Comparison of dexmedetomidine versus propofol sedation on microcirculation and organ injuries in critically ill surgical patients: A randomized controlled pilot study.

BACKGROUND: Recent studies have shown that dexmedetomidine may improve microcirculation and prevent organ failure. However, most evidence was obtained from experimental animals and patients receiving cardiac surgery with cardiopulmonary bypass. This study aimed to investigate the effect of dexmedetomidine on microcirculation and organ injuries in critically ill general surgical patients. METHODS: In this prospective randomized trial, patients admitted to the surgical intensive care unit after general surgery were enrolled and randomly allocated to the dexmedetomidine or propofol groups. Patients received continuous dexmedetomidine or propofol infusions to meet their requirement of sedation according to their grouping. At each time point, sublingual microcirculation images were obtained using the incident dark field video microscope. RESULTS: Overall, 60 patients finished the trial and were analyzed. Microcirculation parameters did not differ significantly between two groups. Heart rate at 4 h after ICU admission and mean arterial pressures at 12 h and 24 h after ICU admission were lower in the dexmedetomidine group than in the propofol group. At 24 h, serum aspartate aminotransferase (41 (25-118) vs 86 (34-129) U/L, p = 0.035) and alanine aminotransferase (50 (26-160) vs 68 (35-172) U/L, p = 0.019) levels were significantly lower in the dexmedetomidine group than in the propofol group. CONCLUSION: Microcirculation parameters did not differ significantly between the dexmedetomidine and propofol groups. At 24 h after ICU admission, serum liver enzyme levels were lower in patients receiving dexmedetomidine as compared to propofol.

Hypothermia is an independent risk factor for prolonged ICU stay in coronary artery bypass surgery: an observational study.

Maintenance of normothermia is a critical perioperative issue. The warming process after hypothermia tends to increase oxygen demand, which may lead to myocardial ischemia. This study explored whether hypothermia was an independent risk factor for increased morbidity and mortality in patients receiving CABG. We conducted a retrospective observational study of CABG surgeries performed from January 2018 to June 2019. The outcomes of interest were mortality, surgical site infection rate, ventilator dependent time, intensive care unit (ICU) stay, and hospitalization duration. Data from 206 patients were analysed. Hypothermic patients were taller (p = 0.012), had lower left ventricular ejection fraction (p = 0.016), and had off-pump CABG more frequently (p = 0.04). Our analysis noted no incidence of mortality within 30 days. Hypothermia was not associated with higher surgical site infection rate or longer intubation time. After adjusting for sex, age, cardiopulmonary bypass duration, left ventricular ejection fraction, and EuroSCORE II, higher EuroSCORE II (p < 0.001; odds ratio 1.2) and hypothermia upon ICU admission (p = 0.04; odds ratio 3.8) were independent risk factors for prolonged ICU stay. In addition to EuroSCORE II, hypothermia upon ICU admission was an independent risk factor for prolonged ICU stay in patients receiving elective CABG.

Design, synthesis, and anticancer evaluation of 1-benzo[1,3]dioxol-5-yl-3-N-fused heteroaryl indoles.

A series of 1-benzo[1,3]dioxol-5-yl-indoles bearing 3-N-fused heteroaryl moieties have been designed based on literature reports of the activity of indoles against various cancer cell lines, synthesized via a Pd-catalyzed C-N cross-coupling, and evaluated for their anticancer activity against prostate (LNCaP), pancreatic (MIA PaCa-2), and acute lymphoblastic leukemia (CCRF-CEM) cancer cell lines. A detailed structure-activity relationship study culminated in the identification of 3-N-benzo[1,2,5]oxadiazole 17 and 3-N-2-methylquinoline 20, whose IC50 values ranged from 328 to 644 nM against CCRF-CEM and MIA PaCa-2. Further mechanistic studies revealed that 20 caused cell cycle arrest at the S phase and induced apoptosis in CCRF-CEM cancer cells. These 1-benzo[1,3]dioxol-5-yl-3-N-fused heteroaryl indoles may serve as a template for further optimization to afford more active analogs and develop a comprehensive understanding of the structure-activity relationships of indole anticancer molecules.

Detecting Volemic, Cardiac, and Autonomic Responses From Hypervolemia to Normovolemia via Non-Invasive ClearSight Hemodynamic Monitoring During Hemodialysis: An Observational Investigation.

Background: Unstable hemodynamics are not uncommon during hemodialysis (HD), which involves a rapid volume depletion, taking the patient from hypervolemia toward euvolemia. Since uremic patients commonly have cardiovascular comorbidities, hemodynamic changes during HD may reflect interactions among the volemic, cardiac, and autonomic responses to gradual volume depletion during ultrafiltration. Accurate identification of inappropriate responses helps with precisely managing intradialytic hypotension. Recently, the non-invasive ClearSight was reported to be able to detect causes of intraoperative hypotension. In this prospective observational study, we aimed to determine whether ClearSight could be used to detect patterns in stroke volemic, cardiac, and vasoreactive responses during HD. Methods: ClearSight was used to monitor chronic stable patients receiving maintenance HD. Data of mean arterial blood pressure (MAP), heart rate (HR), stroke volume index (SVI), cardiac index (CI), and calculated systemic vascular resistance index (SVRI) were obtained and analyzed to examine patterns in volemic, cardiac, and vasoreactive changes from T0 (before HD) until T8 in 30-min intervals (total 4 h). Results: A total of 56 patients with a mean age of 60.5 years were recruited, of which 40 of them were men. The average ultrafiltration volume at T8 was 2.1 ± 0.8 L. The changes in MAP and HR from T0 to T8 were non-significant. SVI at T7 was significantly lower than that at T1, T2, and T3. CI at T4 to T8 was significantly lower than that at T0. SVRI was significantly higher at T3 to T8 than at T0. Pearson's correlation coefficients between SVI and CI and between SVRI and MAP were positive at all time points. The correlation coefficients between SVRI and SVI and between CI and SVRI were significant and negative for all time points. Conclusion: ClearSight was able to detect patterns in hypervolemia during HD and was well tolerated for 4 h. CI decreased significantly after T4, with slightly decreased SVI. Ultrafiltration volume was not correlated with changes in SVI or CI. The vascular tone increased significantly, and this counteracted the reduced cardiac output after T4. With simultaneous monitoring on SVI, CI, and SVRI during HD, therefore, hypotension could be detected and managed by reducing the filtration rate or administering inotrope or vasopressors. Trial Registration: clinicaltrials.gov, ID: NCT03901794.

Surgical resection for congenital lung malformation: Lessons learned from thoracotomy to biportal thoracoscopy under one-lung ventilation.

BACKGROUND: The purpose of this study is to compare the clinical characteristics and surgical outcomes of thoracotomy and video-assisted thoracoscopic surgery (VATS) in children with congenital lung malformations (CLMs) in a tertiary referring center and to report our modified biportal VATS setting. METHODS: This is a single-center retrospective chart review study including children who underwent surgical resection for CLMs between January 2007 and December 2020. Patient characteristics and surgical outcomes were compared between open and thoracoscopy, as well as conventional VATS and biportal VATS. Biportal setting included an anterior utility wound and a camera trocar wound with one-lung ventilation. RESULTS: A total of 100 patients were identified. Twenty patients received thoracotomy, and 80 patients received VATS (67 conventional and 13 biportal VATS). The median age at operation was 0.4 months in the thoracotomy group and 4.7 months in the VATS group. More patients in the thoracotomy group had preoperative symptoms, comorbidities, and emergent operations. The patients who underwent thoracotomy had significantly longer postoperative ICU stays, chest tube durations, hospital stays, and more complications. The pathological analysis revealed 67 congenital pulmonary airway malformations, 27 pulmonary sequestration, 6 hybrid lesions, and one accompanying pleuropulmonary blastoma. Compared to conventional VATS, the ICU stay was shorter in the biportal VATS group, with comparable operative durations, hospital stay and complications. CONCLUSION: VATS for CLMs is associated with better postoperative recovery and fewer complications. Biportal VATS is also a safe and feasible approach.

Effects of polymyxin B hemoperfusion on hemodynamics and prognosis in septic shock patients.

PURPOSE: We designed this study to examine the clinical effects of polymyxin B hemoperfusion (PMX-HP) in septic shock patients. MATERIAL AND METHODS: We retrospectively examined the effects of PMX-HP in septic shock patients with intra-abdominal or gram-negative bacterial infection during October 2013-May 2016. A one-to-one matching between the PMX-HP and conventional groups was performed, and 28-day mortality, and change in inotropic score, Sequential Organ Failure Assessment (SOFA) score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24h in the two groups were compared. In addition, multivariable regression analysis and Cox proportional hazards regression model were applied in all eligible patients. RESULTS: Sixty-nine patients were eligible, of whom fifty patients were enrolled for matched cohort analysis. In matched cohort analysis, change in inotropic score after 24h (-24.8 [19.7] vs. -6.4 [20.0], p=0.002) differed significantly between the PMX-HP and conventional groups. Multivariable regression analysis revealed that PMX-HP was associated with lower 28-day mortality (odds ratio 0.18, 95% CI 0.04-0.92, p=0.039) and greater improvement in inotropic and APACHE II scores. CONCLUSIONS: PMX-HP may have potential benefits for hemodynamic and prognostic outcomes in septic shock patients with intra-abdominal or gram-negative bacterial infection.

Chlorhexidine-related refractory anaphylactic shock: a case successfully resuscitated with extracorporeal membrane oxygenation.

IMPORTANCE: We report a patient with a life-threatening anaphylactic reaction to a chlorhexidine-coated central venous catheter, confirmed with a high serum level of chlorhexidine-specific IgE. To our knowledge, this is the first case successfully resuscitated using extracorporeal membrane oxygenation (ECMO). Great caution is required when using chlorhexidine and chlorhexidine-impregnated catheters, given that its widespread use has the potential to sensitize certain patients and may result in life-threatening anaphylaxis on subsequent exposure. OBSERVATIONS: A case report of a single patient with life-threatening anaphylactic shock to chlorhexidine, who was successfully resuscitated using ECMO. CONCLUSIONS: We have designed a flowchart for the diagnosis and management of severe anaphylaxis. This case report highlights the potential for chlorhexidine to be a source for the development of refractory anaphylactic shock. We suggest that ECMO may save the lives of patients with severe bronchospasm and refractory anaphylactic shock secondary to chlorhexidine.

Injury Location and Mechanism for Complex Regional Pain Syndrome: A Nationwide Population-Based Case-Control Study in Taiwan.

BACKGROUND: Few studies have investigated the relationship between injury location, mechanism and their association with complex regional pain syndrome (CRPS). We conducted a nationwide database survey to explore this issue. METHODS: This was a population-based case-control study. Five hundred and eighty-nine patients with at least one ambulatory visit or admission with a principal diagnosis of CRPS from 2004 to 2009 were selected. For each CRPS patient, ten age- and sex-matched non-CRPS subjects were randomly selected. The odds ratios (PLoS One. 2013;8:e57205) and 95% confidence intervals (95% CIs) of risk factors for CRPS were derived from multivariate logistic regression models. RESULTS: Injury was a risk factor for CRPS (OR, 2.96; 95% CI, 2.18 to 4.02) independent of age and sex. In adjusted models, open wound on the upper limbs (OR 1.25, 95% CI 1.02 to 1.54) conferred higher CRPS risk. Injury mechanisms including nerve and spinal cord injury (OR 2.42, 95% CI 1.44 to 4.08), muscle and joint sprain and strain (OR 1.69, 95% CI 1.40 to 2.03), superficial injury (OR 1.23, 95% CI 1.00 to 1.51), and contusion (OR 1.44, 95% CI 1.20 to 1.74), but not fracture, increased the risk of CRPS. CONCLUSION: Injury in the extremities rather than the trunk is an important risk factor for CRPS. Certain injury mechanisms confer higher risk of CRPS. This nationwide study demonstrated that injury increased CRPS nearly threefold. Open wound, sprain and strain, superficial injury, contusion, and nerve and spinal cord injury are main injury mechanisms. Injury in the extremities confers a higher risk of CRPS.

Evaluation of tracheal intubation: A retrospective study of skill acquisition by medical students in the operating theater.

BACKGROUND/PURPOSE: Tracheal intubation is a critical life-saving invasive procedure. Medical students generally obtain the skill of performing tracheal intubation in the operating theater during their anesthesiology rotation. In this study, we sought to characterize medical students' skill acquisition of tracheal intubation. METHODS: We retrospectively reviewed the logbooks of 94 medical students who had completed a 3-4 week rotation in our department between January 2011 and June 2012. RESULTS: Ninety-four students performed 934 tracheal intubations. The success rate of intubation was 76.7%. After adjustment for age, body mass index, Mallampati class and grade, American Society of Anesthesiology (ASA) scores, and surgical category, the odds ratio of successful tracheal intubation improved with cumulative practice [odds ratio (OR) = 1.05 for each additional intubation performed; 95% confidence interval (CI) 1.00-1.09]. By contrast, the success rate decreased significantly with increasing scores of Mallampati class (OR = 0.32 for each increase in class; 95% CI 0.23-0.24) and grade (OR = 0.57 for each increase in grade; 95% CI 0.39-0.84). The main reason for intubation failure (57%) was poor visualization of vocal cords, due to suboptimal placement of the position of the laryngoscope. The satisfaction and confidence of students regarding the ability of performing tracheal intubation increased with each additional procedure, but decreased significantly after multiple unsuccessful attempts and the occurrence of any complication. CONCLUSION: Medical students acquired the ability of tracheal intubation and overcame major challenges through cumulative clinical practice of the procedure.

Transcatheter aortic valve implantation: Anesthetic experience of retrograde transfemoral approach with CoreValve ReValving System.

OBJECTIVES: Valvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure. METHODS: We included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded. RESULTS: The mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5-10 µg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality. CONCLUSION: TAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.

The Alaris auditory evoked potential monitor as an indicator of seizure inducibility and duration during electroconvulsive therapy: an observational study.

BACKGROUND: Precise control of anesthetic depth during electroconvulsive therapy (ECT) is crucial because most intravenous anesthetics have anticonvulsant effects. In this study, we investigated the association between anesthetic depth measured by the Alaris auditory evoked potential index (AAI) and seizure inducibility and seizure duration during ECT. METHODS: Sixty-four ECTs were evaluated in 12 consecutive patients. General anesthesia was performed with a thiopental-based method. The relationship between the pre-ictal AAI, seizure activity and seizure duration was analyzed, and a possible threshold pre-ictal AAI to induce a seizure duration of at least 25 seconds was calculated. RESULTS: Forty-one of the 64 ECT stimuli successfully induced seizure activity that lasted longer than 25 seconds. Pre-ictal AAI was significantly correlated to seizure duration (r = 0.54, p < 0.001) and the threshold pre-ictal AAi value was calculated to be 26 (area under curve: 0.76, sensitivity: 70.3% and specificity: 73.9%, p < 0.001). ECT with a pre-ictal AAI ≧ 26 had a higher incidence of successful seizure activity ( p < 0.001) and a longer seizure duration (55 ± 35 v.s. 21 ± 27 seconds, p < 0.001). CONCLUSION: Maintenance of a pre-ictal AAI value ≧ 26 was associated with an increased incidence of successful seizure activities and a longer seizure duration. This is the first report to investigate Alaris AEP monitoring during ECT.

Risk stratification and outcome of cardiac surgery for patients with body weight <2 ,500g in an Asian center.

BACKGROUND: Cardiac surgery performed in patients with low body weight is a challenge for surgeons. Currently, such outcomes are mainly reported from European or North American centers. In this study, we review our cardiac surgery experience with neonates and infants weighing <2,500g. METHODS AND RESULTS: We included patients with a body weight <2,500g who received cardiac surgery between January 2008 and December 2012. The survival outcome was compared to that of patients with large body weight, and then the Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1) categorization was used for operative risk stratification. In the 1,245 index operations, 53 patients (4.3%) were <2,500g. The mean body weight was 2,232g (range 1,320-2,500g). The hospital mortality rate was 20.7% (11/53). Most (85%) of the procedures were in RACHS-1 category ≥3. The risk ratio was significantly higher in RACHS-1 category 3 (relative risk [RR]:6.2; 95% confidence interval [CI]:1.6-23.9) and 4 (RR:4.6; 95% CI:1.4-15.0), respectively, while it was not significantly different in category 2 (RR:1.02; 95% CI:1.01-1.02) and category 6 (RR:2.9; 95% CI:0.36-13.3). CONCLUSIONS: Cardiac surgery performed on infants with low body weight is generally a complex procedure, but the results are acceptable. The risk was higher than that for patients with higher body weight in RACHS-1 category 3 and 4. Further investigation to improve the outcome of this high-risk group is needed.

Cardioversion corrects cardiac arrhythmia and reverts the resultant reversed shunt flow direction during transcatheter closure of atrial septal defect--a case report.

Closure of atrial septal defect (ASD) is critically dependent on the shunt flow direction. However, shunt flow direction through ASD may change under variable clinical conditions. We present here a 53-year-old woman with a confirmed left-to-right shunt ASD prior to Amplatzer Septal Occluder placement. The development of atrial flutter during the procedure had been found to change the shunt from unidirectional to bidirectional and the procedure was then forced to a temporary halt. The cardiac arrhythmia and altered shunt direction simultaneously reverted to the old state after cardioversion. A successful placement of Amplatzer septal occluder was successfully performed afterward and she recovered uneventfully.