Effect of Sevoflurane Anesthesia on Diastolic Function: A Prospective Observational Study.

BACKGROUND: The effect of sevoflurane on left ventricular diastolic function is not well understood. We hypothesized that parameters of diastolic function may improve under sevoflurane anesthesia in patients with preexisting diastolic dysfunction compared to patients with normal diastolic function. METHODS: This observational study included 60 patients undergoing breast surgery or laparoscopic cholecystectomy. Patients were assigned to diastolic dysfunction (n = 34) or normal (n = 26) groups of septal e' < 8 or ≥ 8.0 cm/s on the first thoracic echocardiography (TTE) performed before anesthesia. During anesthesia, sevoflurane was maintained at 1 to 2 minimum alveolar concentration (MAC) to maintain the bispectral index at 40 to 50. At the end of surgery, the second TTE was performed under 0.8 to 1 MAC of sevoflurane with the patient breathing spontaneously without ventilator support. Primary end point was the percentage change (Δ) of e' on 2 TTEs (Δe'). Secondary end points were ΔE/e', Δleft atrial volume index (ΔLAVI), and Δtricuspid regurgitation maximum velocity (ΔTR Vmax). These percentage changes (Δ) were compared between diastolic dysfunction and normal groups. RESULTS: e' (Δe': 30 [6, 64] vs 0 [-18, 11]%; P < .001), mitral inflow E wave velocity (E), mitral inflow E/A ratio (E/A), and mitral E velocity deceleration time (DT) improved significantly in diastolic dysfunction group compared to normal group. LAVI decreased in diastolic dysfunction group but did not reach statistical significance between the 2 groups (ΔLAVI:-15 [-31, -3] vs -4 [-20, 10]%, P = .091). ΔE/e' was not different between the 2 groups (11 [-16, 26] vs 12 [-9, 22]%, P = .853) (all: median [interquartile range, IQR]). TR was minimal in both groups. CONCLUSIONS: In this study, echocardiographic parameters of diastolic function, including septal e', E, E/A, and DT, improved with sevoflurane anesthesia in patients with preexisting diastolic dysfunction, but remained unchanged in patients with normal diastolic function.

The arousal effect of sugammadex reversal of neuromuscular blockade differs with anesthetic depth in propofol-remifentanil anesthesia: a randomized controlled trial.

Sugammadex reverses neuromuscular blockade by encapsulating steroidal neuromuscular blockers; therefore, it does not pharmacologically affect sedation levels. However, some clinicians avoid using it because of sudden unwanted acting out or patient arousal. Previous studies suggested sugammadex-induced awakening, but frontal muscle contraction after sugammadex administration compromised reliability of results obtained from EEG-based anesthesia depth monitoring tools like bispectral index (BIS). We hypothesized that sugammadex would affect patients' arousal depending on their baseline levels of sedation. We evaluated arousal signs after sugammadex administration with BIS between 25 - 35 and 45 - 55 under steady-state propofol-remifentanil anesthesia at the end of a surgery (n = 33 in each group). After sugammadex administration, twelve patients with a BIS of 45 - 55 showed clinical signs of awakening but none with a BIS of 25 - 35 (36.4% vs. 0%, P = 0.001). The distribution of the modified observer's assessment of alertness/sedation scale scores was also significantly different between the two groups (P < 0.001). Changes in the BIS were significantly greater in the BIS 45 - 55 than in the 25 - 35 group (median difference, 7; 95% CI 2 - 19, P = 0.002). Arousal after sugammadex was affected by patient sedation levels, and clinical signs of awakening appeared only in those with BIS 45 - 55. Unwanted arousal of the patient should be considered when using sugammadex under shallow anesthesia.Clinical trial registry number: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ; Principal investigator: Jieae Kim; Registration number: KCT0006248; Date of first registration: 11/06/2021).

Comparison of Early and Late Surgeries after Coronary Stent Implantation in Patients with Normal Preoperative Troponin Level: A Retrospective Study.

Current guidelines recommend delaying noncardiac surgery for 6 months after drug eluting stent implantation. However, this recommendation is largely based on limited evidence and various event definitions. Whether early surgery within 6 months of coronary stent implantation increases myocardial injury in patients with normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) has not yet been investigated. This retrospective study assessed patients who received coronary stent implantation and underwent noncardiac surgery (vascular, abdominal, or thoracic) between 2010 and 2017 with normal preoperative hs-cTnI (n = 186). Patients were divided into early (within 6 months of PCI) and late (after 6 months of PCI) groups. The primary endpoint was the incidence of myocardial injury as diagnosed by hs-cTnI within 3 days post-operation. The secondary outcomes were myocardial infarction, stent thrombosis, emergent coronary revascularization, major bleeding (bleeding requiring transfusion or intracranial bleeding), stroke, renal failure, heart failure, or death within 30 days post-operation. Inverse probability treatment weighting (IPTW) was carried out to adjust for the intergroup baseline differences. Myocardial injury occurred in 28.6% (8/28) and 27.8% (44/158) of the early and late groups, respectively, with no difference between groups (odds ratio [OR] 1.067, 95% confidence interval [CI] 0.404, 2.482; p = 0.886). Secondary outcomes did not differ between the groups. IPTW analysis also showed no differences in myocardial injury and secondary outcomes between the groups. In conclusion, early surgery within 6 months after coronary stent implantation did not increase the incidence of myocardial injury in patients with normal preoperative hs-cTnI.

Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: a multicentre randomised clinical trial.

BACKGROUND: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. METHODS: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. RESULTS: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, sd]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; -2.1 [-2.4 to -1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference -2.3%; 95% CI, -8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [sd], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O-1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group. CONCLUSIONS: In lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation. CLINICAL TRIAL REGISTRATION: NCT04260451.

Safety of Rigid Bronchoscopy for Therapeutic Intervention at the Intensive Care Unit Bedside.

Background and Objective: Although rigid bronchoscopy is generally performed in the operating room (OR), the intervention is sometimes emergently required at the intensive care unit (ICU) bedside. The aim of this study is to evaluate the safety of rigid bronchoscopy at the ICU bedside. Materials and Methods: We retrospectively analyzed medical records of patients who underwent rigid bronchoscopy while in the ICU from January 2014 to December 2020. According to the location of rigid bronchoscopic intervention, patients were classified into the ICU group (n = 171, cases emergently performed at the ICU bedside without anesthesiologists) and the OR group (n = 165, cases electively performed in the OR with anesthesiologists). The risk of intra- and post-procedural complications in the ICU group was analyzed using multivariable logistic regression, with the OR group as the reference category. Results: Of 336 patients, 175 (52.1%) were moribund and survival was not expected without intervention, and 170 (50.6%) received invasive respiratory support before the intervention. The most common reasons for intervention were post-intubation tracheal stenosis (39.3%) and malignant airway obstruction (34.5%). Although the overall rate of intra-procedural complications did not differ between the two groups (86.0% vs. 80.6%, p = 0.188), post-procedural complications were more frequent in the ICU group than in the OR group (24.0% vs. 12.1%, p = 0.005). Severe complications requiring unexpected invasive management occurred only post-procedurally and were more common in the ICU group (10.5% vs. 4.8%, p = 0.052). In the fully adjusted model, the ICU group had increased odds for severe post-procedural complications, but statistical significance was not observed (odds ratio, 2.54; 95% confidence interval, 0.73-8.88; p = 0.144). Conclusions: Although general anesthesia is generally considered the gold standard for rigid bronchoscopy, our findings indicate that rigid bronchoscopy may be safely performed at the ICU bedside in selective cases of emergency. Moreover, adequate patient selection and close post-procedural monitoring are required to prevent severe complications.

The Lack of Analgesic Efficacy of Nefopam after Video-Assisted Thoracoscopic Surgery for Lung Cancer: A Randomized, Single-Blinded, Controlled Trial.

Nefopam is a centrally acting non-opioid analgesic, and its efficacy in multimodal analgesia has been reported. This study aimed to assess the analgesic efficacy of intraoperative nefopam on postoperative pain after video-assisted thoracoscopic surgery (VATS) for lung cancer. Participants were randomly assigned to either the nefopam or the control group. The nefopam group received 20 mg of nefopam after induction and 15 min before the end of surgery. The control group received saline. The primary outcome was cumulative opioid consumption during the 6 h postoperatively. Pain intensities, the time to first request for rescue analgesia, adverse events during the 72 h postoperatively, and the incidence of chronic pain 3 months after surgery were evaluated. Ninety-nine patients were included in the analysis. Total opioid consumption during the 6 h postoperatively was comparable between the groups (nefopam group [n = 50] vs. control group [n = 49], 19.8 [13.5-25.3] mg vs. 20.3 [13.9-27.0] mg; median difference: -1.55, 95% CI: -6.64 to 3.69; p = 0.356). Pain intensity during the 72 h postoperatively and the incidence of chronic pain 3 months after surgery did not differ between the groups. Intraoperative nefopam did not decrease acute postoperative opioid consumption or pain intensity, nor did it reduce the incidence of chronic pain after VATS.

Continuous Titration of Inspired Oxygen Using Oxygen Reserve Index to Decrease Oxygen Exposure During One-Lung Ventilation: A Randomized Controlled Trial.

BACKGROUND: A high fraction of inspired oxygen (Fio2) is administered during one-lung ventilation (OLV). However, a high Fio2 is not physiologic and may lead to various complications. We hypothesized that continuous titration of Fio2 using the oxygen reserve index (ORI) reduces oxygen exposure compared to conventional management during OLV. METHODS: In this randomized, double-blinded trial, patients undergoing thoracic surgery were assigned to an ORI (n = 64) or a control group (n = 60). In the ORI group, ORI was continuously displayed using multiwavelength pulse co-oximetry (Masimo) between 0 and 1 (0, no reserve; 1, maximum reserve), and Fio2 was titrated for a target ORI of 0.21 at 5-minute intervals during OLV. In the control group, Fio2 was adjusted using arterial blood gas analysis measured at 15 minutes after OLV initiation. The primary end point was the time-weighted average Fio2 during OLV. RESULTS: Overall, time-weighted average Fio2 did not differ between the groups (control versus ORI: median [interquartile range], 0.87 [0.73-1.00] vs 0.82 [0.68-0.93]; P = .09). However, in a subgroup analysis, the ORI group reduced time-weighted average Fio2 after pulmonary vascular ligation compared to the control group (control versus ORI: median [interquartile range], 0.75 [0.70-1.00] vs 0.72 [0.59-0.89]; P = .0261). The incidence of intraoperative hypoxia (arterial oxygen saturation [Spo2] <94%; control versus ORI: 32% [19/60; 95% confidence interval (CI), 20-45] vs 19% [12/64; 95% CI, 10-31]; P = .09), and postoperative complications within the first 7 days did not differ between the groups. CONCLUSIONS: ORI-guided continuous Fio2 titration does not reduce overall oxygen exposure during OLV.

Preemptive Administration of Albumin during Pancreatectomy Does Not Reduce Postoperative Complications: A Prospective Randomized Controlled Trial.

Despite the empirical use of human albumin during pancreatectomy to replace intraoperative volume loss while preventing fluid overload and edema, its impact on postoperative outcomes remains unclear. In addition, most previous studies have focused on the effects of therapeutic albumin usage. Here, we investigated whether preemptive administration of human albumin to prevent edema during pancreatectomy could reduce the incidence of moderate postoperative complications. Adult patients undergoing pancreatectomy were assigned to either the albumin group (n = 100) or the control group (n = 100). Regardless of the preoperative albumin level, 200 mL of 20% albumin was administered to the albumin group after induction of anesthesia. The primary outcome was the incidence of moderate postoperative complications as defined by a Clavien-Dindo classification grade ≥ 2 at discharge. Intraoperative net-fluid balance, a known risk factor of postoperative complication after pancreatectomy, was lower in the albumin group than in the control group (p = 0.030), but the incidence of moderate postoperative complications was not different between the albumin and control groups (47/100 vs. 38/100, respectively; risk ratio: 1.24, 95% CI: 0.89 to 1.71; p = 0.198). Therefore, preemptive administration of human albumin to prevent fluid overload and edema during pancreatectomy is not recommended because of its lack of apparent benefit in improving postoperative outcomes.

The impact of pulmonary function tests on early postoperative complications in open lung resection surgery: an observational cohort study.

We investigated whether pulmonary function tests (PFTs) can predict pulmonary complications and if they are, to find new cutoff values in current open lung resection surgery. In this observational study, patients underwent open lung resection surgery at a tertiary hospital were analyzed (n = 1544). Various PFTs were tested by area under the receiver-operating characteristic curve (AUCROC) to predict pulmonary complications until 30 days postoperatively. In results, PFTs were generally not effective to predict pulmonary complications (AUCROC: 0.58-0.66). Therefore, we could not determine new cutoff values, and used previously reported cutoffs for post-hoc analysis [predicted postoperative forced expiratory volume in one second (ppoFEV1) < 40%, predicted postoperative diffusing capacity for carbon monoxide (ppoDLCO) < 40%]. In multivariable analysis, old age, male sex, current smoker, intraoperative transfusion and use of inotropes were independent risk factors for pulmonary complications (model 1: AUCROC 0.737). Addition of ppoFEV1 or ppoDLCO < 40% to model 1 did not significantly increase predictive capability (model 2: AUCROC 0.751, P = 0.065). In propensity score-matched subgroups, patients with ppoFEV1 or ppoDLCO < 40% showed higher rates of pulmonary complications [13% (21/160) vs. 24% (38/160), P = 0.014], but no difference in in-hospital mortality [3% (8/241) vs. 6% (14/241), P = 0.210] or mean survival duration [61 (95% CI 57-66) vs. 65 (95% CI 60-70) months, P = 0.830] compared to patients with both > 40%. In conclusion, PFTs themselves were not effective predictors of pulmonary complications. Decision to proceed with surgical resection of lung cancer should be made on an individual basis considering other risk factors and the patient's goals.

Pressure Support versus Spontaneous Ventilation during Anesthetic Emergence-Effect on Postoperative Atelectasis: A Randomized Controlled Trial.

BACKGROUND: Despite previous reports suggesting that pressure support ventilation facilitates weaning from mechanical ventilation in the intensive care unit, few studies have assessed its effects on recovery from anesthesia. The authors hypothesized that pressure support ventilation during emergence from anesthesia reduces postoperative atelectasis in patients undergoing laparoscopic surgery using the Trendelenburg position. METHODS: In this randomized controlled double-blinded trial, adult patients undergoing laparoscopic colectomy or robot-assisted prostatectomy were assigned to either the pressure support (n = 50) or the control group (n = 50). During emergence (from the end of surgery to extubation), pressure support ventilation was used in the pressure support group versus intermittent manual assistance in the control group. The primary outcome was the incidence of atelectasis diagnosed by lung ultrasonography at the postanesthesia care unit (PACU). The secondary outcomes were Pao2 at PACU and oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively. RESULTS: Ninety-seven patients were included in the analysis. The duration of emergence was 9 min and 8 min in the pressure support and control groups, respectively. The incidence of atelectasis at PACU was lower in the pressure support group compared to that in the control group (pressure support vs. control, 16 of 48 [33%] vs. 28 of 49 [57%]; risk ratio, 0.58; 95% CI, 0.35 to 0.91; P = 0.024). In the PACU, Pao2 in the pressure support group was higher than that in the control group (92 ± 26 mmHg vs. 83 ± 13 mmHg; P = 0.034). The incidence of oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively was not different between the groups (9 of 48 [19%] vs. 11 of 49 [22%]; P = 0.653). There were no adverse events related to the study protocol. CONCLUSIONS: The incidence of postoperative atelectasis was lower in patients undergoing either laparoscopic colectomy or robot-assisted prostatectomy who received pressure support ventilation during emergence from general anesthesia compared to those receiving intermittent manual assistance.

Perioperative high inspired oxygen fraction induces atelectasis in patients undergoing abdominal surgery: A randomized controlled trial.

STUDY OBJECTIVE: We evaluated the feasibility of use and effects on postoperative atelectasis and complications of lower inspired oxygen fraction (FIO2) compared to conventional oxygen therapy. DESIGN: Single center, randomized clinical trial. SETTING: University hospital, operating room and postoperative recovery area. PATIENTS: One hundred ninety patients aged ≥50 with an American Society of Anesthesiologists physical status of I-III who underwent abdominal surgery with general anesthesia. INTERVENTIONS: Participants were randomly assigned to either the low FIO2 group (intraoperative: FIO2 0.35, during induction and recovery: FIO2 0.7) or the conventional FIO2 group (intraoperative: FIO2 0.6, during induction and recovery: FIO2 1.0). MEASUREMENTS: The primary outcome was postoperative atelectasis measured with lung ultrasonography at postoperative 30 min in the post-anesthesia care unit (consolidation score: each region 0-3, 12 region, total score range of 0 to 36, a lower score indicating better aeration). MAIN RESULTS: Seven patients in the low FIO2 group were omitted from the study due to changing FIO2 during intervention (7/95 (8.4%) vs. 2/95 (2.1%), p = 0.088; low FIO2 group vs. conventional FIO2 group). Overall, atelectasis was detected in 29.7% (51/172) of patients 30 min after surgery by lung ultrasound and 40.1% (69/172) of patients after 2 days after surgery by chest X-ray. The scores of lung ultrasonography and the incidence of significant atelectasis (consolidation score ≥ 2 at any region) were lower in the low FIO2 group than in the conventional FIO2 group (median [IQR]: 3 [1,6] vs. 7 [3,9], p < 0.001 and 17/85 (20%) vs. 34/87 (39%), RR: 0.512 [95% CI: 0.311-0.843], p = 0.006, respectively). The incidence of surgical site infection and length of hospitalization were not significantly different between the two groups. CONCLUSIONS: Based on our findings, decreased inspired oxygen fraction during anesthesia and recovery did not cause hypoxic events, but instead reduced immediate postoperative atelectasis. The use of intraoperative conventional higher inspired oxygen did not afford any clinical advantages for postoperative recovery in abdominal surgery.

Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4-5 ml.kg-1.h-1 according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg-1.h-1), Cutoff (4-5 ml.kg-1.h-1) and High (≥6 ml.kg-1.h-1) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35-0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4-5 ml.kg-1.h-1 was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.

Driving pressure guided ventilation.

Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.

Association between intraoperative hypotension and postoperative myocardial injury in patients with prior coronary stents undergoing high-risk surgery: a retrospective study.

PURPOSE: We conducted a single-center retrospective study to evaluate the effects of intraoperative hypotension (IOH) on postoperative myocardial injury during major noncardiac surgery in patients with prior coronary stents with preoperatively normal cardiac troponin I levels. Although IOH is assumed to increase the risk of postoperative myocardial injury in patients with prior coronary stents, the level and duration of hazardous low blood pressure have not been clarified. METHODS: Of 2517 patients with prior coronary stents undergoing noncardiac surgery between January 2010 and March 2017, we analyzed 195 undergoing major surgery (vascular, abdominal, and thoracic surgery) who had a normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) level and were followed up postoperatively within 3 days. Postoperative myocardial injury was defined as a hs-cTnI level greater than the 99th percentile reference value. Primary IOH exposure was defined as a decrease of ≥ 50%, 40%, or 30% from the preinduction mean blood pressure. Additional definition of IOH was absolute mean blood pressure < 70, < 60 or < 50 mmHg. Multivariate logistic regression was used to model the exposure and myocardial injury. RESULTS: Myocardial injury occurred in 53 (27.2%) cases. The predefined levels of IOH were not significantly associated with postoperative myocardial injury, but intraoperative continuous inotropes/vasopressors use was significantly higher in patients with myocardial injury (P = 0.004). Operation time ≥ 166 min (OR = 2.823, 95% CI 1.184-6.731, P = 0.019) and abdominal vascular surgery (OR = 2.693, 95% CI 1.213-5.976, P = 0.015) were independent risk factors for myocardial injury. CONCLUSION: Although patients with prior coronary stents with normal hs-cTnI levels did not show association between varying levels of IOH and postoperative myocardial injury after noncardiac surgery, intraoperative need of continuous inotropes/vasopressors was higher in patients with postoperative myocardial injury. Abdominal vascular surgery and surgical time were independent risk factors for myocardial injury after surgery.

The prognostic nutritional index and postoperative complications after curative lung cancer resection: A retrospective cohort study.

OBJECTIVE: The prognostic nutritional index is a score that represents a patient's immune-nutritional status based on the lymphocyte count and serum albumin concentration. We hypothesized that preoperative prognostic nutritional index is associated with postoperative complications and long-term outcomes after curative resection of lung cancer. METHODS: We retrospectively analyzed 1011 patients with pathologic stage I-III adenocarcinoma and squamous cell carcinoma who underwent open thoracotomy for curative resection of lung cancer. The preoperative prognostic nutritional index was calculated as follows based on preoperative laboratory data: 10 × serum albumin (g/dL) + 5 × total lymphocyte count (/nL). The cutoff value of prognostic nutritional index (cutoff value: 50) was obtained by receiver operating characteristics curve and patients were classified as high and low groups. Outcomes were compared with the use of propensity scores and inverse probability weighting adjustment to reduce treatment selection bias. RESULTS: The low group exhibited more postoperative complications (34% [96/285] vs 24% [174/726]; P = .002) especially pneumonia (13% [36/285] vs 6% [41/756]; P < .001) and delirium (10% [29/285] vs 5% [36/726]; P = .002), and greater in-hospital mortality (4% [11/285] vs 1% [9/726]; P = .007) than the high group. A low prognostic nutritional index was associated with greater postoperative pulmonary complications [odds ratio, 1.7; 95% confidence interval, 1.3-2.3], lower recurrence-free survival (hazard ratio, 1.3; 95% confidence interval, 1.1-1.5), and overall survival (hazard ratio, 1.5; 95% confidence interval, 1.2-1.8) after balancing the covariables. CONCLUSIONS: The preoperative prognostic nutritional index was associated with postoperative pulmonary complications and long-term outcomes after curative resection of non-small cell lung cancer.

Role of reactive oxygen species at reperfusion stage in isoflurane preconditioning-induced neuroprotection.

In this in vivo and in vitro study, we aimed to investigate whether isoflurane preconditioning-induced neuronal protection is mediated by reactive oxygen species (ROS) signaling at the reperfusion stage. In the in vivo study, Sprague-Dawley rats were subjected to middle cerebral artery occlusion (MCAO) and in the in vitro study, rat pheochromocytoma (PC12) cells were subjected to oxygen glucose deprivation (OGD). Isoflurane preconditioning was carried out prior to MCAO or OGD and the ROS scavenger, N-2-mercaptopropiopylglycine (2-MPG), was administered at the start of reperfusion. Infarct volume, neurological severity score, and TUNEL staining were analyzed in the in vivo study and cell viability, Bcl-2/Bax ratio, cleaved caspase 3/caspase 3 ratio, and ROS fluorescence intensity were measured in the in vitro study. In the in vivo study, infarct volume, neurological severity score, and TUNEL-positive cell count were significantly decreased with preconditioning but were abrogated by administration of 2-MPG. In the in vitro study, cell viability and Bcl-2/Bax ratio were significantly increased with preconditioning, and cleaved caspase-3/caspase-3 ratio and ROS fluorescence intensity were significantly decreased. Administration of 2-MPG for 10 min abrogated this preconditioning effect, but it did not abolish the protection when administered for 60 min of reperfusion. Isoflurane preconditioning-induced protection was abolished by ROS scavengers at the start of reperfusion, indicating that ROS signaling can mediate the isoflurane preconditioning effect, which suggests that the time window can be important.

The effect of preventive use of corticosteroids on postoperative complications after esophagectomy: A retrospective cohort study.

Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively (n = 980). Patients were divided into Steroid (n = 120) and Control (n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.

Intraoperative use of dexmedetomidine for the prevention of emergence agitation and postoperative delirium in thoracic surgery: a randomized-controlled trial.

PURPOSE: We investigated whether preventive use of dexmedetomidine during surgery was effective for reducing emergence agitation and postoperative delirium. METHODS: In this double-blind randomized-controlled trial, 143 patients undergoing thoracoscopic lung resection surgery were randomly assigned to the dexmedetomidine-sevoflurane (DEX-Sevo, n = 73) or sevoflurane (Sevo, n = 70) groups. Dexmedetomidine or saline administration was started after inducing anesthesia and continued until the end of surgery at a fixed dose (0.5 µg·kg-1·hr-1). The primary endpoint was the incidence of delirium up until the end of postoperative day 3. Emergence agitation and postoperative delirium were measured with the Riker sedation agitation scale and the confusion assessment method, respectively. The secondary endpoints were serum cytokine and catecholamine levels. RESULTS: The DEX-Sevo group showed less frequent emergence agitation than the Sevo group (13% vs 35%, respectively; relative risk, 0.38; 95% confidence interval [CI], 0.18 to 0.79; P = 0.011) but the incidence of delirium after discharge from the postanesthesia care unit was not different (25% vs 25%, DEX-Sevo vs Sevo). Both pro- and anti-inflammatory cytokines were lower in the DEX-Sevo group than in the Sevo group. Nevertheless, the interleukin (IL)6/IL10 ratio (median difference, 5.8; 95% CI,1.8 to 10.0; P = 0.012) and IL8/IL10 ratio (median difference, 0.8; 95% CI, 0.2 to 1.3; P = 0.007) were higher in the DEX-Sevo group than in the Sevo group, indicating a pro-inflammatory cytokine balance in the DEX-Sevo group. Norepinephrine and epinephrine levels were lower in the DEX-Sevo group than in the Sevo group (both, P < 0.001). CONCLUSIONS: Intraoperative dexmedetomidine reduced emergence agitation but not postoperative delirium in patients undergoing thoracic surgery. Dexmedetomidine seemed to affect emergence agitation through catecholamines, but not through an anti-inflammatory action. Trial registration Clinical Research Information Service (KCT 0001877); registered 7 April, 2016.

RéSUMé: OBJECTIF: Nous avons cherché à savoir si l'utilisation préventive de dexmédétomidine au cours de la chirurgie pouvait réduire la survenue de l'agitation au réveil et du delirium postopératoire. MéTHODES: Dans cette étude randomisée, contrôlée à double insu, 143 patients subissant une résection pulmonaire par thoracoscopie ont été randomisés dans un groupe recevant dexmédétomidine-sévoflurane (DEX-Sévo, n = 73) ou dans un groupe recevant seulement du sévoflurane (Sévo, n = 70). L'administration de dexmédétomidine ou de solution saline a débuté après l'induction de l'anesthésie et a continué jusqu'à la fin de l'intervention à une dose fixe de 0,5 µg·kg−1·h−1. Le critère d'évaluation principal était l'incidence du delirium jusqu'à la fin du 3e jour postopératoire. La survenue de l'agitation au réveil et du delirium postopératoire a été mesurée avec, respectivement, l'échelle d'agitation sous sédation de Riker et la méthode d'évaluation de la confusion. Les critères d'évaluation secondaires étaient les taux sériques de cytokines et de catécholamines. RéSULTATS: La survenue d'une agitation au réveil a été moins fréquente dans le groupe DEX-Sévo que dans le groupe Sévo (respectivement, 13 % contre 35 %; risque relatif, 0,38; intervalle de confiance [IC] à 95 % : 0,18 à 0,79; P = 0,011), mais l'incidence du delirium après congé de la salle de réveil n'a pas été différente entre les groupes (DEX-Sévo 25 % contre Sévo 25 %). Les taux de cytokines pro- et anti-inflammatoires ont tous deux été plus bas dans le groupe DEX-Sévo que dans le groupe Sévo. Néanmoins, les ratios d'interleukines (IL) IL-6/IL-10 (différence entre médianes, 5,8; IC à 95 %, 1,8 à 10,0; P = 0,012) et IL-8/IL-10 (différence des médianes, 0,8; IC à 95 %, 0,2 à 1,3; P = 0,007) ont été plus élevés dans le groupe DEX-Sévo que dans le groupe Sévo indiquant un équilibre des cytokines pro-inflammatoires dans le groupe DEX-Sévo. Les taux de norépinéphrine et d'épinéphrine ont été inférieurs dans le groupe DEX-Sévo que dans le groupe Sévo (P < 0,001 pour les deux). CONCLUSIONS: La dexmédétomidine peropératoire a réduit la survenue de l'agitation au réveil, mais pas du delirium postopératoire chez des patients subissant une chirurgie thoracique. La dexmédétomidine a semblé interférer sur la survenue de l'agitation par le biais des catécholamines, mais pas par un effet anti-inflammatoire. Enregistrement de l'essai clinique Service d'information sur la recherche clinique (KCT 0001877); enregistré le 7 avril 2016.

Driving Pressure during Thoracic Surgery: A Randomized Clinical Trial.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Driving pressure (plateau minus end-expiratory airway pressure) is a target in patients with acute respiratory distress syndrome, and is proposed as a target during general anesthesia for patients with normal lungs. It has not been reported for thoracic anesthesia where isolated, inflated lungs may be especially at risk. WHAT THIS ARTICLE TELLS US THAT IS NEW: In a double-blinded, randomized trial (292 patients), minimized driving pressure compared with standard protective ventilation was associated with less postoperative pneumonia or acute respiratory distress syndrome. BACKGROUND: Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure-guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure-guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation. METHODS: In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6 ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure-PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3. RESULTS: Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92). CONCLUSIONS: Application of driving pressure-guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.

Non-intubated video-assisted thoracoscopic lung biopsy for interstitial lung disease: a single-center experience.

BACKGROUND: The mortality and morbidity associated with video-assisted thoracoscopic (VATS) lung biopsy for interstitial lung disease (ILD) are not negligible. We evaluated whether non-intubated VATS lung biopsy, which avoids intubation and general anesthesia, can be safely performed in ILD subjects. METHODS: This retrospective study compared the incidence of complications and surgical mortality between 25 consecutive intubated subjects and 10 non-intubated subjects (a total of 35 consecutive subjects) at a single institution. RESULTS: No major surgical complications or deaths were reported in either group, and non-intubated VATS biopsies were safely performed in subjects with relatively low carbon monoxide diffusing capacity (P=0.08) or poor American Society of Anesthesiologists physical status scores (ASA) (P=0.02). CONCLUSIONS: These preliminary results suggest that non-intubated VATS lung biopsy is a safe and feasible option in patients with ILD.