Intraocular pressure during robotic-assisted laparoscopic prostatectomy: a prospective observational study.

BACKGROUND AND OBJECTIVES: Although previous reports have shown intraocular pressure changes during robotic-assisted laparoscopic prostatectomy, they did not discuss the time course of changes or the timing of the largest change. We conducted this study to quantify pressure changes over time in patients assuming the steep Trendelenburg position during robotic-assisted laparoscopic prostatectomy. METHODS: Twenty-one men were enrolled. Intraocular pressure was measured before anesthesia induction in the supine position (T0); 30 (T1), 90 (T2), and 150 minutes after assuming the Trendelenburg position (T3); and 30 minutes after reassuming the supine position (T4). End-tidal carbon dioxide and blood pressure were also recorded. To compare intraocular pressure between the time points, we performed repeated-measures analysis of variance. A mixed-effects multivariate regression analysis was conducted to adjust for confounding factors. RESULTS: The mean (standard deviation) intraocular pressure was 18.3 (2.4), 23.6 (3.0), 25.1 (3.1), 25.3 (2.2), and 18.1 (5.0) mmHg at T0, T1, T2, T3, and T4, respectively. The mean intraocular pressure was higher at T1, T2, and T3 than at T0 (p < 0.0001 for all). There was no significant difference between T0 and T4, and between T3 and T2 (p > 0.99 for both). CONCLUSIONS: The Trendelenburg position during robotic-assisted laparoscopic prostatectomy increased intraocular pressure. The increase was moderate at 90 minutes after the position was assumed, with the value being approximately 7 mmHg higher than the baseline value. The baseline intraocular pressure was restored at 30 minutes after the supine position was reassumed. TRIAL REGISTRATION: UMIN ID 000014973 DATE OF REGISTRATION: August 27, 2014.

A question is "what are the optimal targets for anticoagulant therapies?"

A high mortality rate is found among septic patients with disseminated intravascular coagulation (DIC). Anticoagulants have been used for treating septic DIC especially in Japanese clinical settings; however, their effectiveness is quite controversial across studies. According to several randomized controlled trials and meta-analyses, antithrombin and recombinant thrombomodulin had no therapeutic benefit in the treatment of sepsis. However, the majority of the previous research did not discuss "septic DIC" but simply "sepsis", and some reviews showed that anticoagulants were benefit only in septic DIC. Although immunothrombosis plays an important role in early host defense, it can lead to DIC and organ failure if dysregulated. Therefore, we advocate anticoagulant therapies might have beneficial effects, but research on optimal patient selection is currently lacking.

Low hematocrit levels: a risk factor for long-term outcomes in patients requiring prolonged mechanical ventilation after cardiovascular surgery. A retrospective study.

While low-risk patients who undergo elective surgery can tolerate low hematocrit levels, the benefits of higher hematocrit levels might outweigh the risk of transfusion in high-risk patients. Therefore, this study aimed to evaluate the effects of perioperative hematocrit levels on mortality in patients requiring prolonged mechanical ventilation (PMV) after a cardiovascular surgery. This single-center retrospective cohort study was conducted on 172 patients who underwent cardiovascular surgery with cardiopulmonary bypass or off-pump coronary artery bypass grafting and required PMV for ≥72 hours in the intensive care unit (ICU) from 2008 to 2012 at the Yokohama City University Medical Center in Yokohama, Japan. Patients were classified according to hematocrit levels on ICU admission: high (≥30%) and low (<30%) groups. Of 172 patients, 86 were included to each of the low-hematocrit and high-hematocrit groups, with median hematocrit levels (first to third quartiles) of 27.4% (25.4%-28.7%) and 33.0% (31.3%-35.5%), respectively. The difference in survival rates was significant between the two groups using the log-rank test (HR 0.55, 95% CI 0.32 to 0.95, p=0.033). Cox regression analysis revealed that ≥30% increase in hematocrit levels on ICU admission was significantly associated with decreased long-term mortality (HR 0.40, 95% CI 0.20 to 0.80, p=0.0095). Lower hematocrit levels on ICU admission was a risk factor for increased long-term mortality, and higher hematocrit levels might outweigh the risk of transfusion in patients requiring PMV after a cardiovascular surgery.

Pre-anesthetic ultrasonographic assessment of the internal jugular vein for prediction of hypotension during the induction of general anesthesia.

PURPOSE: Severe hypotension caused by anesthetic administration for anesthesia induction, which might cause ischemic stroke, myocardial injury, acute kidney injury and postoperative mortality, should be prevented. Anesthesiologists are familiar with ultrasound examination of the internal jugular vein (IJV). This study aimed to clarify whether ultrasonographic IJV evaluation just before induction could predict the occurrence of such hypotension. METHODS: Adult patients undergoing surgery under general anesthesia were enrolled after excluding patients with cardiovascular disease or ASA-PS ≥ III. Ultrasonographic IJV images were recorded in both the supine and 10° Trendelenburg positions immediately before induction. Using these images, IJV area (IJV-A), diameter and change rate with posture were measured. Hypotension during induction was defined as mean BP < 60 mmHg or > 30% decrease from baseline. RESULTS: Hypotension during induction was observed in 37 of 82 patients. IJV-A in the Trendelenburg position was 2.02 ± 0.86 and 1.72 ± 0.68 in the hypotensive and non-hypotensive groups, respectively (P = 0.08). Logistic regression analysis performed using age, use of calcium antagonists, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, baseline mean BP and IJV-A in the Trendelenburg position as variables showed that IJV-A in the Trendelenburg position was an independent predictor of hypotension, with an adjusted odds ratio of 3.11 (95% CI 1.07-9.03, P = 0.04). Area under the curve was 0.595 (95% CI 0.469-0.722) for IJV-A in the Trendelenburg position. CONCLUSION: IJV-A in the Trendelenburg position was an independent predictor of hypotension during induction. Further study is required to examine the diagnostic accuracy of IJV-A as a predictor for hypotension during induction.

[Boy with Coffin-Lowry syndrome associated with spinal cord injuries].

A 12-year-old male patient with Coffin-Lowry syndrome was scheduled for posterior cervical decompression and fusion for cervical spinal injuries. The patient had features of Coffin-Lowry syndrome including mental retardation, prominent forehead, a short nose with a wide tip, a wide mouth with full lips, short stature, microcephaly, and kyphoscoliosis. We anticipated major troubles related to anesthesia such as difficult ventilation and intubation, communication difficulty during induction and extubation, and difficulty in using a naso-pharyngeal airway. In addition, we had to stabilize neck alignments during intubation because cervical vertebrae were unstable and spinal cord has already been injured. Therefore, we scheduled slow induction with sevoflurane maintaining spontaneous respiration. As we found the full mouth opening of the patient after the induction, we inserted an intubating laryngeal mask, through which ventilation was successfully maintained. A tracheal tube was inserted through the intubating laryngeal mask. When the surgery was completed, we extubated using a tube introducer in the trachea. As we found that the patient's airway was open, we removed the introducer. In conclusion, with a thorough planning of the anesthetic management, we successfully managed anesthesia for cervical spinal surgery in a patient with Coffin-Lowry syndrome.

Assimilate translocation and expression of sucrose transporter, OsSUT1, contribute to high-performance ripening under heat stress in the heat-tolerant rice cultivar Genkitsukushi.

High temperature reduces the grain quality of rice, a situation likely to become more frequent because of global warming. We studied the effects of high-temperature stress on grain quality of heat-tolerant cultivar 'Genkitsukushi' and heat-sensitive cultivar 'Tsukushiroman'. When day/night temperatures were 31/26 °C from heading until maturity, the grain quality of 'Genkitsukushi' was rated at the first inspection grade (high quality), whereas 'Tsukushiroman' showed a remarkable increase in the percentage of white immature kernels (low quality). Nonstructural carbohydrate content in the stem of 'Genkitsukushi' the early maturation was significantly higher than in 'Tsukushiroman' and greatly decreased under high temperature. From 14 to 21 days after heading, the expression of the sucrose transporter gene, OsSUT1, was higher in the stem of 'Genkitsukushi' grown under high temperature than in 'Tsukushiroman'. In addition, the expression of OsSUT1 in the grains of 'Genkitsukushi' was significantly higher than in 'Tsukushiroman' during the ripening period. These results indicate that sugar transport functions more effectively in 'Genkitsukushi' than in 'Tsukushiroman', and that the effectiveness of sugar transport contributes to maintaining high grain quality in 'Genkitsukushi' under high-temperature conditions.

[Assessment of cardiac function by TEE].

Transesophageal echocardiography (TEE) is a useful tool for assessment of cardiac function in patients undergoing cardiac surgery or in patients undergoing non-cardiac surgery who have cardiovascular complications. Left ventricular (LV) function is composed of systolic function, diastolic function, preload and afterload. To assess systolic and diastolic function several methods are used, and we must use them based on the property of each parameter. Both systolic and diastolic functions are load dependent. To assess the systolic function, ejection fraction (EF) is commonly used. Transmitral flow (TMF) and pulmonary vein flow patterns are commonly used to assess the diastolic function. Newer techniques including mitral annular velocity and color M-mode TMF propagation velocity (Vp) may be less sensitive to changes in loading conditions. LV dP/dt is not affected by preload, and myocardial performance index (Tei index) can be used to assess both systolic and diastolic functions. Tei index is also useful to assess right ventricular function. The recently developed real time 3-dimensional system provides accurate and objective information, such as LV volumetry, wall motion, dyssyncrony and valvular pathology.

[Preoperative hypercoagulopathy in patients undergoing orthopedic lower extremity surgery].

BACKGROUND: Plasma levels of D-dimer, soluble fibrin monomer complex (SFMC) and FDP were measured in 40 patients for orthopedic lower extremity surgery, using a recently established monoclonal antibody to clarify if these markers are good indicator of deep vein thrombosis(DVT). METHODS: Subjects were 20 patients for total hip arthroplasty (THA) or total knee arthroplasty (TKA) (group A) and 20 patients for hip fracture surgery (group F). D-dimer, SFMC and FDP were measured at induction of anesthesia. RESULTS: Preoperative values of D-dimer, FMC and FDP in group F were higher than those in group A, and these values in group F were higher than normal values. CONCLUSIONS: It is concluded that plasma levels of D-dimer, SFMC and FDP in the patients with hip fracture were higher than those in the patients scheduled for TKA or THA in perioperative period. These suggest that the patients with hip fracture have high risk of DVT.

[Use of gum elastic bougie for tracheal intubation: comparison of different tracheal tubes].

BACKGROUND: Gum elastic bougie (GEB) is one of the most useful devices for patients whose tracheas are difficult to intubate during anesthetic induction. But no previous study has evaluated the effects of the types of the tracheal tube. We hypothesized that wire-reinforced tracheal tubes were superior to standard tracheal tubes in the success rate of tracheal intubation when using GEB. We compared these two different types of tracheal tubes in using GEB. METHODS: Forty patients were subjected and randomly allocated into two groups; patients intubated with standard tracheal tubes (Group , n = 20) and those with wire-reinforced tracheal tubes (Group S, n = 20). Measured variables were intubation time defined as elapsed time from mouth opening to removal of GEB from tracheal tube, heart rate (HR), and systolic blood pressure(SBP). We also compared trial times of intubation and pharyngeal or laryngeal bleeding as a minor side effect. RESULTS: Trachea was successfully intubated in the frist attempt in 37 patients (92.5%), and the rest of the patients were all intubated at second trial. Intubation times of Group P and Group S were 41.5 +/- 13.9s and 41.3 +/- 11.1s, respectively. There were no significant differences in HR and SBP between the groups. CONCLUSIONS: The type of tracheal tube would not affect the success rate and time of intubation when using gum elastic bougie.

[Perioperative changes of the coagulation markers in patients undergoing hip fracture surgery].

BACKGROUND: Plasma levels of D-dimer, fibrin monomer complex (FMC) and FDP were measured in 10 patients who underwent hip fracture surgery, using a recently established monoclonal antibody to clarify if these markers are good indicators of deep vein thrombosis (DVT). METHODS: Subjects were 10 (4 male and 6 female) hip fracture patients, aged 87 +/- 6 years. D-dimer, FMC and FDP were measured at induction of anesthesia and 24 hours as well as 6 days after operation. RESULTS: Preoperative values of D-dimer, FMC and FDP were higher than normal values, and these markers remained high during the postoperative period. CONCLUSIONS: It is concluded that plasma levels of D-dimer, FMC and FDP in the patients with hip fracture were high in perioperative period. Among these markers, FMC was the most useful indicator for the diagnosis at the early stage of DVT.

[Perioperative changes of blood coagulability evaluated by thromboelastography (TEG) in patients undergoing total knee and total hip arthroplasty].

BACKGROUND: A large number of studies have examined the incidence of thromboembolic complications after orthopedic surgery of the lower extremity. We investigated the perioperative changes of coagulability following total knee arthroplasty (TKA) or total hip arthroplasty (THA) using thromboelastography (TEG), which could comprehensively assess the coagulation and fibrinolytic system. METHODS: Thirty patients scheduled for TKA (n= 10), THA (n= 10) and other lower extremity orthopedic surgery (control, n= 10) were studied. TEG was analyzed with K-value, MA-value and coagulation index (CI) before induction of anesthesia and 24 hours after surgery. RESULTS: K-values decreased significantly after TKA and THA compared with the values before the induction of anesthesia. MA-values and CI increased significantly after TKA and THA compared with the values before the induction. There were no significant changes in K-value, MA-value and CI in the control group during the perioperative period. CONCLUSIONS: The results suggest that TKA and THA lead blood coagulation to hypercoagulable state at the early postoperative stage.

[Case of spontaneous intracranial hypotension associated with depressed consciousness].

We experienced a case of spontaneous intracranial hypotension (SIH) complicated with depressed consciousness after its treatment. A 56-year-old woman developed postural headache, and her MRI revealed bilateral chronic subdural hematoma (CSH). After treatment with epidural autolongous blood patch, her headache resolved completely. However, two days after, the patient developed depressed conciousness, and MRI showed brain sagging and downward brain displacement. After management with conservative treatment, including second epidural blood patch and hematoma drainage, the patient became alert and other symptoms resolved gradually. We demonstrated that caution should be taken for the management of SIH, especially in the case associated with CSH.

[Effects of sevoflurane and propofol on evoked potentials during neurosurgical anesthesia].

BACKGROUND: The effect of anesthetics on somatosensory evoked potential (SEP) and auditory brain stem response (ABR) has been a subject of intense reseach over the last two decades. In fact, volatile anesthetics have been repeatedly shown to decrease cortical amplitude in a dose-dependent fashion but the information regarding the effect of propofol is incomplete. The purpose of this study was to compare the effects of sevoflurane and propofol on evoked potentials during comparable depth of anesthesia guided by bispectral index (BIS). METHODS: Forty four patients scheduled for neurosurgery were studied. Anesthesia was maintained with intravenous propofol using target controlled infusion (TCI). We measured the change of amplitude and latency of SEP(N20-P25), ABR (V wave) and visual evoked potential (VEP: P100) at three sets of sevoflurane (0%, 1%, 2%) or propofol concentrations (effect site concentration of 1.5, 2.0, 3.0 microug x ml(-1)). BIS monitor was used to measure relative depth of hypnosis. RESULTS: With increasing concentrations of sevoflurane (0, 1% and 2%), SEP showed dose-related reduction in its amplitude, ABR produced less marked changes and VEP showed a significant reduction at 1%. VEP at the propofol concentration of 3.0 microg x ml(-1) was decreased significantly compared with the amplitude at 1.5 microg x ml(-1) concentration. No significant change was observed with SEP and ABR during the change of propofol dosages. BIS values were almost the same with each anesthetics. CONCLUSIONS: VEP was most strongly affected with anesthetics, and ABR showed less marked influence of sevoflurane and propofol. Propofol based TIVA technique would induce less change in evoked potentials than sevoflurane.

[Evaluation of cerebral oxygen balance during normothermic cardiopulmonary bypass using jugular oxygen saturation].

BACKGROUND: Previous studies suggest that normothermic cardiopulmonary bypass(CPB) impairs cerebral oxygen balance. We studied the effect of normothermic CPB on cerebral oxygen balance evaluated by continuous measurement of oxygen saturation in the jugular vein (SjO2). METHODS: Eleven patients undergoing coronary artery bypass grafting with normothermic CPB were studied. A 4 Fr oxymetry catheter was inserted into the internal jugular bulb for SjO2 monitoring. We measured mean arterial pressure (MAP), SjO2 and hemoglobin (Hgb) concentration at five time points-1) pre CPB, 2) 3) 4) 5, 30, 60 min after the onset of CPB, respectively, 5) 5 min after the end of CPB. RESULTS: MAP decreased significantly 30 min (47 +/- 9 mmHg) and 60 min (48 +/- 9 mmHg) after the onset of CPB compared with the pre CPB (80 +/- 14 mmHg) value. Hgb also decreased significantly 5 min (7.8 +/- 1.1 g x dl(-1)) and 30 min (7.1 +/- 1.0 g x dl(-1)) and 60 min (7.1 +/- 0.8 g x dl(-1)) after the onset of CPB compared with the pre CPB (11 +/- 1.0 g x dl(-1)) value. However, SjO2 showed no significant change throughout the study period. No significant correlation was observed between MAP and SjO2. CONCLUSIONS: Cerebral oxygen balance assessed by SjO2 was not impaired during normothermic CPB, and was unaffected by hypotension and hemodilution.

[Study of nausea and vomiting accompanying intravenous patient-controlled analgesia with fentanyl after cervical spine surgery].

BACKGROUND: Serious side effects of postoperative analgesia with opioid drugs include nausea and vomiting. METHODS: We investigated the effects of various factors (patient background, anesthesia duration, and intraoperative drug use) on the frequency and degree of postoperative nausea and vomiting (PONV) during the first 24 hours of intravenous patient-controlled analgesia (PCA) with fentanyl. RESULTS: PONV occurred in 34% of the male patients and 68% of the female, and in 31% and 58% of smokers and non-smokers, respectively. CONCLUSIONS: Consideration should be given to gender and smoking status prior to starting preventive antiemetic therapy using PCA with fentanyl following cervical spine surgery.