Intraoperative Remifentanil Use Reduces Atrial Fibrillation After Coronary Artery Bypass Surgery.

Objectives: Atrial fibrillation after coronary artery bypass grafting is a relatively well known complication that has been observed for a long time. Though the management and drugs in the perioperative period have changed, their impact on the generation of postoperative atrial fibrillation remains unclear. Therefore, we investigated various perioperative management methods and the occurrence of postoperative atrial fibrillation. Methods: The patients underwent off-pump coronary artery bypass grafting between January 2010 and October 2019. The study was a retrospective observational study, and we investigated the incidence of atrial fibrillation during all 5 postoperative days. Patient factors included age, sex, height, and weight, preoperative factors included oral statin, HbA1c, left ventricular ejection fraction, and left atrial diameter; intraoperative factors included operation time, remifentanil use, beta-blocker use, magnesium-containing infusions use, in-out balance, and number of vascular anastomoses. Results: Postoperative atrial fibrillation was recognized in 81 out of 276 cases. There were significant differences between the two groups in terms of age, left atrial diameter, and intraoperative remifentanil use. A logistic regression analysis presented the effects of age (OR 1.045, 95% CI 1.015-1.076, P < 0.01), preoperative left atrial diameter (OR 1.072, 95% CI 1.023-1.124, P < 0.01), and intraoperative remifentanil use (OR 0.492, 95% CI 0.284-0.852, P = 0.011) on postoperative atrial fibrillation. Conclusions: Operative time did not affect postoperative atrial fibrillation. Age and left atrial diameter had previously been shown to affect postoperative atrial fibrillation, and our results were similar. This study showed that the use of remifentanil reduced the incidence of postoperative atrial fibrillation. On the other hand, no other factors were found to have an effect.

Usefulness of Tulip Airway in Edentulous Elderly Patients.

OBJECTIVE: Mask ventilation can be difficult in elderly edentulous patients. Various solutions have been proposed to address this challenge. This study assessed the use of a new airway-securing device called the Tulip Airway and investigated its application in simulated edentulous patients. METHODS: This pilot study utilized a modified edentulous airway training mannequin and a high-performance simulator. Participants attempted to ventilate the edentulous mannequin using a Guedel oropharyngeal airway and face mask (M method) or the Tulip Airway (T method). Successful inflation of the mannequin model lung was confirmed visually. The time required for the insertion of the Tulip Airway was also assessed. A high-performance simulator was then used to compare ventilation volumes achieved using the M and T methods, and data subsequently analyzed. RESULTS: In the edentulous mannequin, lung inflation was not achieved by any participants using the M method, but all were successful using the T method. Insertion time for the Tulip Airway was ∼8 seconds. Median ventilation volumes achieved using the high-performance simulator were higher for the T method (308 mL) compared with the M method (192 mL; P < .05). CONCLUSION: The results of this pilot study indicate that the Tulip Airway is an effective airway device for use in edentulous patients with difficult mask ventilation.

Mortality at 180-days is affected by serum haptoglobin levels in septic patients with high magnitude serum high mobility group box-1 levels.

AIM: High mobility group box-1 (HMGB1) is a lethal mediator of sepsis that binds to haptoglobin (Hp) and is associated with its prognosis. We investigated the effect of the combination of HMGB1 and Hp on sepsis prognosis. METHODS: This single-center, retrospective study registered 78 patients with sepsis according to Sepsis-3 criteria on day 1 of diagnosis from July 2016 to November 2018. We divided the patients into four groups according to the serum concentration of 6.2 ng/mL HMGB1 and the median value of Hp. The 180-day mortality rates and cytokine concentrations of the low and high HMGB1 groups were compared. RESULTS: There was no difference in the 180-day mortality rate between the low Hp group and the high Hp group in the low HMGB1 group (P = 0.691). In the high HMGB1 group, a statistically significant difference was found between the low Hp group and the high Hp group (P = 0.002). In the high HMGB1 group, high Hp was associated with a better prognosis in univariate analysis (odds ratio, 0.131; 95% confidence interval [CI], 0.027-0.629; P = 0.011), and multivariate analysis (adjusted odds ratio, 0.086; 95% CI, 0.013-0.582; P = 0.009). In addition, in the high HMGB1 group, interleukin-8 levels were significantly higher in the low Hp group than in the high Hp group (P = 0.004). CONCLUSION: Patients with sepsis-induced high serum HMGB1 levels and low serum Hp levels could have a poor long-term prognosis.

Perioperative tight glycemic control using artificial pancreas decreases infectious complications via suppression of inflammatory cytokines in patients who underwent pancreaticoduodenectomy: A prospective, non-randomized clinical trial.

BACKGROUND: We sought to investigate the efficacy of perioperative tight glycemic control (TGC) in reducing of postoperative infectious complications (POICs) and study its impact on early inflammatory mediators in patients who underwent pancreaticoduodenectomy. METHODS: In this non-randomized trial, the artificial pancreas (AP) group received TGC (target glucose range of 80-110 mg/dL; n = 14), while the control group received conventional glycemic control (range of 80-180 mg/dL; n = 15). The primary endpoint was POICs. RESULTS: The AP group had a markedly decreased POIC rate (28.6% vs. 73.3%; P = 0.027), mean glycemic variability (13.5 ± 3.5% vs. 16.4 ± 5.9%; P = 0.038), and plasma interleukin-6 level (26.3 ± 33.8 vs 98.3 ± 89.1 pg/ml; P = 0.036) compared to the control group, but insulin dosage (27.0 ± 13.4 vs. 10.2 ± 16.2 U; P = 0.002) and the adiponectin ratio (i.e., postoperative/preoperative adiponectin; 0.8 ± 0.2 vs. 0.6 ± 0.3; P = 0.021) were markedly higher in the AP group. CONCLUSIONS: Among patients undergoing PD with impaired glucose tolerance, AP facilitated strict glycemic control and resulted in a reduction of anti-inflammatory mediators and POICs. SUMMARY: Perioperative hyperglycemia increases postoperative infectious complications; however, tight glycemic control using artificial pancreas can reduce them via a dual effect. Artificial pancreas facilitates strict and safe glycemic control while reducing anti-inflammatory mediators, including adiponectin, following pancreaticoduodenectomy.

Hyperkalemia caused by rapid red cell transfusion and the potassium absorption filter.

We report a case of transient hyperkalemia during hysterectomy after cesarean section, due to preoperatively undiagnosed placenta accreta that caused unforeseen massive hemorrhage and required rapid red cell transfusion. Hyperkalemia-induced by rapid red cell transfusion is a well-known severe complication of transfusion; however, in patients with sudden massive hemorrhage, rapid red cell transfusion is necessary to save their life. In such cases, it is extremely important to monitor serum potassium levels. For an emergency situation, a system should be developed to ensure sufficient preparation for immediate transfusion and laboratory tests. Furthermore, sufficient stock of preparations to treat hyperkalemia, such as calcium preparations, diuretics, glucose, and insulin is required. Moreover, a transfusion filter that absorbs potassium has been developed and is now available for clinical use in Japan. The filter is easy to use and beneficial, and should be prepared when it is available.

[Case of bronchial obstruction by thrombosis after cardiopulmonary bypass].

A 78-year-old man underwent total arch replacement for an aortic arch aneurysm under cardiopulmonary bypass. After protamine sulfate administration, his peak inspiratory pressure suddenly rose, and his arterial oxygen saturation dropped. We checked his bronchus with a bronchoscope and found that his left main bronchus was blocked by a large thrombus. We tried to remove the thromus with suction via the bronchoscope channel, but it was too large to pick out. We had no way to perform this removal, and we called a respiratory specialist who performed the removal. The size, shape and time of onset suggested that the thrombus had been formed by residual blood left after administration of protamine. This case indicated that residual blood in the bronchus should be cheeked carefully after cardiopulmonary bypass.

Relationship between blood levels of propofol and recovery of memory in electroconvulsive therapy.

AIM: Memory impairment is a potential major adverse effect of electroconvulsive therapy (ECT). Some reports have suggested that propofol, an intravenous anesthetic widely used for general anesthesia in ECT, can minimize adverse effects on memory and cognitive function following ECT. The relation between propofol blood level during ECT and memory impairment after the procedure is unknown. We aimed to determine the relation between predicted blood level of propofol administered by target-controlled infusion during ECT and memory impairment after the procedure. METHODS: Thirty-six patients who underwent a total of 260 series of ECT were enrolled as subjects. Anesthesia was induced with intravenous injection of propofol with a target-controlled infusion pump for predicting blood levels. Orientation and memory testing were performed after completion of ECT. In a subsequent analysis, subjects were divided into early memory recovery (n = 195) and late memory recovery (n = 65) groups. Likewise, for orientation testing,subjects were divided into early recovery (n = 193) and late recovery (n = 67) groups. In both groups, predicted blood propofol levels, total propofol dose, and other variables, such as number of ECT treatments, stimulus energy volume, and spike and slow wave time, were determined for comparison. RESULTS: Predicted blood propofol levels and propofol total dose were significantly higher in the early memory recovery group, while no significant differences were observed for the other variables. As for orientation, there were no significant differences between the early and late orientation recovery groups. CONCLUSIONS: Our data shows that the predicted blood propofol levels and the total dose influences memory impairment after the ECT.

[General anesthesia for a patient with post-polio syndrome].

We gave anesthesia for a patient with post-polio syndrome undergoing laparoscopic sigmoid colectomy. She is a 68-year-old woman and had been diagnosed as post-polio syndrome since she was 55 years of age. Before the operation, paralysis was observed in her right leg. After inducing anesthesia using propofol, muscle relaxation was obtained by rocuronium bromide for intubation. Remifentanil was used during the operation, and good pain relief was obtained by iv-PCA (fentanyl) after operation.

[General anesthetic management of a patient with spinal muscular atrophy type III].

We report a 61-year-old woman (weight 49 kg, height 156 cm) with Kugelberg-Welander disease who was scheduled for bilateral mastectomy under general anesthesia. We administered rocuronium 10 mg (0.20 mg x kg(-1)) for tracheal intubation. After 80 min, train-of-four ratio (TOFR) was 46%. During the operation, we did not administer rocuronium. After surgery, TOFR was 62%. Therefore, we administered sugammadex 100 mg (2 mg x kg(-1)). After 4 min, TOFR became above 90%, and the patient was extubated. There was no respiratory distress, muscle weakness, or neurologic untoward event after the use of sugammadex in the postoperative period. Sugammadex was effective in reversing rocuronium induced neuromuscular block in a patient with Kugelberg-Welander disease.

[Left ventricular migrating thrombus detected by intraoperative transesophageal echocardiography].

Transesophageal echocardiography (TEE) helps detecting intra-cavity thrombus size, mobility and fragility, which are of great importance in surgical removal of the thrombus. Thrombus characteristics may render surgical thrombectomy incomplete, raising the risk of catastrophic embolization. A 50-year-old man, suffering from congestive heart failure, developed a mobile thrombus in the left ventricle (LV). He was scheduled for a LV thrombectomy. TEE showed two thrombi on the apical side of the left ventricle, measuring 2.1 x 1.3 cm and 2.1 x 1.0 cm each. A surgical removal of these thrombi was performed under cardiopulmonary bypass (CPB). Just before separation from CPB, TEE detected a high echogenic mass in the LV Surgical re-explorations found residual thrombi, whose size, figure and echo signal strength resembled papillary muscles. This experience leads us to advocate repeated search for thrombi using TEE scans, in order to facilitate complete removal of thrombi prior to closing the ventriculotomy, and prior to weaning from CPB.