Postoperative laryngeal morbidity and intubating conditions using the McGRATH™ MAC videolaryngoscope with or without neuromuscular blockade: a randomised, double-blind, non-inferiority trial.

Tracheal intubation without neuromuscular blockade may be associated with worse intubating conditions and increased laryngeal morbidity. We hypothesised that tracheal intubation using the McGRATH™ MAC videolaryngoscope would not increase postoperative hoarseness, even without neuromuscular blockade. In this prospective, randomised, parallel-group, double-blind, non-inferiority trial, 248 patients were randomly assigned to tracheal intubation with or without neuromuscular blockade using rocuronium. Hoarseness and sore throat were evaluated at 24 h and 48 h postoperatively. The primary outcome was the incidence of hoarseness at 48 h postoperatively with a pre-defined non-inferiority margin of 10%. Hoarseness at 48 h did not differ between the non-paralysed group and the paralysed group (8.1% vs. 13.6%; absolute difference: -5.4%; 95%CI: -13.3 to 2.4). Also, no significant differences were found between the two groups for hoarseness at 24 h (22.8% vs. 27.1%) or for sore throat at 24 h (12.2% vs. 9.3%) and 48 h postoperatively (1.6% vs. 0.8%). Although more patients in the non-paralysed group showed an adducted position of the vocal cords (29.3% vs. 0%), there were no significant group differences in the ease of laryngoscopy (96.7% vs. 98.3%), Cormack grade laryngeal view 1 (97.6% vs. 96.6%) or first-pass success rate (100% vs. 100%). We conclude that when using the McGRATH MAC videolaryngoscope for tracheal intubation, the incidence of postoperative hoarseness was not inferior if neuromuscular blockade was avoided.

Patterns of spread and prognostic implications of lung cancer metastasis in an era of driver mutations.

BACKGROUND: In the present study, we examined the pattern of metastatic spread in patients with advanced non-small-cell lung cancer (nsclc) and the effect of EGFR mutations. METHODS: Patients were identified from a provincial cancer registry, and individual medical records were reviewed. Patients were included if they had stage iv nsclc and underwent diagnostic EGFR mutation testing. Patients were divided into EGFR mutation-positive (EGFR+) and EGFR wild type (wt) cohorts. The primary endpoint was the cumulative incidence for each metastatic site: lung, bone, brain, liver, adrenal glands, distant nodes, and other. Cumulative incidence curves were estimated using a competing-risks method. The secondary outcome was survival. RESULTS: Of the 543 identified patients, 121 (22.3%) tested as EGFR+, and 422 (77.7%) tested as EGFR wt. The incidence of brain (39.2% vs. 28.2%, p = 0.038) and lung (61.2% vs. 51.0%, p = 0.048) metastasis was higher in the EGFR+ cohort than in the EGFR wt cohort. In the EGFR+ cohort, a higher incidence of liver metastasis was associated with the exon 21 mutation subtype than with the exon 19 deletion subtype [23% vs. 7%, p < 0.01; hazard ratio (hr): 3.47]. Median survival was significantly longer for the EGFR+ cohort than for the EGFR wt cohort (22.4 months vs. 7.9 months, p < 0.001). In multivariable analysis, brain (hr: 1.73), liver (hr: 1.69), and bone (hr: 1.89) metastases were associated with worse survival. CONCLUSIONS: Rates of lung and brain metastases are higher in EGFR mutation carriers, even when adjusted for differences in survival. Brain, liver, and bone metastases are independent negative prognostic factors for survival.

Intravenous dexmedetomidine for cesarean delivery and its concentration in colostrum.

BACKGROUND: Dexmedetomidine is a sedative agent with high α2-adrenoreceptor selectivity. We investigated intravenous dexmedetomidine administration during scheduled cesarean delivery under neuraxial anesthesia; and its concentration in the colostrum. METHODS: Twenty-seven participants having elective cesarean delivery under combined spinal-epidural anesthesia were enrolled. After delivery and cord clamping, 6µg/kg/h of intravenous dexmedetomidine was administered for 10minutes, followed by a dose of 0.7µg/kg/h until peritoneal closure. Sedation, vital signs and side effects were recorded. Blood and colostrum samples were collected from each participant at 6, 12, and 24h after dexmedetomidine administration. Samples were analysed using liquid chromatography tandem-mass spectroscopy. RESULTS: Colostrum samples were collected from 10 patients. The median [95% CI] plasma dexmedetomidine concentration was 333 [303-534] pg/ml at 0h and 19.7 [13.5-25.8] pg/ml at 6h. The colostrum concentration was 12.3 [8.1-20.1] pg/ml at 6h. The dexmedetomidine completely disappeared from both within 24h. The calculated milk-to-plasma ratio at 6h was 0.76 [0.57-0.86]. The relative infant dose was 0.034% [0.020-0.062%]. At dexmedetomidine discontinuation, the Richmond Agitation-Sedation Scale score was -2 (range,-4 to -1). During surgery, no patients complained of nausea, peritoneal irritation or afterbirth pain. CONCLUSIONS: The dexmedetomidine milk-to-plasma ratio did not exceed 1 in any participant, and the relative infant dose was very low. Maternal sedation using dexmedetomidine is unlikely to be harmful for the infant.

Characterization of mesenchymal progenitor cells in crown and root pulp from human mesiodentes.

OBJECTIVE: Mesiodentes are usually found in the central position of the upper or lower jaw as supernumerary teeth. Here, we obtained 10 mesiodentes and three permanent teeth (PT) and separated the dental pulp (DP) from these into crown and root portions. We then characterized and compared the isolated crown portion-derived cells (crown cells) with root portion-derived cells (root cells) using a range of in vitro assays. MATERIALS AND METHODS: Crown cells and root cells were examined for cell surface marker expression, colony-forming unit-fibroblast (CFU-F), cell proliferation, cell cycle characteristics and markers, and osteogenic and adipogenic differentiation. RESULTS: The proportion of CD105-positive cells (CD105(+) cells) in the crown cells vs the root cells varied among the mesiodentes, but not among the PT. When there were more CD105(+) cells in the root cells than in the crown cells, the root cells showed higher CFU-F, proliferation capacity, and osteogenic differentiation capacity. In contrast, when the crown cells contained more CD105(+) cells than the root cells, the crown cells showed the higher CFU-F, proliferation capacity, and osteogenic differentiation capacity. In addition, the sorted CD105(+) cells showed higher CFU-F and proliferation capacity than the sorted CD105(-) cells. CONCLUSION: These results indicated that proportion of CD105(+) cells is an effective means of characterizing DP-derived cells in mesiodentes.

[Safety management for the patient after cardiovascular surgery in the intensive care unit].

In safety management after cardiovascular surgery, the system responding to patients' life-threatening changes must be established. Just a trivial error or the delay of medical treatment will increase the risk of shortening patients' lives in the intensive care unit Ventilators and circulatory assist devices such as a percutaneous cardiopulmonary support (PCPS) and a defibrillator should be well-maintained to be ready to be used. The communication among the staff of various jobs is also important. The effort to reconfirm everything as much as possible is necessary, which will certainly reduce adverse drug events and malpractice of the medical equipment in critical situations. The causes of errors must be thoroughly analyzed for the prevention of recurrences of similar events.

An anaphylactic reaction possibly associated with an intraoperative coronary artery spasm during general anesthesia.

We report a case of anaphylactic reaction occurring during general anesthesia that may have been accompanied by a coronary artery spasm. The present case and a review of the medical literature suggest that coronary artery spasm is evoked by common vasoactive mediators with anaphylactic reactions. Coronary artery spasm should be counted as a symptom of the cardiovascular manifestation of anaphylaxis. Clinicians should be aware of this possible complication when treating an anaphylactic reaction, especially in patients at risk for atherosclerosis. Early recognition of ST segment elevation is essential for diagnosis and treatment of coronary artery spasm.

Enhanced beta-receptor-mediated vasorelaxation in hypoxic porcine coronary artery.

To investigate the beta-adrenoceptor-mediated responses in hypoxic coronary arteries, we studied the effect of isoproterenol (Iso) on isolated porcine coronary arteries contracted with endothelin-1 in media aerated with 0, 5, 7.5, and 95% O(2). The concentration-response curve of Iso was significantly shifted to the left by hypoxia (0 and 5% O(2)). In oxygenated and hypoxic arteries, 3 x 10(-8), 10(-6), and 10(-5) M Iso significantly increased the contents of cAMP. However, there was no difference in the increases of cAMP content induced by 3 x 10(-8) M Iso between oxygenated and hypoxic arteries. The content of cAMP induced by high concentrations of Iso (10(-6) and 10(-5) M) was significantly larger in hypoxic than in oxygenated arteries. Furthermore, the potentiation by hypoxia of the Iso-induced vasorelaxation was inhibited by glibenclamide and depolarization by KCl, but not by removal of endothelium and indomethacin. The vasodilatory response to forskolin and dibutyryl cAMP was unaffected by hypoxia. We conclude that activation of the ATP-sensitive K(+) channel may account for the potentiation of the response to Iso in hypoxic coronary arteries.

Auto-positive end-expiratory pressure during one-lung ventilation using a double-lumen endobronchial tube.

The present study was undertaken to investigate the possible relationships between the magnitude of autopositive end-expiratory pressure (auto-PEEP) and measured PaO2 during one-lung ventilation (OLV). Forty-one adults received OLV anesthesia using a tidal volume of 8 mL/kg and a respiratory rate of 12 breaths/min. Auto-PEEP was quantified using an end-expiratory port occlusion method. During two-lung ventilation (2LV), auto-PEEP was observed in 18 of 41 patients and ranged from 0.5 to 2.5 cm H2O. During OLV, auto-PEEP was observed in 34 of 41 patients and ranged from 0.5 to 10 cm H2O. The mean (+/- SD) value of auto-PEEP was significantly higher during OLV than during 2LV (3.2 +/- 3.3 cm H2O versus 0.5 +/- 0.7 cm H2O, P < 0.0001). Auto-PEEP during OLV correlated inversely with preoperative forced expiratory volume in 1 s/forced vital capacity (y = 12.5 - 0.13x, r = -.05, P < 0.005). During OLV, there was no significant correlation between auto-PEEP and measured PaO2. These findings confirm that many patients do not exhale completely to functional residual capacity during OLV.

Hypoxia modifies the vasodilatory effects of nitroglycerin, prostaglandin E1, and hydralazine on isolated porcine coronary arteries.

To evaluate the potency of vasodilatory drugs in hypoxia, we studied the effects of nitroglycerin (NTG), prostaglandin E1 (PGE1), and hydralazine on porcine coronary artery constricted with endothelin-1 (ET-1) in both oxygenated and hypoxic conditions. Removal of endothelium potentiated NTG-induced relaxation in oxygenated conditions. Hypoxia potentiated relaxation of endothelium-intact arteries induced by NTG, but not relaxation of endothelium-denuded arteries. These findings suggest that hypoxia may modify endothelial function in NTG-induced relaxation. The relaxation of endothelium-intact and -denuded arteries induced by PGE1 in hypoxia was significantly greater than that in the oxygenated condition. PGE1 significantly increased the content of cyclic AMP in the hypoxic condition; it was much greater than that in the oxygenated condition, suggesting that hypoxia may enhance PGE1-induced relaxation by increasing cyclic AMP levels. Hypoxia attenuated hydralazine-induced relaxation in both endothelium-intact and denuded arteries. Indomethacin and aspirin attenuated hydralazine-induced relaxation in the oxygenated condition, suggesting that cyclooxygenase-related eicosanoid(s) may be involved in hydralazine-induced relaxation. However, indomethacin did not alter relaxation of hypoxic arteries induced by hydralazine. These findings suggest that hypoxia may inactivate cyclooxygenase in hydralazine-induced relaxation. Hypoxia may greatly modify the action of vasodilators on porcine coronary smooth muscle.

Cerebral blood flow and cerebral oxygen consumption in patients with COPD on mechanical ventilation.

OBJECTIVE: To investigate the effect of PaCO2 on cerebral blood flow (CBF) in chronic obstructive pulmonary disease (COPD). DESIGN: Before-after trial. SETTING: General ICU in a regional hospital. PATIENTS: 7 patients undergoing mechanical ventilation because of an exacerbation of COPD. INTERVENTION: CBF and cerebral metabolic rate of oxygen (CMRO2) of COPD were measured before and after hyperventilation and were compared by those of normal patients. CBF was measured by the Kety-Schmidt technique using 15% N2O. MEASUREMENTS/RESULTS: Hyperventilation produced a significant reduction in CBF in COPD with no concomitant change in CMRO2. CMRO2 in COPD was significantly lower than those in normal patients. The regression equation was shifted significantly more to the right in COPD. CONCLUSION: The sensitivity of CBF in CO2 remained but CMRO2 was reduced markedly in COPD patients.

The effects of dopamine infusion during operation on the postoperative liver dysfunction.

Dopamine improves renal function and renal blood flow by increasing cardiac output but its effect to ameriolate postoperative liver dysfunction has not yet been defined. Effect of 3-5 microg.kg(-1).min(-1) dopamine was studied in 22 patients who had total gastrectomy (dopamine group), and was compared with 22 patients who underwent the same operation and without dopamine infusion (control group). Liver function was evaluated from serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) values. Although postoperative SGOT and SGPT values in both groups were increased significantly higher than the preoperative values, the increases in SGOT (40 +/- 14 IU) and SGPT (32 +/- 15 IU) values in the dopamine group were significantly less than those in the control group (67 +/- 27 IU, 43 +/- 19 IU) ( P < 0.05, P < 0.01).In conclusion, these results suggested that this observation might be explained by amelioration of the postoperative liver dysfunction by infusion of dopamine. Dopamine infusion at a small dose during upper abdominal surgery is beneficial for liver function.

The effects of inversed ratio ventilation (IRV) on arterial oxygenation during mechanical ventilation in patients with acute respiratory failure.

We investigated the effects of inversed ratio ventilation by altering the inspiratory:expiratory (I:E) ratio and assessing the time course changes in the intrapulmonary shunting (Qs/Qt) in 14 patients with acute respiratory failure. Stepwise prolongation of the I:E ratio from 1:1.9 to 2:1 and then to 2.6 or 4:1 was applied when PEEP failed to raise the PaO2 above 80 mmHg while breathing oxygen. A significant decrease in Qs/Qt was observed following prolongation of the I:E ratio from 1:1.9 (Qs/Qt = 45 +/- 9%) to 2:1 (Qs/Qt = 29 +/- 9%) but not with further prolongation of the I:E ratio (Qs/Qt = 27 +/- 7%). Improvement of the pulmonary ventilation/perfusion imbalance became more marked with continued IRV and a significant increase in PaO2 was observed at 6 h after initiating prolongation of the inspiratory time (P less than 0.05). There were no significant changes in hemodynamics, PaCO2, or peak inspiratory pressure during IRV. This ventilatory pattern may be indicated when PEEP fails to improve PaO2, but prolongation of the inspiratory time above an I:E ratio of 2:1 did not produce a greater improvement in Qs/Qt and further increases in PaO2 did not occur after more than 10 h of IRV in our 14 patients.

Combined effects of inversed ratio ventilation (IRV) with positive end-expiratory pressure ventilation (PEEP) on cardiorespiratory function in acute respiratory failure.

Combined effects of inversed ratio ventilation (IRV) with positive end-expiratory pressure (PEEP) on cardiorespiratory function were examined in 24 patients with acute respiratory failure. Patients were divided into two groups: the IRV group (n = 12) who showed no significant increase in Pa(O)(2) with a 6 cmH(2)O of PEEP and PEEP group (n = 12) who were ventilated mechanically with PEEP only at maximum level of 10 cmH(2)O. In IRV group step-wise prolongation of the I : E ratio from 1 : 1.9 to 2.6 : 1 or 4 : 1 was applied as a Pa(O)(2) was improved and in PEEP group also level of PEEP was increased from 0, 5 to 10 cmH(2)O after one hour period irrespective of Pa(O)(2). Inversed ratio ventilation and PEEP increased significantly Pa(O)(2)/F i(O)(2), the increase being observed 6 hrs (I : E = 2 : 1) and 2 hrs (10 cmH(2)O) after starting IRV or PEEP. Further improvement of oxygenation was not observed in IRV even if I : E ratio was prolonged up to 2.6 : 1 or 4 : 1. These results suggested that combinations of IRV with PEEP were effective and an I : E ratio of 2 : 1 may be optimal, and IRV is advantageous compared to PEEP, but will take more long time to improve oxygenation than PEEP.

[An autopsy case of cerebral sinus thrombosis which showed papilledema and was accompanied by idiopathic thrombocytopenic purpura].

In a 53-year-old woman with papilledema and idiopathic thrombocytopenic purpura (ITP) brain CT examinations failed to detect the cause of papilledema, pseudotumor cerebri was suspected and lumbo-peritoneal shunt operation was performed to decrease the intracranial pressure. Unfortunately the patient died of intracerebral hemorrhage. The autopsy revealed superior sagittal sinus thrombosis to be the cause of papilledema, which indicate that sinus thrombosis can develop with such a hemorrhagic disease as ITP.

Limbal anesthesia for cataract surgery.

We present a new technique for the administration of anesthesia in cataract surgery. The technique consists of injecting 0.5 ml of locally-acting anesthetic subconjunctivally (or sub-Tenon's) along the superior limbal border. Using this method, we performed extracapsular cataract extraction (ECCE) with and without posterior chamber intraocular lens (PC-IOL) implantation or secondary PC-IOL implantation on 176 cataract patients. Anesthesia was successfully induced in the majority of these patients and all surgeries were carried out successfully with no major complications. Voluntary eye movements remained but did not interfere with surgery. On the contrary, they helped expose certain surgical sites. This new anesthetic method for cataract surgery is simple and minimizes complications attributed to other blind anesthetic techniques.