: 1.57-13.2). Thirty-seven patients experienced postoperative delirium after cardiovascular surgery using cardiopulmonary bypass, and low preoperative hand grip strength was positively associated with its occurrence.

Perioperative Dental Injury Associated With Intubated General Anesthesia.

OBJECTIVE: Factors related to perioperative dental injury have likely changed as a variety of airway devices and preventive measures have been introduced. This retrospective chart review used data from an institutional registry to evaluate the incidence, timing, and contributing factors of patient self-reported dental injury and to assess the impact of dental injury on patient satisfaction. METHODS: Multivariate logistic analysis was performed on the records of 14,820 patients using the incidence of dental injury as the dependent variable and covariates in the anesthesia registry and a postoperative questionnaire as independent variables to investigate factors significantly associated perioperative dental injury. In addition, satisfaction with the anesthesia service was compared between patients with and without injury using a matched-pair population. RESULTS: A total of 101 dental injuries were identified. Of those, 25% were associated with intubation and extubation in the operating room, while most other injuries occurred postoperatively. Duration of anesthesia (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03) and emergency surgery (OR, 1.92; 95% CI, 1.11-3.30) were independently associated with perioperative dental injury. Dental injury did not significantly decrease a patient's satisfaction with the anesthesia service (P = .441). CONCLUSION: Most perioperative dental injuries are unrelated to anesthesia procedures. However, the duration of anesthesia and emergency surgery were significantly associated with perioperative dental injury, while decreased patient satisfaction was not.

Radiating pain during epidural needle insertion and catheter placement cannot be associated with postoperative persistent paresthesia: a retrospective review.

BACKGROUND: It has been suggested that radiating pain during spinal or epidural needle insertion and catheter placement can be an indicator of needle-related nerve injury. In this study, using a historical cohort, we investigated what factors could be associated with postoperative persistent paresthesia. In addition, we focused on radiating pain during epidural needle insertion and catheterization. METHODS: This was a retrospective review of an institutional registry containing 21,606 anesthesia cases. We conducted multivariate logistic analysis in 2736 patients, who underwent epidural anesthesia, using the incidence of postoperative persistent paresthesia as a dependent variable and other covariates, including items of the anesthesia registry and the postoperative questionnaire, as independent variables in order to investigate the factors that were significantly associated with the risk of persistent paresthesia. RESULTS: One hundred and seventy-six patients (6.44%) were found to have persistent paresthesia. Multivariate analysis revealed that surgical site at the extremities (odds ratio (OR), 12.5; 95% confidence interval (CI), 2.77-56.4; the reference was set at abdominal surgery), duration of general anesthesia (per 10 min) (OR, 1.02; 95% CI, 1.01-1.03), postoperative headache (OR, 1.78; 95% CI, 1.04-2.95), and days taken to visit the consultation clinic (OR, 1.03; 95% CI, 1.01-1.06) were independently associated with persistent paresthesia. Radiating pain was not significantly associated with persistent paresthesia (OR, 1.56; 95% CI, 0.69-3.54). CONCLUSION: Radiating pain during epidural procedure was not statistically significantly associated with persistent paresthesia, which may imply that this radiating pain worked as a warning of nerve injury.