Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial.

Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.

Anterior Quadratus Lumborum Block and Quadriceps Strength: A Prospective Cohort Study.

The decrease in quadriceps strength after anterior quadratus lumborum block (AQLB) has not been quantified. This prospective cohort study investigated the incidence of quadriceps weakness after AQLB. We enrolled patients undergoing robot-assisted partial nephrectomy, and AQLB was performed at the L2 level with 30 mL of 0.375% ropivacaine. We evaluated each quadriceps' maximal voluntary isometric contraction using a handheld dynamometer preoperatively and postoperatively at 1 and 4 days. The incidence of muscle weakness was defined as a 25% reduction in muscle strength compared with the preoperative baseline, and "muscle weakness possibly caused by nerve block" was defined as a 25% reduction compared with the non-block side. We also assessed the numerical rating scale and quality of recovery-15 scores. Thirty participants were analyzed. The incidence of muscle weakness compared with preoperative baseline and the non-block side was 13.3% and 30.0%, respectively. Patients with a numerical rating scale ≥ 4 or quality of recovery-15 score < 122, which was classified as moderate or poor, had decreased muscle strength with relative risks of 1.75 and 2.33, respectively. All patients ambulated within 24 h after surgery. The incidence of quadriceps weakness possibly caused by nerve block was 13.3%; however, all patients could ambulate after 1 day.

The ultrasound-guided nerve blocks of abdominal wall contributed to anesthetic management of cholecystectomy in a patient with Becker muscular dystrophy without using muscle relaxants.

Becker muscular dystrophy (BMD) is a progressive neuromuscular disorder caused by mutations in the dystrophin gene. The sensitivity to non-depolarizing muscle relaxant in a patient with muscle dystrophy is reportedly higher than that in normal individuals, and the duration of the effect is known to be prolonged. In this report, we present the case of a 58-year-old man with BMD who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis under total intravenous anesthesia without the use of muscle-relaxant drugs and supplemented with regional anesthesia. Anesthesia was induced and maintained with propofol, remifentanil, and fentanyl; ultrasound-guided bilateral rectus sheath block (RSB) and right-sided subcostal transversus abdominis plane block (TAP) were performed. The procedure required conversion to open surgery because of hard conglutination; intraoperative and postoperative periods were uneventful. Adequate analgesia was maintained after extubation because of the effect of RSB and TAP.

[Effects of RSB and TAPB on Postoperative Pain in Laparoscopic Cholecystectomy].

BACKGROUND: Several reports have examined meth- ods to control pain after a laparoscopic cholecystec- tomy (LC) and have shown regional anesthesia to be an effective method. We had been performing LC using simple general anesthesia (G); however, in 2013, we adapted a rectus sheath block (RSB), and in 2014, we used a combination of RSB and a subcostal transversus abdominis plane block (TAPB) on the right side. We report on the transition from G to regional anesthesia in LC and its effect on postoperative pain. METHODS: We anesthetized three groups of patients undergoing LC. Group 1 received G (n =32) ; group 2 received RSB (n=28); and group 3 received a combination of RSB and TAPB (n=31). Patients used the numeric rating scale (NRS) to record their levels of postoperative pain, and the scores were compared for each group. RESULTS: No significant differences were noted in NRS scores between the G and RSB groups; however, the scores in the RSB group tended to be lower. NRS scores were significantly lower in the RSB-TAPB group than in both the RSB and G groups. CONCLUSIONS: This study showed that the combina- tion of RSB-TAPB effectively controlled pain after LC and lowered NRS scores.

[Unilateral Thoracic Paravertebral Block for Effective Control of Pain : A Case Report of a Patient with Esophageal Cancer and Cirrhosis of the Liver.]

We report a case in which unilateral thoracic para- vertebral block was used to effectively control pain in a 78-year-old male patient with Child's A liver cirrhosis and esophageal cancer. Epidural anesthesia was con- sidered risky in this case because of the low platelet count from cirrhosis. Therefore, we performed a unilat- eral thoracic paravertebral block and cannulation under general anesthesia. We administered 0.33% levobupi- vacaine 10 ml through the catheter for intraoperative analgesia. After the operation, we confirmed the place- ment of the catheter with a chest X-ray image : then, the patient was extubated and returned to the ward. Three hours after the operation, the patient com- plained of pain in his wound : hence, 0.33% levobupi- vacaine 5 ml was injected through the catheter, which effectively controlled pain for 10 hours. Further injec- tions were done 13 and 21 hours after the operation, and the catheter was removed 21 hours after the operation. While the catheter was in place, the patient scarcely complained of pain. The unilateral thoracic paravertebral block covered the wide range of wounds and provided good analgesia for the patient.

DSR-71167, a novel mineralocorticoid receptor antagonist with carbonic anhydrase inhibitory activity, separates urinary sodium excretion and serum potassium elevation in rats.

Mineralocorticoid receptor (MR) antagonists, such as spironolactone (SPI) and eplerenone (EPL), are useful for treating hypertension and heart failure. However, these two agents have the serious side effect of hyperkalemia. We hypothesized that adding the ability to inhibit carbonic anhydrase (CA) would reduce the risk of hyperkalemia associated with MR antagonists. We investigated the profiles of DSR-71167 [2-([(2,2-difluoroethyl)amino]methyl)-2'-fluoro-N-(3-methoxy-4-sulfamoylphenyl)biphenyl-4-carboxamide hydrochloride; an MR antagonist with weak CA inhibitory activity] with regard to antimineralocorticoid actions by examining relationships between the urinary excretion of sodium (index of antimineralocorticoid action) in deoxycorticosterone acetate-treated rats and elevation of serum levels of potassium in potassium-loaded rats compared with a DSR-71167 derivative without CA inhibition (2-(hydroxymethyl)-N-[4-(methylsulfonyl)phenyl]-2'-(trifluoromethyl)biphenyl-4-carboxamide), SPI, and EPL. DSR-71167 dose-dependently increased urinary excretion of sodium in deoxycorticosterone acetate-treated rats without elevating serum levels of potassium in potassium-loaded rats. 2-(Hydroxymethyl)-N-[4-(methylsulfonyl)phenyl]-2'-(trifluoromethyl)biphenyl-4-carboxamide, SPI, and EPL elevated serum levels of potassium significantly in potassium-loaded rats at doses that increased MR inhibitory activity. We confirmed that DSR-71167 significantly increases urinary bicarbonate and decreases blood bicarbonate, as pharmacodynamic markers of CA inhibition, in intact rats. Chronic DSR-71167 administration showed antihypertensive effects in high salt-loaded Dahl hypertensive rats. These results demonstrate that DSR-71167 is a novel type of MR antagonist, with CA inhibitory activity, which is expected to become a safer MR antagonist with a low potential risk for hyperkalemia.

[Retrospective evaluation of predictors and frequency of hypotension in hypertensive patients after induction of general anesthesia].

BACKGROUND: It is reported that hypotension during general anesthesia is associated with adverse outcomes in patients having both noncardiac and cardiac surgery. The present retrospective study was undertaken to evaluate the incidence and the predictors of hypotension after induction of general anesthesia (GA) until the start of operation. METHODS: After the IRB approval, 157 patients with hypertension who had undergone surgery under general anesthesia were enrolled. Data were collected using medical chart and anesthesia record. We divided the period into two intervals, from entering the operating room to tracheal intubation (first interval) and from tracheal intubation to start of operation (second period). Hypotension was defined when blood pressure decreased more than or equal to 25 percent compared to blood pressure measured at first in operating room. RESULTS: Hypotension occurred in 73.2% during the first interval and 96.8% during the second interval. The age was a significant predictor for hypotension during the second interval (P = 0.0087). CONCLUSIONS: The result in this study indicated that the age was a significant predictor for hypotension from tracheal intubation to start of operation.

[Intraoperative acute airway obstruction due to the damage of a reinforced endotracheal tube in thyroidectomy].

A 55-year-old woman was scheduled for left thyroidectomy. Anesthesia was induced without problems and maintained without nitrous oxide. Sixteen minutes after the start of the procedure, airway pressures and endtidal carbon dioxide concentration increased suddenly. An attempt to pass a suction catheter down the endotracheal tube was unsuccessful. A protuberance was found in the reinforced endotracheal tube. After reintubation with a new reinforced endotracheal tube, ventilation was improved immediately. The rest of the procedure was done uneventfully. Similar phenomenon was reported in the reuse of endotracheal tube and the use of nitrous oxide. In our case, airway obstruction was caused by the pinhole that was created in a manufacturing process. We have to keep in mind that endotracheal tube itself may be out of order if other causes have been excluded.

The effect of hypercapnia and hypertension on cerebral oxygen balance during one-lung ventilation for lung surgery during propofol anesthesia.

STUDY OBJECTIVE: To investigate whether jugular bulb venous oxygen saturation (SjO(2)) values increased with induced hypercapnia or induced hypertension during propofol-based anesthesia for one-lung ventilation (OLV). DESIGN: Prospective clinical study. SETTING: Operating room at University hospital. PARTICIPANTS: 15 adult patients scheduled for elective thoracic procedures in the lateral position. INTERVENTIONS: General anesthesia was maintained with propofol combined with epidural anesthesia. During OLV, hypercapnia (PaCO(2) = 50 mmHg) and hypertension (20% increase in mean arterial pressure) were applied. MEASUREMENTS: SjO2 values were measured. MAIN RESULTS: With hypercapnia, SjO(2) values increased 30 ± 18% (from 54.3 ± 8.8% to 69.3 ± 6.3%). With hypertension, SjO(2) values were increased by 9 ± 18% (from 54.4 ± 9.0% to 58.5 ± 8.8%). These changes were significantly different. No significant differences regarding SaO(2) were observed during OLV in the experimental period. CONCLUSION: Hypercapnia, not hypertension, significantly improved cerebral oxygen balance without observed side effects during propofol anesthesia.

Posttreatment but not pretreatment with selective beta-adrenoreceptor 1 antagonists provides neuroprotection in the hippocampus in rats subjected to transient forebrain ischemia.

BACKGROUND: beta-Adrenoreceptor antagonists provide neuroprotection against focal cerebral ischemia, but the effects of these antagonists on experimental global cerebral ischemia are unknown. That is, the effect of beta-adrenoreceptor antagonism in vulnerable brain regions after ischemic insult has not been examined. Therefore, we investigated the neuroprotective effects of preischemic or postischemic administration of propranolol (a nonselective beta-adrenoreceptor antagonist), esmolol, and landiolol (selective beta-adrenoreceptor 1 antagonists) against forebrain ischemia in rats. METHODS: IV administration of saline 10 microL . h(-1), propranolol 100 microg . kg(-1) . min(-1), esmolol 200 microg . kg(-1) . min(-1), or landiolol 50 microg . kg(-1) . min(-1) in male Sprague-Dawley rats was started 30 minutes before or 60 minutes after 8-minute bilateral carotid artery occlusion combined with hypotension (35 mm Hg) under isoflurane (1.5%) anesthesia. All drugs were administered continuously until 5 days after reperfusion, and the animals were evaluated neurologically and histologically after this 5-day period. RESULTS: Preischemic treatment with propranolol, esmolol, or landiolol failed to provide neuroprotection against forebrain ischemia in the hippocampus. Rats treated with propranolol tended to have a worse score for motor activity and a higher mortality rate (up to 64%), but the differences with other groups were not statistically significant. Postischemic treatment with esmolol and landiolol, but not with propranolol, reduced neuronal injury after forebrain ischemia. However, motor activity did not differ among rats treated postischemically with any of the beta-adrenoreceptor antagonists or saline. CONCLUSIONS: Postischemic treatment with esmolol and landiolol provided neuroprotection in the hippocampus in rats subjected to bilateral carotid artery occlusion combined with hemorrhagic shock, whereas treatment with propranolol failed to show neuroprotection. We suggest that concomitant beta-blockade and shock might work as a systemic depressant, rather than a neuroprotectant, resulting in exacerbation of cerebral ischemia.

Ketamine eliminates propofol pain but does not affect hemodynamics during induction with double-lumen tubes.

BACKGROUND AND OBJECTIVE: Propofol injection during induction of anesthesia induces pain. Ketamine has been shown to reduce the injection pain. However, ketamine has unfavorable adverse effects, including increased secretion production and hemodynamic responses, which might induce pulmonary or hemodynamic adverse events, especially in patients undergoing lung surgery who require a double-lumen tube (DLT). The aim of this study was to determine whether ketamine can safely reduce propofol injection pain during induction of anesthesia for lung surgery. METHODS: Forty-five patients scheduled for elective lung surgery requiring DLT were randomly allocated into three groups. Patients received saline (control), ketamine 0.5 mg kg(-1) (0.5 ketamine), or ketamine 1.0 mg kg(-1) (1.0 ketamine), followed by 5 ml propofol 30 s later. An anesthesiologist blinded to the study group assessed pain score during induction, hemodynamics during DLT placement, and secretion production during anesthetic management. RESULTS: Pretreatment of 0.5 mg kg(-1) ketamine reduced the incidence and intensity of propofol injection pain, whereas 1.0 mg kg(-1) ketamine completely eliminated the pain. There were no significant differences regarding oxygenation during one-lung ventilation (OLV) and hemodynamics during induction among the three groups, although ketamine increased secretion production. CONCLUSIONS: One milligram per kilogram of ketamine completely eliminated pain associated with propofol injection without affecting hemodynamics during induction of anesthesia and oxygenation during OLV.

Jugular bulb venous oxygen saturation during one-lung ventilation under sevoflurane- or propofol-based anesthesia for lung surgery.

OBJECTIVE: During one-lung ventilation (OLV), systemic oxygenation can be compromised. In such a scenario, if anesthetic techniques were used that adversely affected cerebral oxygen balance, the risk for impaired cerebral oxygen balance may be increased. In this study, jugular bulb venous oxygen saturation (SjO(2)) during OLV under sevoflurane- or propofol-based anesthesia for lung surgery was investigated. DESIGN: Prospective clinical study. SETTING: University hospital. PARTICIPANTS: Fifty-two adult patients scheduled for elective thoracic procedures in the lateral position. INTERVENTIONS: Patients were randomly allocated to either the sevoflurane or propofol group (n = 26). General anesthesia was maintained with sevoflurane or propofol combined with epidural anesthesia. MEASUREMENTS AND MAIN RESULTS: Arterial and jugular bulb blood samples were measured before OLV, 15 minutes after OLV, 30 minutes after OLV, and 15 minutes after the termination of OLV. SjO(2) values in both sevoflurane and propofol groups significantly declined during OLV (p < 0.05). SjO(2) values in the sevoflurane group were higher than in the propofol group, although SaO(2) values were similar (p < 0.05). Regarding the incidence of SjO(2) <50% (cerebral oxygen desaturation), there were significant differences between the sevoflurane group and the propofol group during both normally ventilated conditions (0% v 7.7%, p < 0.05, relative risk [RR]: not applicable) and OLV (1.9% v 26.9%, p < 0.05, RR = 14; 95% confidence interval [CI] 1.91-103). Significant increase in the incidence of SjO(2) <50% during OLV was also observed only in the propofol group (from 7.7% to 26.9%, p < 0.05, RR = 3.5; 95% CI 1.29-12.4). CONCLUSION: Cerebral oxygen desaturation was more frequently detected during OLV under propofol- versus sevoflurane-based anesthesia. Cerebral oxygen balance during OLV for lung surgery was less impaired under sevoflurane-based anesthesia compared with propofol; however, the clinical outcome or implications for cognitive function need to be determined.

Delta opioid receptors stimulation with [D-Ala2, D-Leu5] enkephalin does not provide neuroprotection in the hippocampus in rats subjected to forebrain ischemia.

It has been reported that delta opioid agonists can have neuroprotective efficacy in the central nervous system. This study was conducted to test the hypothesis that a delta opioid receptor (DOR) agonist, [D-Ala2, D-Leu5] enkephalin (DADLE), can improve neuron survival against experimental forebrain ischemia in rats. Using male rats (n=125), intraperitoneal injection of DADLE (0, 0.25, 1, 4, 16 mg kg-1) was performed 30 min before ischemia. Ten minutes interval forebrain ischemia was provided by the bilateral carotid occlusion combined with hypotension (35 mm Hg) under isoflurane (1.5%) anesthesia. All animals were neurologically and histologically evaluated after a recovery period of 1 week. As histological evaluation, percentages of ischemic neurons in the CA1, CA3, dentate gyrus (DG) were measured. During the recovery period, 27 rats died because of apparent upper airway obstruction, seizure, or unidentified causes. There were no differences in the motor activity score among the groups. Ten minutes forebrain ischemia induced approximately 75, 20, and 10% neuronal death in the CA1, CA3, and DG, respectively. Any doses of DADLE did not attenuate neuronal injury in the hippocampus after ischemia. Pre-ischemic treatment of DORs agonism with DADLE did not provide any neuroprotection to the hippocampus in rats subjected to forebrain ischemia.

Effects of increasing concentrations of propofol on jugular venous bulb oxygen saturation in neurosurgical patients under normothermic and mildly hypothermic conditions.

BACKGROUND: Recent evidence suggested that propofol can deteriorate the cerebral oxygen balance compared with inhalational anesthetics. However, dose-related influences of propofol on cerebral oxygen balances were not clearly investigated. In the current study, the authors investigated the effects of increasing concentrations of propofol on jugular venous bulb oxygen saturation (Sj(O2)) in neurosurgical patients under normothermic and mildly hypothermic conditions. METHODS: After institutional approval and informed consent were obtained, 30 adult patients undergoing elective craniotomy were studied. Patients were randomly allocated to either normothermic or hypothermic group (n = 15 in each group). In the normothermic and hypothermic groups, tympanic membrane temperature was maintained at 36.5 degrees and 34.5 degrees C, respectively. Sj(O2) was measured at predicted propofol concentrations of 3, 5, and 7 microg/ml using a target-controlled infusion system in both groups. RESULTS: At a predicted propofol concentration of 3 microg/ml, there were no significant differences in Sj(O2) values between the normothermic and hypothermic groups, although the incidence of desaturation (Sj(O2) < 50%) was significantly higher in the normothermic group than in the hypothermic group (30% vs. 13%; P < 0.05). Sj(O2) values and the incidence of desaturation remained unchanged during the changes in predicted propofol concentration from 3 to 7 microg/ml both in the normothermic and hypothermic groups. CONCLUSION: The results indicated that the increasing concentrations of propofol did not affect Sj(O2) values in neurosurgical patients under normothermic and mildly hypothermic conditions.

Synthesis of a 4,5-epoxy-2-cyclohexen-1-one derivative via epoxide ring opening, 1,3-carbonyl transposition and epoxide ring regeneration: a synthetic study on a scyphostatin analogue.

A 6-alkyl-4,5-epoxy-6-hydroxy-2-cyclohexen-1-one derivative, a model compound for the hydrophilic moiety of scyphostatin, was stereoselectively synthesized from the Diels-Alder adduct. The key steps were the reductive cleavage of the 4,5-epoxide ring of the epoxidated adduct, the 1,3-carbonyl transposition of the 3-carbonyl group to the C1 position by a Wharton reaction and stereoselective bromination to provide a trans bromohydrin derivative, a precursor to the desired compound. Desilylation of the bromohydrin derivative with TBAF directly gave the target compound.

[Evaluation of the different doses of olprinone for continuous infusion after cardiopulmonary bypass for coronary artery bypass surgery].

BACKGROUND: We evaluated the hemodynamic efficacy of combined cathecholamine and three different continuous infusion doses of olprinone (0.05, 0.1, 0.3 microgram.kg-1.min-1) in 24 cases (0.05 group: 8 cases, 0.1 group: 8 cases, 0.3 group: 8 cases) undergoing coronary artery bypass grafting (CABG). METHODS: Olprinone was administered as a single dose (0.1 mg.kg-1) into the venous reservoir of the CPB circuit 15 min prior to the end of emergence from CPB, followed by continuous infusion. Hemodynamics were measured at the time of preCPB (M 0), just after the end of CPB (M 1), pre chest closure (M 2) and after chest closure (M 3). Cathecholamines were used to maintain mean arterial pressure (> 65 mmHg) and cardiac index (> 3.0 l.min-1.m-2). Hemodynamics (at M 0, M 1, M 2 and M 3) and the number of cases requiring combined cathecholamine were compared among the 3 doses. RESULTS: Three doses showed no significant difference on hemodynamics. In the number of cases requiring combined cathecholamine, group 0.3 were significantly lower than group 0.05 at dobutamine, and group 0.05 were significantly higher than group 0.1 and 0.3 at norepinephrine. CONCLUSIONS: The higher continuous infusion dose of olprinone (0.3 > 0.1 > 0.05 microgram.kg-1.min-1) can diminish the number of cases requiring combined cathecholamine administration during coronary artery bypass grafting.

[Effects of amrinone in patients undergoing off-pump coronary artery bypass grafting].

We evaluated the effect of amrinone in 41 patients undergoing off-pump coronary artery bypass grafting(CABG) retrospectively. Amrinone was intravenously administered at the rate of 5 mcg.kg-1.min-1 after coronary artery anastomosis (A 1 group: 11 cases) or after induction of anesthesia(A 2 group: 13 cases). The hemodynamic variables and use of concomitant drugs were compared among A 1, A 2 and the non-amrinone group (control group: 17 cases). Hemodynamics was measured before, during, after coronary artery anastomosis, and after the chest closure. Catecholamine and vasodilator were used to maintain mean arterial pressure (> 60 mmHg) and cardiac index(> 3.0 l.min-1.m-2). Mean pulmonary artery pressure, right atrial pressure and pulmonary artery wedge pressure were significantly higher during anastomosis than before anastomosis in control and A 1 group, but no significant changes in these parameters were observed in A 2 group. In addition, these variables increased significantly after chest closure in control group, but were unchanged in A 1 and A 2 groups. Patients with concomitant use of catecholamine and vasodilator in A 2 group were fewer than those in control and A 1 group. In conclusion, in the patients undergoing off-pump CABG, infusion of amrinone was recommended from the end of the induction of anesthesia.