The Involvement of the Hypothalamus-Pituitary-Adrenal Axis in the Development of Hyperalgesia during the Early Postoperative Period.

INTRODUCTION: Hyperalgesia frequently occurs after surgery and is associated with adverse effects on surgical outcomes. Thus, we aimed to examine whether the hypothalamus-pituitary-adrenal (HPA) axis function after surgery is involved in the development of postoperative hyperalgesia. METHODS: Surgery- and pain-related variables were measured 24 and 48 h after the first and second total knee arthroplasties (TKAs) in postmenopausal patients undergoing 1-week-interval staged bilateral TKA. Two sets of saliva samples were consecutively collected from patients before (pre-T1) and 1 week after (post-T1) the first TKA (n = 69). HPA axis function was analyzed in a subgroup of 20 patients with a typical cortisol awakening response (CAR) in both the sets of saliva samples. RESULTS: Surgery-related variables were comparable between the first and second TKAs. However, pain-related variables (pain ratings and the amount of opioid analgesics consumed) were greater after the second than the first TKA. Cortisol and dehydroepiandrosterone (DHEA) secretion during the post-awakening period (CARauc and Daucawk, respectively) was higher at post-T1 than at pre-T1, but the molar CARauc/Daucawk ratio was comparable between the time points examined. No relationship was observed between the pre-T1 CARauc and pain ratings after the first TKA. However, post-T1 CARauc showed a positive correlation with pain ratings after the second TKA. Postoperative pain ratings were negatively correlated with Daucawk and positively correlated with the molar CARauc/Daucawk ratio at all examined time points. DISCUSSION/CONCLUSION: The results suggest that adrenocortical steroidogenic activity favoring the production of cortisol over DHEA after surgery may contribute to the development of hyperalgesia during the early postoperative period.

Arabidopsis non-TZF gene AtC3H17 functions as a positive regulator in salt stress response.

Functional studies of CCCH-type zinc finger proteins in abiotic stress responses have largely focused on tandem CCCH-type zinc finger (TZF) genes, whereas the study of functional roles of non-TZF genes in abiotic stress responses has largely been neglected. Here, we investigated the functional roles of AtC3H17, a non-TZF gene of Arabidopsis, in salt stress responses. AtC3H17 expression significantly increased under NaCl, mannitol, and ABA treatments. AtC3H17-overexpressing transgenic plants (OXs) were more tolerant under NaCl and MV treatment conditions than the wild type (WT). atc3h17 mutants were more sensitive under NaCl and MV treatment conditions compared with the WT. The transcription of the salt stress-responsive genes in ABA-dependent pathway, such as RAB18, COR15A, and RD22, was significantly higher in AtC3H17 OXs than in WT both under NaCl-free condition and after NaCl treatment. Our results demonstrate that AtC3H17 functions as a positive regulator in salt stress response, via the up-regulation of ABA-dependent salt stress-response pathway.

AtC3H17, a Non-Tandem CCCH Zinc Finger Protein, Functions as a Nuclear Transcriptional Activator and Has Pleiotropic Effects on Vegetative Development, Flowering and Seed Development in Arabidopsis.

Despite increasing reports that CCCH zinc finger proteins function in plant development and stress responses, the functions and molecular aspects of many CCCH zinc finger proteins remain uncharacterized. Here, we characterized the biological and molecular functions of AtC3H17, a unique Arabidopsis gene encoding a non-tandem CCCH zinc finger protein. AtC3H17 was ubiquitously expressed throughout the life cycle of Arabidopsis plants and their organs. The rate and ratio of seed germination of atc3h17 mutants were slightly slower and lower, respectively, than those of the wild type (WT), whereas AtC3H17-overexpressing transgenic plants (OXs) showed an enhanced germination rate. atc3h17 mutant seedlings were smaller and lighter than WT seedlings while AtC3H17 OX seedlings were larger and heavier. In regulation of flowering time, atc3h17 mutants showed delayed flowering, whereas AtC3H17 OXs showed early flowering compared with the WT. In addition, overexpression of AtC3H17 affected seed development, displaying abnormalities compared with the WT. AtC3H17 protein was localized to the nucleus and showed transcriptional activation activity in yeast and Arabidopsis protoplasts. The N-terminal region of AtC3H17, containing a conserved EELR-like motif, was necessary for transcriptional activation activity, and the two conserved glutamate residues in the EELR-like motif played an important role in transcriptional activation activity. Real-time PCR and transactivation analyses showed that AtC3H17 might be involved in seed development via transcriptional activation of OLEO1, OLEO2 and CRU3. Our results suggest that AtC3H17 has pleiotropic effects on vegetative development such as seed germination and seedling growth, flowering and seed development, and functions as a nuclear transcriptional activator in Arabidopsis.

The effect of low-dose dexmedetomidine on hemodynamics and anesthetic requirement during bis-spectral index-guided total intravenous anesthesia.

The purpose of this study was to evaluate the effects of low-dose dexmedetomidine on hemodynamics and anesthetic requirements during propofol and remifentanil anesthesia for laparoscopic cholecystectomy. Thirty adult patients were randomly allocated to receive dexmedetomidine infusion of 0.3 µg/kg/h (dexmedetomidine group, n = 15) or comparable volumes of saline infusion (control group, n = 15). Target controlled infusion of propofol and remifentanil was used for anesthetic induction and maintenance, and adjusted in order to maintain a bispectral index of 40-55 and hemodynamic stability. We measured hemodynamics and recorded total and mean infused dosages of propofol and remifentanil. For anesthesia induction and maintenance, mean infused doses of propofol (121 ± 27 vs. 144 ± 29 µg/kg/min, P = 0.04) and remifentanil (118 ± 27 vs. 150 ± 36 ng/kg/min, P = 0.01) were lower in the dexmedetomidine group than in the control group, respectively. The dexmedetomidine group required 16 % less propofol and 23 % less remifentanil. During anesthetic induction and maintenance, the dexmedetomidine group required fewer total doses of propofol (9.6 ± 2.3 vs. 12.4 ± 3.3 mg/kg, P = 0.01) and remifentanil (9.6 ± 3.4 vs. 12.7 ± 2.6 µg/kg, P = 0.01). The change in mean arterial pressure over time differed between the groups (P < 0.05). Significantly lower mean arterial pressure was observed in the dexmedetomidine group than in the control group at immediately and 5 min after pneumoperitoneum. The time to extubation after completion of drug administration did not differ between the groups (P = 0.25). This study demonstrated that a low-dose dexmedetomidine infusion of 0.3 µg/kg/h reduced propofol and remifentanil requirements as well as hemodynamic change by pneumoperitoneum without delayed recovery during propofol-remifentanil anesthesia for laparoscopic cholecystectomy.

Arabidopsis HRE1α, a splicing variant of AtERF73/HRE1, functions as a nuclear transcription activator in hypoxia response and root development.

KEY MESSAGE: HRE1α shows transcriptional activation activity in its C-terminal region via GCC box but not DRE/CRT and plays an important role in root development via root meristem cell division regulation. AtERF73/HRE1 protein, a member of the Arabidopsis AP2/ERF family, contains a conserved AP2/ERF DNA-binding domain. Here, we studied the molecular function of HRE1α, a splicing variant of AtERF73/HRE1, as well as its role in root development. HRE1α-overexpressing transgenic plants (OXs) showed tolerance to submergence. HRE1α showed transcriptional activation activity via GCC box but not DRE/CRT. The 121-211 aa region of HRE1α was responsible for the transcriptional activation activity, and the region was conserved among homologs of other species but was not found in other Arabidopsis proteins. HRE1α OXs showed increased primary root length due to elevated root cell division. Our results suggest that HRE1α functions as a transcription activator in the nucleus, and plays an important role in root development through regulation of root meristem cell division.

Unintentional Injection Into the Retrodural Space of Okada During Transforaminal Epidural Steroid Injection.

BACKGROUND: Transforaminal epidural steroid injection (TFESI) is commonly used for radicular pain, but can lead to an unintentional injection into the retrodural Space of Okada (RSO), an extradural space located dorsal to the ligamentum flavum, instead of the epidural space. OBJECTIVES: To determine the prevalence and describe the fluoroscopic imaging features of an unintentional injection into the RSO during a TFESI and to review the history of injections into the RSO. STUDY DESIGN: Observational study and original research. SETTING: This work was conducted at Jeju National University School of Medicine, Jeju, Republic of Korea. METHODS: A total of 5,429 lumbar TFESIs performed from the September 1, 2018 through October 31, 2021 were analyzed for unintentional RSO injections using fluoroscopic-guided contrast medium patterns. RESULTS: The rate of unintentional injection into the RSO was 0.20% (11 incidents). Contrast medium patterns in the RSO had a sigmoid or ovoid shape confined to the affected facet joint, or a butterfly-shaped pattern extending into the contralateral facet joint, but rarely extending beyond the upper or lower level. LIMITATION: The rarity of unintentional injection into the RSO prevented a randomized controlled study design. CONCLUSIONS: Careful fluoroscopic examination of contrast medium patterns during lumbar TFESI is crucial to identify needle placement in the RSO. If detected, the procedure can be corrected by slightly advancing the needle into the foramen.

Oral administration of aprepitant to prevent postoperative nausea in highly susceptible patients after gynecological laparoscopy.

PURPOSE: The use of opioids following surgery is associated with a high incidence of postoperative nausea and vomiting (PONV). We conducted a prospective, randomized, double-blind, placebo-controlled study to investigate the effect of orally administered aprepitant, a neurokinin-1 receptor antagonist, for reducing PONV in patients with fentanyl-based, patient-controlled analgesia (PCA) given intravenously after gynecological laparoscopy. METHODS: One hundred and twenty female patients (ages 21-60) undergoing laparoscopic hysterectomy were randomly allocated to receive 80 mg (A80 group, n = 40) or 125 mg aprepitant (A125 group, n = 40) or placebo (control group, n = 40) orally 2 h before anesthesia induction. Anesthesia was maintained with isoflurane and remifentanil, and PCA IV using fentanyl and ketorolac were provided for 48 h after surgery. Incidences of nausea, vomiting/retching, and use of rescue antiemetics were recorded at 2, 24, and 48 h after surgery. Complete response was defined as no PONV and no need for rescue treatment. RESULTS: The incidence of complete response was significantly lower in the A80 and A125 groups than in controls, 56 % and 63 %, vs. 28 %, respectively, P = 0.007 and P = 0.003, respectively, during the first 48 h, and 65 % and 65 % vs. 38 %, respectively, both P = 0.025, during the first 2 h. However, there were no statistically significant differences between A80 and A125 groups in the incidences of complete response and PONV during the study period. CONCLUSIONS: Aprepitant 80 mg orally was effective in lowering the incidence of PONV in the first 48 h after anesthesia in patients receiving fentanyl-based PCA after gynecological laparoscopy.

The effect of alfentanil versus ketamine on the intubation condition and hemodynamics with low-dose rocuronium in children.

PURPOSE: We investigated the effect of alfentanil and ketamine on the intubation condition and hemodynamic parameters during propofol anesthesia with low-dose rocuronium in children. METHODS: Fifty-four children, aged 3-9 years undergoing tonsillectomy, were randomly allocated to receive either alfentanil 20 µg/kg (alfentanil group, n = 27) or ketamine 0.5 mg/kg (ketamine group, n = 27) 1 min before anesthesia induction. Anesthesia was induced with propofol 2.5 mg/kg and rocuronium 0.3 mg/kg and maintained with propofol infusion (6 mg/kg/h). The neuromuscular relaxation was monitored, and intubation conditions, hemodynamic changes, and recovery time were assessed. RESULTS: All patients were successfully intubated and there were no significant differences in the intubation conditions between alfentanil and ketamine groups. At the time of tracheal intubation, the median [inter-quartile range] twitch height was similar between two groups (37 [4-48] % in the alfentanil group vs. 29 [4-43.5] % in the ketamine group, p = 0.326). CONCLUSIONS: This study showed that both ketamine 0.5 mg/kg and alfentanil 20 µg/kg provided adequate intubation condition during propofol induction with low-dose rocuronium in children. The mean arterial pressure and heart rate were higher in the ketamine group after propofol injection but they remained within the normal limit in both groups throughout the study period.

Effects of magnesium sulphate on neostigmine-induced recovery from moderate neuromuscular blockade with rocuronium: a randomized controlled trial.

Magnesium enhances the effects of neuromuscular blocking agents. However, there is a paucity of evidence demonstrating possible effects of magnesium on neostigmine-induced recovery from neuromuscular blockade with rocuronium. This study compared the profiles of recovery from neuromuscular blockade between groups treated with magnesium (Group M) and placebo controls (Group C). Sixty-four patients were randomly allocated to Group M or Group C. Patients in Group M received a loading dose of 50 mg/kg magnesium and continuous infusion of 15 mg/kg/hr. Patients in Group C received a comparable amount of saline. Rocuronium at 0.6 mg/kg was used for tracheal intubation and 0.1 mg/kg of rocuronium was additionally administered to maintain train-of-four (TOF) status of 2-3 during surgery. At the end of surgery, neostigmine (50 µg/kg) plus glycopyrrolate (10 µg/kg) were administered, and the recovery time for TOF ratios of 0.7, 0.8, and 0.9 was measured. The primary outcome was the time from neostigmine administration to recovery with a TOF ratio of 0.9. In addition, rocuronium onset time (time from administration of rocuronium to 95% suppression of the first TOF twitch response), additional requirements for rocuronium and spontaneous recovery period (the time from administration of rocuronium to reappearance of the first TOF twitch response) were also measured. Neostigmine-induced recovery time was comparable between Group M and Group C (10.6 ± 4.3 vs. 9.1 ± 5.0 min, respectively, p = 0.22). The rocuronium onset time was shorter in Group M, and the spontaneous recovery period was longer in Group M. The amount of additional rocuronium administered was 27% lower in Group M, but this difference was not significant. Magnesium was not shown to prolong neostigmine-induced recovery time from neuromuscular blockade with rocuronium, however, it enhanced the clinical effects of rocuronium.

Management of a trauma patient with alcohol withdrawal who developed neuroleptic malignant syndrome in Korea: a case report.

Neuroleptic malignant syndrome (NMS) is a rare but fatal condition, with a high mortality rate. NMS is characterized by altered mental status, fever, myoclonus, autonomic dysfunctions, and elevated creatinine phosphokinase. The clinical manifestations may be confused with alcohol-related symptoms, trauma, sepsis, postoperative agitation, or malignant hyperthermia. A 69-year-old male patient with alcohol withdrawal was admitted to the operating theatre to rule out septic shock due to mesenteric injury after multiple trauma. He was suspected NMS with abrupt increase body temperature to 41.7°C after haloperidol administration. Active cooling and rapid fluid infusion was done during anesthesia. Delayed diagnosis and treatment of NMS lead to catastrophic result. Therefore, if the patient's past medical history is unknown or clinical symptoms develop that are suggestive of NMS, early treatment must be considered.

Effect of High-Flow Nasal Oxygenation on Gastric Insufflation in Patients Undergoing Laryngeal Microsurgery under Tubeless General Anesthesia with Neuromuscular Blockade.

BACKGROUND: High-flow nasal oxygenation is an oxygen delivery method by which high concentrations of heated humidified oxygen are supplied via the nasal cavity. This study aimed to investigate the effect of high-flow nasal oxygenation on gastric volume change in adult patients undergoing laryngeal microsurgery under tubeless general anesthesia with neuromuscular blockade. METHODS: Patients aged 19-80 years with an American Society of Anesthesiologists physical status 1 or 2 who were scheduled to undergo laryngoscopic surgery under general anesthesia were recruited. Patients received high-flow nasal oxygenation therapy at 70 L/min during surgery under general anesthesia with neuromuscular blockade. The cross-sectional area of the gastric antrum was measured via ultrasound in the right lateral position before and after high-flow nasal oxygenation, and the gastric volume was calculated. The duration of apnea, i.e., the duration of administration of high-flow nasal oxygenation in the paralyzed state, was also recorded. RESULTS: Of the 45 patients enrolled, 44 completed the study. There were no significant differences in the antral cross-sectional area in the right lateral position, gastric volume, and gastric volume per kg between before and after high-flow nasal oxygenation application. The median duration of apnea was 15 (interquartile range, 14-22) min. CONCLUSION: High-flow nasal oxygenation at 70 L/min during apnea with the mouth open did not influence the gastric volume in patients undergoing laryngeal microsurgery under tubeless general anesthesia with neuromuscular blockade.

Evaluation of novel antioxidant triterpenoid saponins from the halophyte Salicornia herbacea.

As a part of an ongoing search for novel antioxidants from the salt marsh plants, bioactivity-isolation and structure determination of constituents from Salicornia herbacea were performed. One new triterpenoid saponin (4), along with three known saponins (1-3), has been isolated from n-BuOH fraction of S. herbacea. On the basis of the spectroscopic methods, the structure of the new saponin 4 was elucidated as 3ß-hydroxy-23-oxo-30-noroleana-12, 20(29)-diene-28-oic acid 3-O-ß-D-glucuronopyranosyl-28-O-ß-d-glucopyranoside. Scavenging effects of saponins 1-4 were examined on 1,1-diphenyl-2-picryl-hydrazyl (DPPH) radical and peroxynitrite. Particularly, saponin 3 exerted significant antioxidant activity on both authentic peroxynitrite and peroxynitrite generated from morpholinosydnonimine (SIN-1).

Arabidopsis MKKK20 is involved in osmotic stress response via regulation of MPK6 activity.

Plants have developed various regulatory pathways to adapt to environmental stresses. In this study, we identified Arabidopsis MKKK20 as a regulator in the response to osmotic stress. mkkk20 mutants were found to be sensitive to high concentration of salt and showed higher water loss rates than wild-type (WT) plants under dehydration conditions. In addition, mkkk20 mutants showed higher accumulation of superoxide, a reactive oxygen species (ROS), compared to WT plants under high salt condition. In contrast, transgenic plants overexpressing MKKK20 displayed tolerance to salt stress. MKKK20 transcripts were increased by the treatments with NaCl, mannitol, MV, sorbitol, and cold, suggesting that MKKK20 is involved in the response to osmotic, ROS, and cold stresses. In-gel kinase assay showed that MKKK20 regulates the activity of MPK6 under NaCl, cold, and H(2)O(2) treatments. Taken together, our results suggest that MKKK20 might be involved in the response to various abiotic stresses, especially osmotic stress, through its regulation of MPK6 activity.

A noninferiority trial comparing left paratracheal pressure versus cricoid pressure on tracheal intubation conditions using the Pentax Airway Scope.

There are no studies evaluating the effect of left paratracheal pressure (PP) on difficulty of intubation using Pentax Airway Scope (Pentax), so we conducted this study to show that PP was not inferior to cricoid pressure (CP) in intubation time using the Pentax. Patients aged 19-70 years, with an American Society of Anesthesiologists physical status 1 or 2, and undergoing otorhinolaryngological, gynecological surgery, and cholecystectomy at a single university hospital were enrolled. Intubation was performed using the Pentax under PP or CP of 30 N. The primary outcome was intubation time, and the secondary outcomes were tube advancement difficulty and glottis view. The mean difference in intubation time (PP group - CP group) was - 4.19 s (95% CI - 8.24 to - 0.15), which was within the non-inferiority margin of 6.5 s, thus proving non-inferiority of the PP compared with the CP group. However, the score for tube advancement difficulty was significantly lower in the PP group than in the CP group (p = 0.02). PP did not prolong the intubation time and showed comparable intubation conditions to CP in intubation using the Pentax. Therefore, PP may be a good alternative maneuver to prevent gastric regurgitation during intubation using the Pentax.

EMF1 interacts with EIP1, EIP6 or EIP9 involved in the regulation of flowering time in Arabidopsis.

The EMBRYONIC FLOWER (EMF) 1 gene has been shown to be necessary for maintenance of vegetative development. To investigate the molecular mechanism of EMF1-mediated plant development, we screened EMF1-interacting proteins and identified 11 candidate proteins using the yeast two-hybrid system. Among the candidate genes, three EMF1-Interacting Protein (EIP) genes, EIP1, EIP6 and EIP9, are predicted to encode a WNK (with-no-lysine) kinase, a B-box zinc-finger protein and a DnaJ-domain protein, respectively. The expression patterns of EIP1, EIP6 and EIP9 were similar to that of EMF1, and EMF1-EIP1, EMF1-EIP6 and EMF1-EIP9 heterodimers were localized in the nucleus. In addition, eip1, eip6 and eip9 mutants flowered early and showed increased expression of flowering-time and floral organ identity genes, while EIP1-, EIP6- and EIP9-overexpressing transgenic plants showed late flowering phenotypes. Our results suggest that EMF1 interacts with EIP1, EIP6 and EIP9 during vegetative development to regulate flowering time in Arabidopsis.

AtERF71/HRE2 transcription factor mediates osmotic stress response as well as hypoxia response in Arabidopsis.

Various transcription factors are involved in the response to environmental stresses in plants. In this study, we characterized AtERF71/HRE2, a member of the Arabidopsis AP2/ERF family, as an important regulator of the osmotic and hypoxic stress responses in plants. Transcript level of AtERF71/HRE2 was highly increased by anoxia, NaCl, mannitol, ABA, and MV treatments. aterf71/hre2 loss-of-function mutants displayed higher sensitivity to osmotic stress such as high salt and mannitol, accumulating higher levels of ROS under high salt treatment. In contrast, AtERF71/HRE2-overexpressing transgenic plants showed tolerance to salt and mannitol as well as flooding and MV stresses, exhibiting lower levels of ROS under high salt treatment. AtERF71/HRE2 protein was localized in the nucleus, and the C-terminal region of AtERF71/HRE2 was required for transcription activation activity. Taken together, our results suggest that AtERF71/HRE2 might function as a transcription factor involved in the response to osmotic stress as well as hypoxia.

Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia.

Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.

Discrepancy between the Demand and Supply of Intensive Care Unit Beds in South Korea from 2011 to 2019: A Cross-Sectional Analysis.

PURPOSE: Intensive care unit (ICU) bed availability is key to critical patient care. In many countries, older patients generally account for a significant proportion of hospitalizations and ICU admissions. Therefore, considering the rapidly increasing aging population in South Korea, it is important to establish whether the demand for critical care is currently met by available ICU beds. MATERIALS AND METHODS: We evaluated a 9-year trend in ICU bed supply and ICU length of stay in South Korea between 2011 and 2019 in a population-based cross-sectional analysis, using data from the Korean Health Insurance Review & Assessment Service and Statistics database. We described the changes in ICU bed rates in adult (≥20 years) and older adult (≥65 years) populations. ICU length of stay was categorized similarly and was used to predict future ICU bed demands. RESULTS: The ICU bed rate per 100000 adults increased from 18.5 in 2011 to 19.5 in 2019. In contrast, the ICU bed rate per 100000 older adults decreased from 127.6 in 2011 to 104.0 in 2019. ICU length of stay increased by 43.8% for adults and 55.6% for older adults. In 2019, the regional differences in the ICU bed rate nearly doubled, and the ICU length of stay increased six-fold. The ICU bed occupancy rate in South Korea is expected to rise to 102.7% in 2030. CONCLUSION: The discrepancy between the demand and supply of ICU beds in South Korea requires urgent action to anticipate future ICU demands.

A Randomized Comparison Between Two Injections from Two Planes versus Two Injections with a Uniplanar Approach for Ultrasound-Guided Supraclavicular Block.

BACKGROUND: The brachial plexus courses along the lateral to posterior aspect of the subclavian artery located within the supraclavicular region as a trunk or division. Therefore we hypothesized that 2 injections, one along the lateral and one along the posterior aspect of the brachial plexus, could be performed by changing the angle of the ultrasound probe, thereby achieving a 3-dimensional (3-D) even distribution of local anesthetics. Previously, we confirmed the efficacy of this type of approach with that of a single cluster approach. These findings represent a subsequent study. OBJECTIVES: This study was conducted to confirm the superiority of block quality achieved by 2 injections from 2 planes (control group; group C) over 2 injections in one plane (experimental group; group E). STUDY DESIGN: A randomized, controlled trial. SETTING: Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center. METHODS: In group C (n = 35), the brachial plexus sheath was penetrated in 2 planes by anteriorly altering the angle of the ultrasound probe without changing its position. In group E (n = 35), the upper and lower portions of the brachial plexus sheath were penetrated in one plane. A total of 15 mL of lidocaine 1.5% containing epinephrine (1:200,000) was injected at each point in both groups. The ultrasound-guided supraclavicular brachial plexus block was evaluated every 5 minutes for 30 minutes. The main outcome variables were rates of blockage of all 4 nerves and ulnar nerve sparing. RESULTS: The rate of blockage of all 4 nerves (median, ulnar, radial, and musculocutaneous nerves) was not significantly different between the 2 groups (94% in group C vs. 86% in group E, respectively; P = 0.232). The number of spared ulnar nerves was similar (1 vs. 5, respectively; P = 0.088). Group procedure times, onset times, and Visual Analog Scale scores for the blocks were similar. LIMITATIONS: For the 2 plane, 2 injection approach, only 2-D imaging was performed rather than 3-D imaging. CONCLUSIONS: Two injections performed in one plane offered similar benefits to 2 injections performed in 2 planes. The 2 techniques provided comparable block qualities and could be viewed as equally effective alternatives.

CONSORT the effect of a bolus dose of dexmedetomidine on postoperative pain, agitation, and quality of recovery after laparoscopic cholecystectomy.

BACKGROUND: The perioperative administration of dexmedetomidine may improve the quality of recovery (QoR) after major abdominal and spinal surgeries. We evaluated the effect of an intraoperative bolus of dexmedetomidine on postoperative pain, emergence agitation, and the QoR after laparoscopic cholecystectomy. METHODS: Patients undergoing elective laparoscopic cholecystectomy were randomized to receive dexmedetomidine 0.5 µg/kg 5 minutes after anesthesia induction (dexmedetomidine group, n = 45) or normal saline (control group, n = 45). The primary outcome was the QoR at the first postoperative day using a 40-item scoring system (QoR-40). Secondary outcomes included intraoperative hemodynamic parameters, postoperative agitation, pain, and nausea and vomiting. RESULTS: The heart rate and the mean blood pressure were significantly lower in the dexmedetomidine group than in the control group (P < .001 and .007, respectively). During extubation, emergence agitation was significantly lower in the dexmedetomidine group than in the control group (23% vs 64%, P < .001). The median pain scores in the post-anesthetic care unit were significantly lower in the dexmedetomidine group than in the control group (4 [2-7] vs 5 [4-7], P = .034). The incidence of postoperative agitation, pain, and nausea and vomiting was not different between the groups. On the first postoperative day, recovery profile was similar between the groups. However, the scores on the emotional state and physical comfort dimensions were significantly higher in the dexmedetomidine group than in the control group (P = .038 and .040, respectively). CONCLUSIONS: A bolus dose of dexmedetomidine after anesthesia induction may improve intraoperative hemodynamics, emergence agitation, and immediate postoperative analgesia. However, it does not affect overall QoR-40 score after laparoscopic cholecystectomy.