Clinical effect of rectus sheath block compared to intrathecal morphine injection for minimally invasive colorectal cancer surgery: a propensity score-matched study.

PURPOSE: To evaluate the postoperative outcomes of a multimodal perioperative pain management protocol with rectus sheath blocks (RSBs) or intrathecal morphine (ITM) injection for minimally invasive colorectal cancer surgery. METHODS: A total of 112 patients underwent minimally invasive colorectal surgery. Forty-one patients underwent RSB (group 1), whereas 71 patients underwent ITM (group 2) in addition to multimodal pain management using enhanced recovery after the surgery protocol. To adjust for the baseline differences and selection bias, baseline characteristics and postoperative outcomes were compared using propensity score matching. RESULTS: Forty patients were evaluated in each group. There was no significant difference in the length of hospital stay between the two groups. According to the Comprehensive Complication Index (CCI) score, the postoperative complication rate was significantly lower in the RSB group (3.0 ± 7.8) than in the ITM group (8.1 ± 10.9; p = 0.016). During the first 24 h after surgery, the median postoperative visual analog scale score was significantly higher in the RSB group than in the ITM group (2.0 ± 1.1 vs. 1.5 ± 1.2; p = 0.048). Postoperative morphine use was also significantly higher in the RSB group than in the ITM group in the first 24 h (23.7 ± 19.8 vs 11.6 ± 15.6%; p = 0.003) and 48 h (16.9 ± 24.8 vs. 7.5 ± 11.9; p = 0.036) after surgery. Significant urinary retention occurred after the in the RSB and ITM groups (5% vs. 45%; p < 0.001). CONCLUSION: Although the RSB group had higher morphine use during the first 48 h after surgery, the length of hospital stay remained the same and the complications were less in terms of the CCI score. Thus, transperitoneal RSB is a safe and feasible approach for postoperative pain management following minimally invasive procedures.

Male Patients may be More Vulnerable to Acute Kidney Injury After Colorectal Surgery in an Enhanced Recovery Program: A Propensity Score Matching Analysis.

BACKGROUND: Although many reports have shown that enhanced recovery after surgery (ERAS) programs improve the perioperative outcomes of patients undergoing colorectal surgery, the prevalence of early acute kidney injury (AKI) after surgery in such patients requires attention. Protective roles of the female sex in terms of chronic kidney disease and progression of ischemic renal injury have been described in many studies. We thus explored whether a sex difference was evident in terms of postoperative AKI in a colorectal ERAS setting. METHODS: From January 2017 to August 2019, 453 patients underwent laparoscopic colorectal cancer resection in an enhanced recovery program. Of these, 217 female patients were propensity score (PS)-matched with 236 male patients. Then, 215 patients of either sex were compared in terms of postoperative renal function and complications. RESULTS: Among the PS-matched patients, the incidence of AKI was significantly higher in male than female patients (24.2% vs. 9.8%, P < 0.001). Male patients also exhibited a greater reduction in the postoperative estimated glomerular filtration rate, compared with female patients. The male sex was associated with an approximately threefold increase in the risk of AKI. The rate of surgical complications was significantly higher in male than female patients. CONCLUSIONS: Caution must be taken to prevent postoperative AKI in patients (particularly males) participating in colorectal ERAS programs. The mechanism underlying the sex difference remains unclear. Additional studies are required to determine whether male patients require perioperative management that differs from that of females, to prevent postoperative AKI.

Combined B-type Natriuretic Peptide as strong predictor of short-term mortality in patients after Liver Transplantation.

Background: B-type natriuretic peptide (BNP) is a well-known predictor for prognosis in patients with cardiac and renal diseases. However, there is a lack of studies in patients with advanced hepatic disease, especially patients who underwent liver transplantation (LT). We evaluated whether BNP could predict the prognosis of patients who underwent LT. Material and Methods: The data from a total of 187 patients who underwent LT were collected retrospectively. The serum levels of BNP were acquired at four time points, the pre-anhepatic (T1), anhepatic (T2), and neohepatic phases (T3), and on postoperative day 1 (T4). The patients were dichotomized into survival and non-survival groups for 1-month mortality after LT. Combined BNP (cBNP) was calculated based on conditional logistic regression analysis of pairwise serum BNP measurements at two time points, T2 and T4. The area under the receiver operating characteristic curve (AUROC) was analyzed to determine the diagnostic accuracy and cut-off value of the predictive models, including cBNP. Results: Fourteen patients (7.5 %) expired within one month after LT. The leading cause of death was sepsis (N = 9, 64.3 %). The MELD and MELD-Na scores had an acceptable predictive ability for 1-month mortality (AUROC = 0.714, and 0.690, respectively). The BNPs at each time point (T1 - T4) showed excellent predictive ability (AUROC = 0.864, 0.962, 0.913, and 0.963, respectively). The cBNP value had an outstanding predictive ability for 1-month mortality after LT (AUROC = 0.976). The optimal cutoff values for cBNP at T2 and T4 were 137 and 187, respectively. Conclusions: The cBNP model showed the improved predictive ability for mortality within 1-month of LT. It could help clinicians stratify mortality risk and be a useful biomarker in patients undergoing LT.

Role of thrombocytopenia in risk stratification for acute kidney injury after living donor liver transplantation.

The aim of our study was to investigate pre and intraoperative clinical factors, including platelet count, which could inform risk stratification of early acute kidney injury (AKI) after living donor liver transplantation (LDLT). Additionally, the impact of severe thrombocytopenia on AKI risk was assessed using a propensity score (PS)-matched analysis. In total, 591 adult patients who underwent LDLT between January 2009 and December 2018 at our hospital were retrospectively analyzed. Early postoperative AKI was determined based on the KDIGO criteria, and 149 patients (25.2%) developed AKI immediately after surgery. In a multivariate analysis, a lower preoperative platelet count was significantly associated with early postoperative AKI, together with diabetes mellitus, lower hourly urine output, and longer graft ischemic time; furthermore, a decrease in platelet count was correlated with AKI severity. After adjusting for the PS, the probability of AKI was significantly (1.9-fold) higher in patients with severe thrombocytopenia than in those without severe thrombocytopenia. Patients with thrombocytopenia showed a higher postoperative incidence of AKI and a higher requirement for dialysis than those without thrombocytopenia. The platelet count can easily be obtained via regular blood analysis of patients scheduled for LDLT and can be used to identify patients at risk for AKI.

Analgesic efficacy of intrathecal morphine and bupivacaine during the early postoperative period in patients who underwent robotic-assisted laparoscopic prostatectomy: a prospective randomized controlled study.

BACKGROUND: The present study was performed to investigate the analgesic efficacy of intrathecal morphine and bupivacaine (ITMB) in terms of treating early postoperative pain in adult patients who underwent robotic-assisted laparoscopic prostatectomy (RALP). METHODS: Fifty patients were prospectively enrolled and randomly classified into the non-ITMB (n = 25) and ITMB (n = 25) groups. The ITMB therapeutic regimen consisted of 0.2 mg morphine and 7.5 mg bupivacaine (total 1.7 mL). All patients were routinely administered the intravenous patient-controlled analgesia and appropriately treated with rescue intravenous (IV) opioid drugs, based on the discretion of the attending physicians who were blinded to the group assignments. Cumulative IV opioid consumption and the numeric rating scale (NRS) score were assessed at 1, 6, and 24 h postoperatively, and opioid-related complications were measured during the day after surgery. RESULTS: Demographic findings were comparable between patients who did and did not receive ITMB. The intraoperative dose of remifentanil was lower in the ITMB group than in the non-ITMB group. Pain scores (i.e., NRS) at rest and during coughing as well as cumulative IV opioid consumption were significantly lower in patients who received ITMB than in those who did not in the post-anesthesia care unit (PACU; i.e., at 1 h after surgery) and the ward (i.e., at 6 and 24 h after surgery). ITMB was significantly associated with postoperative NRS scores of ≤ 3 at rest and during coughing in the PACU (i.e., at 1 h after surgery) before and after adjusting for cumulative IV opioid consumption. In the ward (i.e., at 6 and 24 h after surgery), ITMB was associated with postoperative NRS scores of ≤ 3 at rest and during coughing before adjusting for cumulative IV opioid consumption but not after. No significant differences in complications were observed, such as post-dural puncture headache, respiratory depression, nausea, vomiting, pruritus, or neurologic sequelae, during or after surgery. CONCLUSION: A single spinal injection of morphine and bupivacaine provided proper early postoperative analgesia and decreased additional requirements for IV opioids in patients who underwent RALP. TRIAL REGISTRATION: Clinical Research Information Service, Republic of Korea; approval number: KCT0004350 on October 17, 2019. https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=15637.

Impact of intraoperative zero-balance fluid therapy on the occurrence of acute kidney injury in patients who had undergone colorectal cancer resection within an enhanced recovery after surgery protocol: a propensity score matching analysis.

PURPOSE: An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI. METHODS: Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared. RESULTS: AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9 mL/min/1.73 m2 vs. - 1.4 mL/min/1.73 m2, p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group. CONCLUSIONS: Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.

Predictive Impact of Modified-Prognostic Nutritional Index for Acute Kidney Injury within 1-week after Living Donor Liver Transplantation.

Background. Acute kidney injury (AKI) is one of the common complications after living donor liver transplantation (LDLT) and is associated with increased mortality and morbidity. The prognostic nutritional index (PNI) has been used as a predictive model for postoperative complications. Here, we create a new predictive model based on the PNI and compared its predictive accuracy to other models in patients who underwent LDLT. Material and Methods: The data from 423 patients were collected retrospectively. The patients were dichotomized into the non-AKI and the AKI groups. Multivariate adjustment for significant postoperative variables based on univariate analysis was performed. A new predictive model was created using the results from logistic regression analysis, dubbed the modified-PNI model (mPNI). The area under the receiver operating characteristic curve (AUC) was generated to determine the diagnostic accuracy and cutoff value of individual models. The net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to investigate diagnostic improvement by the mPNI. Results: Fifty-four patients (12.7 %) were diagnosed with AKI within 1-week after LDLT. The mPNI had the highest predictive accuracy (AUC = 0.823). The model of end-stage liver disease (MELD) scores and PNI were 0.793 and 0.749, respectively, and the INR and serum bilirubin were 0.705 and 0.637, respectively. The differences in the AUCs were statistically significant among the mPNI, PNI, INR, and serum bilirubin. The cutoff value for mPNI was 8.7. The NRI was 10.4% and the IDI was 3.3%. Conclusions: The mPNI predicted AKI within 1-week better than other scoring systems in patients who underwent LDLT. The recommended cutoff value of mPNI is 8.7.

Comparison of the impact of propofol versus sevoflurane on early postoperative recovery in living donors after laparoscopic donor nephrectomy: a prospective randomized controlled study.

BACKGROUND: Enhancing postoperative recovery of the donor is important to encourage living kidney donation. We investigated the effects of anesthetic agents (intravenous [IV] propofol versus inhaled [IH] sevoflurane) on the quality of early recovery of healthy living kidney donors after hand-assisted laparoscopic nephrectomy (HALN) under analgesic intrathecal morphine injection. METHODS: This single-center, prospective randomized controlled study enrolled 80 living donors undergoing HALN from October 2019 to June 2020 at Seoul St. Mary's Hospital. Donors were randomly assigned to the IV propofol group or IH sevoflurane group. To measure the quality of recovery, we used the Korean version of the Quality of Recovery-40 questionnaire (QoR-40 K) on postoperative day (POD) 1, and ambulation (success rate, number of footsteps) 6-12 h after surgery and on POD 1. The pain score for the wound site, IV opioid requirement, postoperative complications including incidences of nausea/vomiting, and length of in-hospital stay were also assessed. RESULTS: The global QoR-40 K score and all subscale scores (physical comfort, emotional state, physical independence, psychological support, and pain) were significantly higher in the IV propofol group than in the IH sevoflurane group. The numbers of footsteps at all time points were also higher in the IV propofol group. Donors in the IV propofol group had a lower incidence of nausea/vomiting, and a shorter hospitalization period. CONCLUSIONS: Total IV anesthesia with propofol led to better early postoperative recovery than that associated with IH sevoflurane. TRIAL REGISTRATION: Clinical Research Information Service, Republic of Korea (approval number: KCT0004351 ) on October 18, 2019.

Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study.

BACKGROUND: We explored the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received intravenous patient-controlled analgesia (IV-PCA), rectus sheath bupivacaine block (RSB), or intrathecal morphine with bupivacaine block (ITMB). METHODS: This was a prospective, observational clinical trial. Patients were divided into three groups: IV-PCA (n = 30), RSB (n = 30), and ITMB (n = 30). Peak pain scores at rest and with coughing, cumulative IV-PCA drug consumption, the need for IV rescue opioids, and Quality of Recovery-15 (QoR-15) questionnaire scores collected on POD 1 were compared among the groups. RESULTS: The preoperative and intraoperative findings were comparable among the groups; the ITMB group required the least remifentanil of all groups. During POD 1, the ITMB group reported lower levels of pain at rest and with coughing, compared with the other two groups. During POD 1, incidences of severe pain at rest (10.0% vs. 23.3% vs. 40.0%) and with coughing (16.7% vs. 36.7% vs. 66.7%) were the lowest in the ITMB group compared with the RSB and IV-PCA groups, respectively. After adjustment for age, body mass index, diabetes mellitus, hypertension, and intraoperative remifentanil infusion, severe pain at rest was 0.167-fold less common in the ITMB group than in the IV-PCA group, while pain with coughing was 0.1-fold lower in the ITMB group and 0.306-fold lower in the RSB group, compared with the IV-PCA group. The ITMB group required lower cumulative IV-PCA drug infusions and less IV rescue opioids, while exhibiting a better QoR-15 global score, compared with the other two groups. Complications (nausea and pruritus) were significantly more common in the ITMB group than in the other two groups; however, we noted no ITMB- or RSB-related anesthetic complications (respiratory depression, post-dural headache, nerve injury, or puncture site hematoma or infection), and all patients were assessed as Clavien-Dindo grade I or II during the hospital stay. CONCLUSION: Although ITMB induced complications of nausea and pruritus, this analgesic technique provided appropriate pain relief that enhanced patient perception related to early postoperative recovery. TRIAL REGISTRATION: Clinical Research Information Service, Republic of Korea, (approval number: KCT0005040 ) on May 20, 2020.

Delayed remnant kidney function recovery is less observed in living donors who receive an analgesic, intrathecal morphine block in laparoscopic nephrectomy for kidney transplantation: a propensity score-matched analysis.

BACKGROUND: This study analyzed remnant kidney function recovery in living donors after laparoscopic nephrectomy to establish a risk stratification model for delayed recovery and further investigated clinically modifiable factors. PATIENTS AND METHODS: This retrospective study included 366 adult living donors who underwent elective donation surgery between January 2017 and November 2019 at our hospital. ITMB was included as an analgesic component in the living donor strategy for early postoperative pain relief from November 2018 to November 2019 (n = 116). Kidney function was quantified based on the estimated glomerular filtration rate (eGFR), and delayed functional recovery of remnant kidney was defined as eGFR < 60 mL/min/1.73 m2 on postoperative day (POD) 1 (n = 240). RESULTS: Multivariable analyses revealed that lower risk for development of eGFR < 60 mL/min/1.73 m2 on POD 1 was associated with ITMB, female sex, younger age, and higher amount of hourly fluid infusion (area under the receiver operating characteristic curve = 0.783; 95% confidence interval = 0.734-0.832; p < 0.001). Propensity score (PS)-matching analyses showed that prevalence rates of eGFR < 60 mL/min/1.73 m2 on PODs 1 and 7 were higher in the non-ITMB group than in the ITMB group. ITMB adjusted for PS was significantly associated with lower risk for development of eGFR < 60 mL/min/1.73 m2 on POD 1 in PS-matched living donors. No living donors exhibited severe remnant kidney dysfunction and/or required renal replacement therapy at POD 7. CONCLUSIONS: We found an association between the analgesic impact of ITMB and better functional recovery of remnant kidney in living kidney donors. In addition, we propose a stratification model that predicts delayed functional recovery of remnant kidney in living donors: male sex, older age, non-ITMB, and lower hourly fluid infusion rate.

Intraoperative changes in whole-blood viscosity in patients undergoing robot-assisted laparoscopic prostatectomy in the steep Trendelenburg position with pneumoperitoneum: a prospective nonrandomized observational cohort study.

BACKGROUND: The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes. METHODS: Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30 min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300 s- 1) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5 s- 1) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as > 13.0 cP at 300 s- 1 and diastolic blood hyperviscosity was defined as > 4.1 cP at 5 s- 1. RESULTS: The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications. CONCLUSIONS: Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum. TRIAL REGISTRATION: Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.

Risk stratification for early bacteremia after living donor liver transplantation: a retrospective observational cohort study.

BACKGROUND: This study investigated perioperative clinical risk factors for early post-transplant bacteremia in patients undergoing living donor liver transplantation (LDLT). Additionally, postoperative outcomes were compared between patients with and without early post-transplant bacteremia. METHODS: Clinical data of 610 adult patients who underwent elective LDLT between January 2009 and December 2018 at Seoul St. Mary's Hospital were retrospectively collected. The exclusion criteria included overt signs of infection within 1 month before surgery. A total of 596 adult patients were enrolled in this study. Based on the occurrence of a systemic bacterial infection after surgery, patients were classified into non-infected and infected groups. RESULTS: The incidence of bacteremia at 1 month after LDLT was 9.7% (57 patients) and Enterococcus faecium (31.6%) was the most commonly cultured bacterium in the blood samples. Univariate analysis showed that preoperative psoas muscle index (PMI), model for end-stage disease score, utility of continuous renal replacement therapy (CRRT), ascites, C-reactive protein to albumin ratio, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, and sodium level, as well as intraoperative post-reperfusion syndrome, mean central venous pressure, requirement for packed red blood cells and fresh frozen plasma, hourly fluid infusion and urine output, and short-term postoperative early allograft dysfunction (EAD) were associated with the risk of early post-transplant bacteremia. Multivariate analysis revealed that PMI, the CRRT requirement, the NLR, and EAD were independently associated with the risk of early post-transplant bacteremia (area under the curve: 0.707; 95% confidence interval: 0.667-0.745; p < 0.001). The overall survival rate was better in the non-infected patient group. Among patients with bacteremia, anti-bacterial treatment was unable to resolve infection in 34 patients, resulting in an increased risk of patient mortality. Among the factors included in the model, EAD was significantly correlated with non-resolving infection. CONCLUSIONS: We propose a prognostic model to identify patients at high risk for a bloodstream bacterial infection; furthermore, our findings support the notion that skeletal muscle depletion, CRRT requirement, systemic inflammatory response, and delayed liver graft function are associated with a pathogenic vulnerability in cirrhotic patients who undergo LDLT.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report.

BACKGROUND: We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT). CASE PRESENTATION: A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO2 insufflation and the head-up position. SpO2 decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO2 or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax. CONCLUSION: This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO2 gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Simple calculation of the optimal insertion depth of esophageal temperature probes in children.

Placing an esophageal temperature probe (ETP) in the optimal esophageal site is important in various anesthetic and critical care settings to accurately monitor the core temperature of a pediatric patient. However, no reported study has provided a formula to calculate the optimal insertion depth of ETP placement in children based on direct measurement of the optimal depth. The aim of this study was to develop a simple and reliable method to determine the optimal depth of ETP placement in children via their mouth. Using preoperative chest computed tomography scans, intraoperative chest X-rays, and the actual depth of ETP insertion, we measured the optimal depth of ETP placement retrospectively in 181 children aged 3-13 years who underwent minimally invasive repairs of the pectus excavatum and removal of a pectus bar. A linear regression analysis was performed to assess the correlation of the optimal depth of ETP placement with the children's age, weight, and height. The optimal depth of ETP placement had a greater correlation with height than with age or weight, and the best-fit equation was '0.180 × height + 6.749 (cm) (R2 = 0.920).' We obtained three simplified formulae, which showed no statistically significant difference in predicting the optimal depth of ETP placement: height/6 + 8 (cm), height/5 + 4 (cm), and height/5 + 5 (cm). The optimal depth of ETP via children's mouths has a close correlation with height and can be calculated with a simple formula 'height/5 + 5 (cm)'.

Analysis of pre- and intraoperative clinical for successful operating room extubation after living donor liver transplantation: a retrospective observational cohort study.

BACKGROUND: Early extubation after liver transplantation is safe and accelerates patient recovery. Patients with end-stage liver disease undergo sarcopenic changes, and sarcopenia is associated with postoperative morbidity and mortality. We investigated the impact of core muscle mass on the feasibility of immediate extubation in the operating room (OR) after living donor liver transplantation (LDLT). METHODS: A total of 295 male adult LDLT patients were retrospectively reviewed between January 2011 and December 2017. In total, 40 patients were excluded due to emergency surgery or severe encephalopathy. A total of 255 male LDLT patients were analyzed in this study. According to the OR extubation criteria, the study population was classified into immediate and conventional extubation groups (39.6 vs. 60.4%). Psoas muscle area was estimated using abdominal computed tomography and normalized by height squared (psoas muscle index [PMI]). RESULTS: There were no significant differences in OR extubation rates among the five attending transplant anesthesiologists. The preoperative PMI correlated with respiratory performance. The preoperative PMI was higher in the immediate extubation group than in the conventional extubation group. Potentially significant perioperative factors in the univariate analysis were entered into a multivariate analysis, in which preoperative PMI and intraoperative factors (i.e., continuous renal replacement therapy, significant post-reperfusion syndrome, and fresh frozen plasma transfusion) were associated with OR extubation. The duration of ventilator support and length of intensive care unit stay were shorter in the immediate extubation group than in the conventional extubation group, and the incidence of pneumonia and early allograft dysfunction were also lower in the immediate extubation group. CONCLUSIONS: Our study could improve the accuracy of predictions concerning immediate post-transplant extubation in the OR by introducing preoperative PMI into predictive models for patients who underwent elective LDLT.

Perioperative loss of psoas muscle is associated with patient survival in living donor liver transplantation.

Patients with end-stage liver disease show sarcopenia, and preoperative sarcopenia is independently associated with patient mortality after liver transplantation. However, few studies have examined the relationship between perioperative loss of core muscle and patient mortality in living donor liver transplantation (LDLT). This study was performed to investigate the association between a perioperative decrease in the psoas muscle index (PMI) and patient mortality after LDLT. Adult patients (age ≥ 18 years) undergoing LDLT between January 2009 and December 2016 were classified into low-loss (>25th quartile) versus high-loss (≤25th quartile) groups according to PMI change between the day before surgery and postoperative day (POD) 7. Patient survival was compared between the 2 groups, and factors affecting survival were analyzed. The median (interquartile range) level of PMI change from the day before surgery to POD 7 was -4.8% (-11.7%-1.2%). Although there was no preoperative difference in PMI between the low-loss and high-loss groups, patients with PMI change ≤-11.7% showed poorer survival than those with PMI change >-11.7% during the follow-up period. A PMI decrease ≤-11.7% between the day before surgery and POD 7 is an independent predictor of patient mortality after LDLT. In addition, intraoperative packed red blood cell transfusion, graft fat percentage, and reoperation and infection after surgery were significantly associated with patient mortality. In conclusion, a PMI decrease ≤-11.7% between the day before surgery and POD 7 is an independent predictor of patient mortality after LDLT. It is necessary to identify the factors responsible for the perioperative decrease in skeletal muscle mass and to ascertain if they are modifiable to improve patient survival after LDLT. Liver Transplantation 24 623-633 2018 AASLD.

Predictive Role of Serum Cytokine Profiles in Acute Kidney Injury after Living Donor Liver Transplantation.

INTRODUCTION: Previous studies have shown that a higher serum interleukin- (IL-) 6 level is associated with a higher risk of acute kidney injury (AKI) development after major nontransplant surgery. Our study investigated the potential association of preoperative serum cytokine profiles with new AKI development in patients who underwent living donor liver transplantation (LDLT). METHODS: Serum levels of cytokines IL-2, IL-6, IL-10, IL-12, and IL-17, interferon-γ, and tumor necrosis factor- (TNF-) α were measured in 226 LDLT recipients preoperatively and analyzed retrospectively. Recipients with a preoperative functional impairment of the kidney were excluded. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. RESULTS: In a univariate regression model, IL-6, IL-17, and TNF-α levels showed an association with AKI development after LDLT. Multivariate analysis showed an independent association of the preoperative serum IL-6 level with AKI development after LDLT and a significant relationship between higher serum IL-6 levels and a greater likelihood of developing AKI. Serum IL-6 levels were higher in patients with stage 3 AKI than in patients who did not develop AKI. CONCLUSIONS: Our results support the need for further investigations of IL-6 as a predictor of AKI development in patients undergoing LDLT.

Enhanced optical output of InGaN/GaN near-ultraviolet light-emitting diodes by localized surface plasmon of colloidal silver nanoparticles.

We report on the characteristics of localized surface plasmon (LSP)-enhanced near-ultraviolet light-emitting diodes (NUV-LEDs) fabricated by using colloidal silver (Ag) nanoparticles (NPs). Colloidal Ag NPs were deposited on the 20 nm thick p-GaN spacer layer using a spray process. The optical output power of NUV-LEDs with colloidal Ag NPs was increased by 48.7% at 20 mA compared with NUV-LEDs without colloidal Ag NPs. The enhancement was attributed to increased internal quantum efficiency caused by the resonance coupling between excitons in the multiple quantum wells and the LSPs in the Ag NPs.

The Efficacy of Lumbosacral Spine Phantom to Improve Resident Proficiency in Performing Ultrasound-Guided Spinal Procedure.

OBJECTIVE: To evaluate the efficacy of a lumbosacral spine phantom to improve novices' proficiency in performing ultrasound-guided facet joint injection and medial branch block. DESIGN AND SETTING: Prospective study in a university hospital. SUBJECTS: In total, 30 participants with no experience of spinal ultrasonography were included and were allocated to one of two groups (control group, N = 10 and training group, N = 20). METHODS: A lumbosacral spine phantom was prepared using a lumbosacral spine model embedded in a mixture of gelatin and psyllium husk. All participants were tested (test-1) following a basic education introductory program. Participants in the control group were then tested again after 1 week (test-2). Those in the training group received a further 3-h training, individually, and were tested again after 1 week (test-2). RESULTS: The mean performance scores on test-1 were 57.6 ± 6.0 in the control group and 57.3 ± 6.7 in the training group; and at test-2, 61.0 ± 8.6 and 91.7 ± 4.9 (P < 0.001), respectively. The median time of performance at test-1 was 158.3 ± 41.9 seconds in the control group and 185.3 ± 68.1 seconds in the training group; and at test-2, 146.9 ± 38.9 seconds and 69.9 ± 22.0 seconds (P < 0.001), respectively. In the training group, the mean self-rating level of proficiency scores were 2.2 ± 1.0 at pretraining, and 6.8 ± 0.8 at post-training, respectively (P < 0.001). CONCLUSION: Training using a gelatin-based spine phantom helped novices to acquire the skills necessary to perform ultrasound-guided lumbar facet joint injections and medial branch blocks.