Preoperative laboratory testing in elderly patients.

PURPOSE OF REVIEW: Preoperative testing in elderly patients is performed to examine the patient's current medical condition in the context of evaluating vulnerabilities and predicting postoperative complications to ensure that all functions recover before surgery. This review focused on preoperative laboratory tests in geriatric patients. RECENT FINDINGS: Preoperative complete blood count, electrolyte testing, and blood chemistry can predict postoperative complications. Preoperative elevated morning/evening salivary cortisol secretion ratio, C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratios, and preoperative decreased serum albumin level or 25-hydroxyvitamin D levels can predict postoperative cognitive dysfunction. Elevated brain-type natriuretic peptide or serum alkaline phosphatase levels can be biomarkers of major postoperative adverse cardiac events. Decreased preoperative estimated glomerular filtration rates and serum albumin levels can predict acute kidney injury. Hyponatremia, hypocalcemia, and low albumin/fibrinogen ratio predict postoperative complications. Hypoalbuminemia can predict surgical site infection or postoperative mortality after hip fracture surgery. A high CAR can predict anastomotic site leakage and is a risk factor for one-year mortality after hip surgery. SUMMARY: Preoperative laboratory testing helps predict postoperative adverse complications; thus, a plan of care can be initiated.

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

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

Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures, multiple fractures and severely injured patients.

INTRODUCTION: Femoral shaft fractures in adults are high-energy fractures typically accompanied by additional fractures of the upper and lower extremities and brain, thoracic, or abdominal injuries. Intramedullary nailing enables early ambulation with a few complications, but rates of non-union remain high. Therefore, we aimed to compare bone union after femoral shaft fractures in adults (20-65 years old) depending on the injury severity and presence of multiple fractures. PATIENTS AND METHODS: This study retrospectively examined 178 patients (145 male and 33 female) who underwent intramedullary nailing for a femoral shaft fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association 32 type) between January 2014 and December 2018 and were followed up for at least 1 year. Patients who underwent intramedullary nailing after the preliminary application of an external fixator were excluded. Patients were divided into groups with isolated femoral shaft fractures (IS group), an injury severity score of ≤14, and multiple fractures of the extremities and the pelvic bone (at least three locations), including a femoral shaft fracture (MU group), and severely injured (injury severity score ≥15) with femoral shaft fractures (SE group). Non-union rate by group and risk factors related to bone union and bone union rate according to time to full weight bearing were analyzed. RESULTS: In total, 29, 54, and 95 patients were assigned to the IS group, MU group, and SE group, respectively. Non-union was observed in two patients in the IS group (6.9%), six patients in the MU group (11.1%), and 11 patients in the SE group (11.6%). There were no significant differences in the bone union rate, according to multiple fractures (p=0.515) and injury severity score (p=0.561). Additionally, no differences in the bone union rate were observed according to the time to full weight bearing. Depending on open fracture (p=0.004) and fracture severity (p=0.011), the non-union rate showed a difference of up to four times or greater. CONCLUSIONS: When intramedullary nailing is performed to treat femoral shaft fractures, multiple fractures and severe trauma do not directly affect bone union. However, it should be noted that open fracture and greater fracture severity lead to higher chances of non-union.

Effects of an Alveolar Recruitment Maneuver During Lung Protective Ventilation on Postoperative Pulmonary Complications in Elderly Patients Undergoing Laparoscopy.

PURPOSE: Controversy remains over whether alveolar recruitment maneuvers (ARMs) can reduce postoperative pulmonary complications. We hypothesized that performing an ARM in addition to lung protective ventilation (LPV) could improve intraoperative arterial oxygenation and postoperative pulmonary complications (PPCs) in elderly patients undergoing laparoscopy in the Trendelenburg position. PATIENTS AND METHODS: Sixty-two patients (aged 65-85) scheduled for laparoscopic low anterior resection were randomized to receive LPV only (LPV group, n = 32) or LPV with an ARM (ARM group, n = 30). LPV was set to a tidal volume of 6 mL/kg with a positive end expiratory pressure (PEEP) of 5 cmH2O. The ARM was performed by serially increasing the PEEP to 10 cmH2O for 3 breaths, 15 cmH2O for 3 breaths, then 20 cmH2O for 10 breaths, both immediately before and after abdominal insufflation. The primary end-point was the frequency of PPCs such as desaturation (SpO2 <90%), atelectasis, and pneumonia. Secondary end-points were changes in intraoperative respiratory and gas exchange parameters and hemodynamic variables. RESULTS: One patient in the LPV group experienced desaturation on the first postoperative day. The frequency of chest X-ray abnormalities such as atelectasis or pleural effusion was comparable between groups (6 (19%) and 5 (17%) patients, respectively, P = 0.676). Changes in other respiratory, gas exchange and hemodynamic parameters over time were not significantly different between the groups. However, vasopressor requirements during surgery were higher in the ARM than the LPV group (9 (30%) and 2 (6%) patients, respectively, P = 0.014). CONCLUSION: This study suggests that performing an ARM during LPV may not improve postoperative respiratory outcomes and intraoperative oxygenation compared to LPV alone in geriatric patients undergoing laparoscopy in the Trendelenburg position. In addition, since the ARM could cause a significant deterioration in hemodynamic parameters, applying ARM to elderly patients should be carefully considered.

Comparison of McGrath, Pentax, and Macintosh laryngoscope in normal and cervical immobilized manikin by novices: a randomized crossover trial.

BACKGROUND: The aim of this study was to compare tracheal intubation performance regarding the time to intubation, glottic view, difficulty, and dental click, by novices using McGrath videolaryngoscope (VL), Pentax Airway Scope (AWS) and Macintosh laryngoscope in normal and cervical immobilized manikin models. METHODS: Thirty-five anesthesia nurses without previous intubation experience were recruited. Participants performed endotracheal intubation in a manikin model at two simulated neck positions (normal and fixed neck via cervical immobilization), using three different devices three times each. Performance parameters included intubation time, success rate of intubation, Cormack Lehane laryngoscope grading, dental click, and subjective difficulty score. RESULTS: Intubation time and success rate during first attempt were not significantly different between the 3 groups in normal airway manikin. In the cervical immobilized manikin, the intubation time was shorter (p = 0.012), and the success rate with the first attempt was significantly higher (p < 0.001) when using McGrath VL and Pentax AWS compared with Macintosh laryngoscope. Both VLs showed less difficulty score (p < 0.001) and more Cormack Lehane grade I (p < 0.001) in both scenarios. The incidence of dental clicks was higher with Macintosh laryngoscope compared with McGrath VL in cervical immobilized airway (p < 0.001). CONCLUSIONS: McGrath VL and Pentax AWS did not show clinically significant decrease in intubation time, however, they achieved higher first attempt success rate, easier intubation and better glottis view compared with Macintosh laryngoscope by novices in a cervical immobilized manikin model. McGrath VL may reduce the risk of dental injury compared with Macintosh laryngoscope in cervical immobilized scenario. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03161730), May 22, 2017 https://clinicaltrials.gov/ct2/hom.

Randomized comparison of McGrath MAC videolaryngoscope, Pentax Airway Scope, and Macintosh direct laryngoscope for nasotracheal intubation in patients with manual in-line stabilization.

BACKGROUND: The objective of this study was to determine the clinical usefulness of videolaryngoscopes (VLs) by comparing the time to intubation (TTI) and the ease of intubation of McGrath MAC VL (MVL), Pentax Airway Scope VL (PVL), and Macintosh direct laryngoscope (DL) during nasotracheal intubation using manual in-line stabilization to simulate difficult airways. METHODS: One hundred and twenty patients were randomly assigned to the MVL group (n = 40), the PVL group (n = 40), and the DL group (n = 40). Nasotracheal intubation was performed using MVL, PVL, or DL, according to group assignments. The primary outcome was TTI and secondary outcomes were glottic view, ease of intubation, and bleeding. RESULTS: The TTI was significantly shorter in the MVL group than in the DL group (45 sec vs 57 sec; difference in means: - 12; 95% confidence interval [CI], - 21 to - 3; P = 0.01). The percentage of glottic opening and Cormack Lehane grade were significantly superior in the MVL and the PVL groups compared with the DL group (both P < 0.001). The intubation difficulty scale and numeric rating scale regarding ease of intubation were also significantly lower in the MVL and PVL groups than in the DL group (all P < 0.007). The incidence of bleeding was significantly lower in the MVL group than in the DL group (3 vs 15, relative risk 0.2; 95% CI, 0.06 to 0.64; P = 0.001). CONCLUSION: This study showed that both MVL and PVL provided better visualization of the glottis and easier intubation, with less additional manipulation than DL during nasotracheal intubation in simulated difficult airways. Additionally, use of the MVL significantly shortened the TTI compared with the DL. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02647606); registered 6 January, 2016.

RéSUMé: CONTEXTE: L'objectif de cette étude était de déterminer l'utilité clinique des vidéolaryngoscopes (VL) en comparant le temps jusqu'à intubation (TTI) et la facilité d'intubation du VL McGrath MAC (MVL), du VL Pentax Airway Scope (PVL), et du laryngoscope avec lame Macintosh (DL) pour une intubation nasotrachéale avec stabilisation manuelle en ligne simulant des voies aériennes difficiles. MéTHODE: Cent vingt patients ont été aléatoirement alloués au groupe MVL (n = 40), au groupe PVL (n = 40) ou au groupe DL (n = 40). L'intubation nasotrachéale a été réalisée à l'aide du MVL, du PVL ou du DL selon l'attribution de groupe. Le critère d'évaluation principal était le TTI et les critères secondaires comprenaient la visualisation glottique, la facilité d'intubation et les saignements. RéSULTATS: Le TTI était significativement plus court dans le groupe MVL que dans le groupe DL (45 sec vs 57 sec; différence de moyennes : -12; intervalle de confiance [IC] 95 %, -21 à -3; P = 0,01). Le pourcentage d'ouverture glottique et le grade de Cormack et Lehane étaient significativement supérieurs dans les groupes MVL et PVL par rapport au groupe DL (P < 0,001 pour les deux). L'échelle de difficulté d'intubation et l'échelle d'évaluation numérique concernant la facilité d'intubation étaient également significativement plus basses dans les groupes MVL et PVL que dans le groupe DL (tous P < 0,007). L'incidence de saignements était significativement plus basse dans le groupe MVL que dans le groupe DL (3 vs 15, risque relatif 0,2; IC 95 %, 0,06 à 0,64; P = 0,001). CONCLUSION: Cette étude a démontré que le MVL et le PVL procuraient tous deux une meilleure visualisation glottique et une intubation plus facile, avec moins de manipulations supplémentaires qu'un DL pendant l'intubation nasotrachéale de voies aériennes difficiles simulées. En outre, l'utilisation d'un MVL a significativement réduit le TTI par rapport à un DL. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02647606); enregistrée le 6 janvier 2016.

Discordant lumbar epidural hematoma after caudal steroid injection: A case report (CARE-compliant).

RATIONALE: Caudal epidural injection is one of the conventional treatments of chronic back pain. Even though spinal epidural hematoma after caudal epidural injection is rare but it can cause serious neurologic complication. PATIENT CONCERNS: An 83-year-old woman taking cilostazol received caudal epidural steroid injection because of her chronic back pain. Six hours later, she experienced an acute hip pain which worsened with time. DIAGNOSIS: Magnetic resonance image showed acute cord compression due to a spinal epidural hematoma at L2-S1 level with concomitant central canal compromise at L2/3, L3/4 level. INTERVENTIONS: Emergency decompressive laminectomy and evacuation of the lumbar epidural hematoma were performed. OUTCOMES: All of her symptoms were resolved over the 72 hours following surgery. LESSONS: Continuous vigilance after caudal epidural injection is important to prevent catastrophic neurologic deterioration with early detection and early treatment.

CONSORT the effect of intraoperative dexmedetomidine on hemodynamic responses during emergence from nasotracheal intubation after oral surgery.

BACKGROUND: Dexmedetomidine provides smooth emergence with reduced agitation. The authors hypothesized low-dose dexmedetomidine infusion might contribute to hemodynamic stability during and after nasotracheal tube extubation. METHODS: Ninety-three adult patients scheduled for oral and maxillofacial surgery were enrolled in this prospective study. Patients were randomly assigned to receive normal saline (control group, n = 31), dexmedetomidine at 0.2 µg/kg/h (DEX0.2 group, n = 31), or dexmedetomidine at 0.4 µg/kg/h (DEX0.4 group, n = 31). Mean arterial pressure (MAP), heart rate (HR), and response entropy (RE) and state entropy (SE) were recorded during emergence from anesthesia. RESULTS: Extubation times were similar in the 3 groups. Mean MAP was significantly lower at eye opening (T3) and immediately after extubation (T4) in the DEX0.2 (P = .013 and .003, respectively) and DEX0.4 group (P = .003 and .027, respectively) than in the control group. At T3 and T4, mean HR was significantly higher in the control group than in the DEX0.2 (P = .014 and .022, respectively) or DEX0.4 groups (P = .003 and <.001, respectively). In the postanesthetic care unit, mean MAP and HR were significantly lower in the DEX0.2 (P = .03 and .022, respectively) and DEX0.4 groups (P = .027 and <.001, respectively) than in the control group. CONCLUSION: Intraoperative dexmedetomidine infusion at rates of 0.2 or 0.4 µg/kg/h during oral and maxillofacial surgery could provide stable hemodynamic profiles during anesthetic emergence from nasotracheal intubation without delaying extubation times.

Anesthetic experience of an adult male with citrullinemia type II: a case report.

BACKGROUND: Citrullinemia type II is an autosomal recessive urea cycle disorder and a subtype of citrin deficiency. However, the management of recurrent hyperammonemia with neurologic symptoms in patients with citrullinemia type II is quite different from the management of other types of urea cycle disorders. In pats with citrullinemia type II, regional anesthesia might be a good choice for the early detection of hyperammonemic symptoms and addressing psychic stress. CASE PRESENTATION: A 48-year-old male with adult onset citrullinemia type II was scheduled for urethral scrotal fistula repair. During the first operation, spinal anesthesia with conscious sedation using dexmedetomidine was used, a second operation was performed after confirmation of infection control and a stable neurologic condition. In this patient, dietary planning with close monitoring of serum ammonia level and close observation of neurologic conditions might lead to successful perioperative care. CONCLUSION: For anesthesia of patients with adult onset citrullinemia type II, close monitoring of neurologic signs and serum ammonia are important to reduce neurologic complications induced by hyperammonemia. Regional anesthesia with a proper dietary plan might reduce patient stress and prevent metabolic tragedy.

Prediction of in-hospital mortality and morbidity using high-sensitivity C-reactive protein after burr hole craniostomy.

BACKGROUND: The purpose of this study was to assess whether preanesthetic laboratory values can predict in-hospital mortality and morbidity in patients who have undergone burr hole craniostomy due to chronic subdural hematoma. METHODS: From January 2007 to February 2016, the records of 502 consecutive patients who underwent burr hole craniotomy were analyzed. All cases of burr hole craniostomy were fitted with a drain, as required by our institutional protocol. RESULTS: Patients' demographic data and preoperative laboratory values were subjected to logistic regression analysis to predict in-hospital mortality and morbidity after burr hole craniostomy. Hemoglobin, prothrombin time, activated partial thromboplastin time, serum glucose, and high-sensitivity C-reactive protein (hsCRP) were found to be significantly associated with in-hospital mortality and morbidity by univariate regression analysis, but of these, only hsCRP (hazard ratio 1.210, 95 % confidence interval 1.089-1.345, P < 0.001) was found to significantly predict in-hospital mortality and morbidity by multivariate regression analysis. Areas under the curve for predicting in-hospital mortality and morbidity were 0.765 (95 % confidence interval 0.624-0.906, P = 0.002) and 0.646 (0.559-0.733, P = 0.001), respectively. CONCLUSIONS: Preoperative hsCRP was found to be an independent predictor of in-hospital mortality and morbidity after burr hole craniostomy due to chronic subdural hematoma.

Comparison of remifentanil EC50 for facilitating i-gel and laryngeal mask airway insertion with propofol anesthesia.

OBJECTIVE: Each supraglottic airway requires different anesthetic depth because it has a specific structure and different compressive force in the oropharyngeal cavity. We designed the study to compare the effect-site concentration (Ce) of remifentanil in 50 % of patients (EC50) for successful insertion of the i-gel second-generation supraglottic airway device with that for laryngeal mask airway (LMA) insertion during target-controlled infusion (TCI) of propofol. METHODS: Forty-one female patients were randomized to the i-gel group (n = 20) or the LMA group (n = 21). Anesthesia was induced with propofol Ce of 5 µg/ml and the predetermined remifentanil Ce, and the i-gel or LMA was inserted 5 min later. The remifentanil Ce was estimated by modified Dixon's up-and-down method (initial concentration: 3.0 ng/ml, step size: 0.5 ng/ml). The patient's response to device insertion was classified as either "success (no movement)" or "failure (movement)". RESULTS: Using the Dixon's up-and-down method, EC50 of remifentanil Ce for the i-gel (1.58 ± 0.41 ng/ml) was significantly lower than that for LMA (2.25 ± 0.55 ng/ml) (p = 0.038). Using isotonic regression, EC50 (83 % CI) of remifentanil in the i-gel group [1.50 (1.37-1.80) ng/ml] was statistically lower than that in the LMA group [2.00 (1.82-2.34) ng/ml]. EC95 (95 % CI) of remifentanil in the i-gel group [2.38 (1.48-2.50) ng/ml] was statistically lower than that in the LMA group [3.35 (2.58-3.48) ng/ml]. CONCLUSIONS: We found that EC50 of remifentanil Ce for i-gel insertion (1.58 ng/ml) was significantly lower than that for LMA insertion (2.25 ng/ml) in female patients during propofol TCI without neuromuscular blockade.

Perioperative Concerns for Profound Metabolic Alkalosis During Kidney Transplantation: A Case Report.

INTRODUCTION: Profound metabolic alkalosis is an uncommon consideration for the anesthetic management of kidney transplantation. Serum total carbon dioxide content and complex electrolyte abnormalities might be important diagnostic clues for the presence of metabolic alkalosis in the absence of arterial blood gas analysis. CASE PRESENTATION: A 34-year-old female visited Gachon University Gil Medical Center, Incheon, South Korea during year 2015. She experienced aggravated renal function due to chronic hypokalemia and severe hypochloremic metabolic alkalosis, induced by laxative abuse, and underwent ABO incompatible kidney transplantation. Serum total carbon dioxide content remained high (about 60 mEq/L) over eight months of monthly follow-up prior to kidney transplantation. CONCLUSIONS: The authors described their anesthetic experience of profound metabolic alkalosis with complex electrolyte abnormalities and provided a review of relevant literature.

Ultrasound evaluation of the radial artery for arterial catheterization in healthy anesthetized patients.

The purpose of this study was to assess the anatomy of the radial artery using ultrasound in anesthetized patients, and to correlate its anatomical data with patients' characteristics. The success rate of radial artery cannulation using ultrasound was also evaluated to analyze the relationship between the anatomical data and the success rate. Study 1 One hundred ninety-five patients scheduled for general anesthesia were enrolled. Ultrasound measurements were obtained when the vital signs were stable after anesthesia induction. The wrist joint of patients were extended to 30°. The diameter and depth of the radial artery, and the angle between the radial artery and skin surface were measured using ultrasound. Anatomical data were correlated with patients' characteristics. Study 2 Arterial cannulation was performed in 125 patients using long-axis in-plane technique to evaluate the success rate using ultrasound. Study 1 The diameter of the radial artery was mean value of 2.2 ± 0.4 mm and larger than 0.9 mm in all patients. It had significant correlation with body surface area (BSA) (Pearson correlation 0.292, P < 0.001). The incidence of abnormal angle between the radial artery and skin surface was significantly higher in elderly patients (≥65 years) than young patients (P = 0.017). Study 2 The first attempt success rate of arterial catheterization using ultrasound was 92.5 % using long-axis in-plane technique, regardless of patient's characteristics. For small sized adult patients, a 22G angio-catheter should be used during radial artery cannulation, because the radial artery diameter significantly correlated with BSA in healthy anesthetized patients. In addition, ultrasound-guided catheterization is recommended in elderly patients because the incidence of abnormal angle between the radial artery and skin surface was high.

Ultrasound-guided central cluster approach for the supraclavicular brachial plexus block: a case series.

There are many different approaches to ultrasound-guided supraclavicular brachial plexus block (US-SCBPB), and each has a different success rate and complications. The most commonly performed US-SCBPB is the corner pocket approach in which the needle is advanced very close to the subclavian artery and pleura. Therefore, it may be associated with a risk of subclavian artery puncture or pneumothorax. We advanced the needle into the central part of the neural cluster after penetrating the sheath of the brachial plexus in US-SCBPB. We refer to this new method as the "central cluster approach." In this approach, the needle does not have to advance close to the subclavian artery or pleura. The aim of this study was to evaluate the clinical outcomes of the central cluster approach in US-SCBPB.

Predicted EC50 and EC95 of Remifentanil for Smooth Removal of a Laryngeal Mask Airway Under Propofol Anesthesia.

PURPOSE: The purpose of this study was to determine the effect-site concentration (Ce) of remifentanil in 50% of patients (EC50) and 95% of patients (EC95) for smooth laryngeal mask airway (LMA) removal in adults under propofol and remifentanil anesthesia. MATERIALS AND METHODS: Twenty-five patients of ASA physical status I-II and ages 18-60 years who were to undergo minor gynecological or orthopedic surgery were assessed in this study. Anesthesia was induced and maintained with propofol and remifentanil target-controlled infusion (TCI). Remifentanil was maintained at a predetermined Ce during the emergence period. The modified Dixon's up-and-down method was used to determine the remifentanil concentration, starting from 1.0 ng/mL (step size of 0.2 ng/mL). Successful removal of the LMA was regarded as absence of coughing/gagging, clenched teeth, gross purposeful movements, breath holding, laryngospasm, or desaturation to SpO2<90%. RESULTS: The mean±SD Ce of remifentanil for smooth LMA removal after propofol anesthesia was 0.83±0.16 ng/mL. Using isotonic regression with a bootstrapping approach, the estimated EC50 and EC95 of remifentanil Ce were 0.91 ng/mL [95% confidence interval (CI), 0.77-1.07 ng/mL] and 1.35 ng/mL (95% CI, 1.16-1.38 ng/mL), respectively. CONCLUSION: Our results showed that remifentanil TCI at an established Ce is a reliable technique for achieving safe and smooth emergence without coughing, laryngospasm, or other airway reflexes.

Preanesthetic mortality prediction in diabetics undergoing major lower limb amputation at a tertiary referral hospital: Implications of preoperative echocardiographic and laboratory values.

PURPOSE: Cardiac comorbidities in patients undergoing amputation due to diabetic foot ulcer are associated with high mortality rates. The authors investigated whether preanesthetic echocardiographic and laboratory values can predict inhospital mortality in type II diabetes patients undergoing major lower limb amputation under spinal anesthesia. METHODS: The archived medical records of 215 patients were retrospectively reviewed. Demographic data and preoperative laboratory and transthoracic echocardiographic values were analyzed by multivariate logistic regression for factors independently associated with inhospital mortality. RESULTS: Of the 215 patients, 12 died in hospital after amputation. Preoperative hemoglobin level (hazard ratio, 0.082; 95% confidence interval, 0.013-0.509; P = .007) and left ventricular ejection fraction (hazard ratio, 0.874; 95% confidence interval, 0.779- 0.981; P = .023) were found to be significant predictors of inhospital mortality. CONCLUSIONS: Preoperative hemoglobin level and left ventricular ejection fraction are highly correlated with inhospital mortality in type II diabetes patients undergoing major lower extremity amputation under spinal anesthesia.

Effect of mild hypocapnia on hemodynamic and bispectral index responses to tracheal intubation during propofol anesthesia in children.

The purpose of this study was to investigate the effect of mild hypocapnia on hypertension and arousal response after tracheal intubation in children during propofol anesthesia. Forty-four children, American Society of Anesthesiologists physical status I-II patients, aged 3-9 years were randomly allocated to either the normocapnia group [end-tidal carbon dioxide tension (ETCO2=35 mmHg, n=22)] or the hypocapnia group (ETCO2=25 mmHg, n=22). Anesthesia was induced with propofol 2.5 mg/kg. Five minutes after the administration of rocuronium 0.6 mg/kg, laryngoscopy was attempted. The mean arterial pressure (MAP), heart rate (HR), SpO2 and bispectral index (BIS) were measured during induction and intubation periods. The maximal change in the BIS with tracheal intubation (ΔBIS) was defined as the difference between the baseline value and the maximal value within the first 5 min after intubation. Before tracheal intubation, the change in BIS over time was not different between the groups. After tracheal intubation, the changes in the MAP, HR and BIS over time were not significantly different between the groups. The mean value±SD of ΔBIS was 5.7±5.2 and 7.4±5.5 in the normocapnia and hypocapnia groups, respectively, without any intergroup difference. This study showed that mild hypocapnia did not attenuate hemodynamic and BIS responses to tracheal intubation in children during propofol anesthesia. Our results suggested that hyperventilation has no beneficial effect on hemodynamic and arousal responses to tracheal intubation in children.

The effect of desflurane versus propofol on regional cerebral oxygenation in the sitting position for shoulder arthroscopy.

The sitting position may cause significant hemodynamic instability and cerebral hypoperfusion. We investigated the effects of desflurane and propofol on regional cerebral oxygenation (rSO2) in the sitting position during arthroscopic shoulder surgery. Forty patients undergoing arthroscopic shoulder surgery in the sitting position were randomly allocated to the desflurane group (n = 20) or the propofol group (n = 20). Anesthetic agents were maintained and adjusted with the effect-site concentration of propofol (2-3.5 µg/ml) or desflurane (4-7 vol%) to obtain a bispectral index (BIS) of 40-50. The hemodynamic variables, end-tidal carbon dioxide tension (ETCO2) and rSO2 were measured and evaluated. There were no differences in BIS, hemodynamic variables and ETCO2 between the groups. The rSO2 values in the desflurane group were higher compared to the propofol group at 3, 5, 7 and 9 min after the sitting position (P = 0.031, 0.047, 0.025 and 0.034, respectively). However, it decreased significantly from the baseline values at 3, 5, 7 and 9 min after the sitting position in both groups (P < 0.001). The change in rSO2 across time was not significantly different between the groups (P = 0.183). The incidence of rSO2 <75% of the baseline values after the sitting position was similar between the groups (0 and 10% in the desflurane and propofol group, respectively, P = 0.487). When anesthetized patients were raised to the sitting position, desflurane preserved cerebral oxygenation better than propofol at equipotent concentrations in terms of BIS. However, both anesthetics were associated with significant decrease in the rSO2 values during the sitting position.