Utility of oxygen insufflation through working channel during fiberoptic intubation in apneic patients: a prospective randomized controlled study.

BACKGROUND: Airway management is a part of routine anesthetic procedures; however, serious complications, including hypoxia and death, are known to occur in cases of difficult airways. Therefore, alternative techniques such as fiberoptic bronchoscope-assisted intubation (FOB intubation) should be considered, although this method requires more time and offers a limited visual field than does intubation with a direct laryngoscope. Oxygen insufflation through the working channel during FOB intubation could minimize the risk of desaturation and improve the visual field. Therefore, the aim of this prospective randomized controlled study was to evaluate the utility and safety of oxygen insufflation through the working channel during FOB intubation in apneic patients. METHODS: Thirty-six patients were randomly allocated to an N group (no oxygen insufflation) or an O group (oxygen insufflation). After preoxygenation, FOB intubation was performed with (O group) or without (N group) oxygen insufflation in apneic patients. The primary outcome was the velocity of decrease in the partial pressure of oxygen (PaO2) during FOB intubation (VPaO2, mmHg/sec) defined as the difference of PaO2 before and after intubation divided by the time to intubation. The secondary outcomes included the success rate for FOB intubation, time to intubation, visual field during FOB intubation, findings of arterial blood gas analysis, and occurrence of FOB intubation-related complications. RESULTS: We found that VPaO2 was significantly greater in the N group than in the O group (1.0 ± 0.4 vs. 0.4 ± 0.4; p < 0.001), while the visual field was similar between groups. There were no significant intergroup differences in the secondary outcomes. CONCLUSIONS: These findings suggest that oxygen insufflation through the working channel during FOB intubation aids in extending the apneic window during the procedure. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02625194 , registered at December 9, 2015.

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.

Effects of propofol on the inflammatory response during robot-assisted laparoscopic radical prostatectomy: a prospective randomized controlled study.

Robot-assisted laparoscopic radical prostatectomy (RALRP) is a minimally invasive procedure; however, some amount of surgical trauma that can trigger systemic inflammation remains. Moreover, pneumoperitoneum during RALRP induces ischemia-reperfusion injury (IRI). Propofol, an anesthetic, is known to have anti-inflammatory and antioxidant properties. In the present study, we compared the effects of propofol with those of desflurane on inflammation and IRI during RALRP via measurements of different biomarkers and evaluation of perioperative renal function. Fifty patients were randomized to receive either desflurane (n = 25) or propofol (n = 25) with remifentanil during RALRP. Serum levels of interleukin (IL)-6 (IL-6), tumor necrosis factor alpha, C-reactive protein, and nitric oxide were measured 10 min after anesthesia induction (T1), 100 min after carbon dioxide (CO2) insufflation (T2), and 10 min after CO2 deflation (T3). Perioperative urine outputs and the serum creatinine level at 24 h after surgery were also recorded. We found that IL-6 levels at T2 and T3 were higher than those at T1 in both groups, although the increases were significant attenuated only in the propofol group. The other parameters showed no differences among the three time points in both groups. The intraoperative urine output was significantly higher in the propofol group than in the desflurane group, while the creatinine level showed no significant changes in either group. Our findings suggest that propofol can not only attenuate the inflammatory response during and after pneumoperitoneum in patients undergoing RALRP but also prevent oliguria during pneumoperitoneum.

Discrimination ability of the endotracheal tube location using real-time palpation during intubation using an endotracheal tube with a preloaded stylet.

PURPOSE: Palpation during intubation could be used as an ancillary method of providing real-time information of the endotracheal tube (ETT) placement before manual ventilation. This study aimed to evaluate the ability to discriminate the ETT location using a modified real-time palpation method with a preloaded stylet during intubation. PATIENTS AND METHODS: The examiner performing the real-time palpation method placed three fingers on the lateral sides of the trachea between the sternal notch and the thyroid cartilage to determine if endotracheal intubation was successful. Endotracheal intubation was confirmed by auscultation and quantitative carbon dioxide waveform using capnography. RESULTS: Eighty-eight patients were enrolled in this study. The discrimination accuracy of the real-time palpation method was 98.9% (95% CI: 93.8-99.8) for identifying the location of ETT between the trachea and esophagus. There was one false negative, reported as esophageal intubation rather than tracheal intubation. CONCLUSION: The real-time palpation method during intubation using an ETT with a preloaded stylet is an instantly applicable technique with good discrimination ability. The addition of real-time information through this palpation method to the conventional intubation process, especially in patients with poor vocal cord visualization, would be useful to facilitate the process of safe and careful endotracheal intubation.

Prediction of emergence agitation using withdrawal reaction following rocuronium injection in preschool-aged patients undergoing inguinal herniorrhaphy: a preliminary exploratory observational trial.

PURPOSE: The development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA. METHODS: A total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale. RESULTS: There was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU. CONCLUSION: The findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated.

Prevalence and impact of incompetence of internal jugular valve on postoperative cognitive dysfunction in elderly patients undergoing robot-assisted laparoscopic radical prostatectomy.

Internal jugular vein (IJV) is the main pathway of cerebral venous drainage and its valves prevent regurgitation of blood to the brain. IJV valve incompetence (IJVVI) is known to be associated with cerebral dysfunctions. It occurs more often in male over 50 years old, conditions elevating intra-abdominal or intra-thoracic pressure. In robot-assisted laparoscopic radical prostatectomy (RALRP), elderly male undergoes surgery in Trendelenburg position with pneumoperitoneum applied. Therefore, we assessed the IJVVI during RALRP and its influence on postoperative cognitive function. 57 patients undergoing RALRP were enrolled. Neurocognitive tests including Mini-Mental State Examination (MMSE), Auditory Verbal Learning Test, Digit Symbol Substitution Test, Color Word Stroop Test, digit span test, and grooved pegboard test were performed the day before and 2 days after surgery. During surgery, IJVVI was assessed with ultrasonography in supine position with and without pneumoperitoneum, and Trendelenburg position with pneumoperitoneum. 50 patients underwent sonographic assessment and 41 patients completed neurocognitive examination. A total of 27 patients presented IJVVI, 19 patients in supine position without pneumoperitoneum, 7 patients in supine position with pneumoperitoneum and 1 patient in Trendelenburg position with pneumoperitoneum. In neurocognitive tests, patients with IJVVI showed statistically significant decline of score in MMSE postoperatively (p<0.05). IJVVI occurred in 38% in supine position but the incidence was increased to 54% after Trendelenburg position and pneumoperitoneum. Patients with IJVVI did not show significant differences in cognitive function tests except MMSE. Clinical and neurological significance of physiologic changes associated RALRP should be studied further.

Modelling of the Sedative Effects of Propofol in Patients undergoing Spinal Anaesthesia: A Pharmacodynamic Analysis.

Sedation can increase patient comfort during spinal anaesthesia. Understanding the relationship between the propofol effect-site concentration (Ce) and patient sedation level could help clinicians achieve the desired sedation level with minimal side effects. We aimed to model the relationship between the propofol Ce and adequate and deep sedation and also incorporate covariates. Thirty patients scheduled for orthopaedic surgery received spinal anaesthesia with 0.5% bupivacaine. Propofol was administered via an effect-site target-controlled infusion device using the Schnider pharmacokinetic model. The pharmacodynamic models for both adequate sedation [Observer's Assessment of Alertness/Sedation (OAA/S) scores of 3-4] and deep sedation (OAA/S scores of 1-2) were developed using nonlinear mixed-effects modelling. Increments in the propofol Ce were associated with increased depths of sedation. In the basic model, the estimated population Ce50 values for adequate and deep sedation were 0.94 and 1.52 µg/ml, respectively. The inclusion of the patient's age and sensory block level for adequate sedation and of age for deep sedation as covariates significantly improved the basic model by decreasing the objective function's minimum value from 10696.72 to 10677.92 (p = 0.0003). The simulated Ce50 values for adequate sedation in 20-year-old patients with a T12 sensory level and in 80-year-old patients with a T4 level were 1.63 and 0.53 µg/ml, respectively. Both age and sensory block level should be considered for adequate sedation, and the propofol concentration should be reduced for elderly patients with a high spinal block to avoid unnecessarily deep levels of sedation.

Effect of glucose-insulin-potassium on hyperlactataemia in patients undergoing valvular heart surgery: A randomised controlled study.

BACKGROUND: Hyperlactataemia represents oxygen imbalance in the tissues and its occurrence during cardiac surgery is associated with adverse outcomes. Glucose-insulin-potassium (GIK) infusion confers myocardial protection against ischaemia-reperfusion injury and has the potential to reduce lactate release while improving its clearance. OBJECTIVES: The objective of this study is to compare the effect of GIK on the incidence of hyperlactataemia in patients undergoing valvular heart surgery. DESIGN: A randomised controlled study. SETTING: Single university teaching hospital. PATIENTS: One hundred and six patients scheduled for elective valvular heart surgery with at least two of the known risk factors for hyperlactataemia. INTERVENTION: Patients were randomly allocated to receive either GIK solution (insulin 0.1 IU kg(-1) h(-1) and an infusion of 30% dextrose and 80 mmol l(-1) potassium at 0.5 ml kg(-1) h(-1)) or 0.9% saline (control) throughout surgery. MAIN OUTCOME MEASURES: The primary outcome was the incidence of hyperlactataemia (lactate ≥ 4 mmol l(-1)) during the operation and until 24 h after the operation. Secondary outcomes included haemodynamic parameters, use of vasopressor or inotropic drugs, and fluid balance until 24 h postoperatively. Postoperative morbidity endpoints were also assessed. RESULTS: The incidences of hyperlactataemia were similar in the groups (32/53 patients in each of the control and GIK groups, P > 0.999). There were no intergroup differences in haemodynamic parameters, use of vasopressor and inotropic drugs, or fluid balance. The incidences of postoperative morbidity endpoints were similar in both groups. CONCLUSION: Despite its theoretical advantage, GIK did not provide beneficial effects in terms of the incidence of hyperlactataemia or outcome in patients undergoing valvular heart surgery. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01825720.

Efficacy of palonosetron versus ramosetron on preventing opioid-based analgesia-related nausea and vomiting after lumbar spinal surgery: a prospective, randomized, and double-blind trial.

STUDY DESIGN: A prospective, randomized, and double-blind study. OBJECTIVE: To compare the efficacy of ramosetron and palonosetron on preventing postoperative nausea and vomiting (PONV) associated with opioid-based intravenous patient-controlled analgesia (IV-PCAopioid) after lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: IV-PCAopioid, an effective method to control pain after lumbar spinal surgery, accompanies PONV. Ramosetron and palonosetron are novel 5-hydroxytryptamine 3 antagonists known to have longer action duration and higher receptor affinity than their congeners, whereas their relative efficacy has not been validated yet. METHODS: One hundred ninety-six patients were randomly and evenly allocated to receive either 0.3 mg of ramosetron or 0.075 mg of palonosetron 10 minutes before the end of operation. Ramosetron or palonosetron were also added to the IV-PCAopioid, which was continuously infused for 48 hours postoperatively. The incidence and intensity of PONV were serially assessed for 72 hours postoperatively. Intensity of pain, volume of IV-PCAopioid consumption, use of rescue analgesics and antiemetics, and adverse events were also assessed. RESULTS: The overall incidence of PONV was lower in the ramosetron group than the palonosetron group (50% vs. 67%, P = 0.014) without any intergroup difference in the incidence of vomiting. Nausea intensity scores were also lower until 6 (P = 0.041) and 24 hour (P = 0.026) postoperatively in the ramosetron group than the palonosetron group. Pain intensity scores were significantly lower in the ramosetron group than the palonosetron group for 72 hours postoperatively. CONCLUSION: Ramosetron was superior to palonosetron in term of reducing the incidence and severity of nausea associated with IV-PCAopioid after lumbar spinal surgery. This favorable influence of ramosetron on PONV was translated to significant postoperative pain reduction compared with palonosetron. LEVEL OF EVIDENCE: 1.

Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection.

BACKGROUND: Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery in heterogeneous patient cohorts, including various aortic diseases and the use of deep hypothermic circulatory arrest. Moderate hypothermia with cerebral perfusion makes deep hypothermia nonessential, but can make end organs susceptible to ischemia during circulatory arrest. We investigated the incidence and risk factors of AKI after thoracic aortic surgery with and without moderate hypothermic circulatory arrest for acute dissection. METHODS: We reviewed the medical records of 98 patients undergoing graft replacement of the thoracic aorta for acute dissection between 2008 and 2011 at a university hospital. Acute kidney injury was defined by RIFLE criteria, which is based on serum creatinine or glomerular filtration rate. RESULTS: The mean age was 55±15 years. The surgical procedures, 96% of which were emergencies, involved the ascending aorta (67%), aortic arch (41%), descending aorta (41%), and aortic valve (5%). Moderate hypothermic circulatory arrest was performed in 75%. The overall incidence of AKI was 54%, and 11% of 98 patients required renal replacement therapy. Thirty-day mortality increased with AKI severity (p=0.002). Independent risk factors for AKI were long cardiopulmonary bypass duration (>180 minutes; odds ratio, 7.50; p=0.008) and preoperative serum creatinine level (odds ratio, 8.43; p=0.016). CONCLUSIONS: Acute kidney injury was common after thoracic aortic surgery for acute dissection with or without moderate hypothermic circulatory arrest and worsened 30-day mortality. Prolonged cardiopulmonary bypass and increased preoperative serum creatinine were independent risk factors for AKI, but moderate hypothermic circulatory arrest was not.

Effects of propofol on beta-adrenoceptor-mediated signal transduction in cardiac muscle; role of cAMP.

BACKGROUND: Propofol may decrease myocardial contractility via actions on the beta-adrenoceptor-mediated signal transduction. The aim of this study was to evaluate the effect of propofol via beta-adrenoceptor-mediated signal transduction by measuring the tissue levels of cAMP (cyclic adenosine monophosphate). METHODS: The effects of propofol on beta-adrenoceptor mediated cascades were measured with cAMP concentrations, which were stimulated by agonists (l-isoproterenol, GTPgammaS, and forskolin) of each step of beta-adrenoceptor-mediated cascades. RESULTS: While the production of cAMP stimulated by isoproterenol, GTPgammaS, or forskolin are increased (P < 0.05), application of each concentration of propofol (0.1, 1, 10, 100 microM) did not alter the levels of cAMP. CONCLUSIONS: Considering that propofol did not alter the tissue cAMP levels when stimulated by isoproterenol, GTPgammaS, and forskolin, propofol appears to have no effect on the beta-adrenoceptor signaling pathway in guinea pig ventricular myocardium.

Effects of thoracic epidural analgesia combined with general anesthesia on intraoperative ventilation/oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy.

PURPOSE: The purpose of this study was to evaluate the effects of thoracic epidural analgesia (TEA) on intraoperative ventilation/oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy requiring high-pressure pneumoperitoneum and the extreme head-down position. METHODS: Seventy-two patients (age range, 58-76 years) scheduled for elective robot-assisted laparoscopic radical prostatectomy were randomly assigned to receive either TEA combined with general anesthesia (TEA group, n = 36) or general anesthesia (GA group, n = 36). T4-sensory block using 1% lidocaine was continuously provided during surgery in the TEA group but not in the GA group. The mode of ventilation was volume controlled with a linear ramp in the pressure wave. Maximum peak inspiratory pressure was preset at 35 mm Hg, and no positive end-expiratory pressure was administered to the patients. Minute ventilation was adjusted to maintain end-tidal CO(2) between 30 and 35 mm Hg by changing respiratory rate during surgery. Intraoperative ventilatory parameters and blood gas analyses were checked. Clinical and radiological pulmonary complications were observed for 3 days postoperatively. RESULTS: Patients in the TEA group showed significantly lower peak inspiratory pressure and higher dynamic compliance with larger expiratory tidal volume during surgery than those in the GA group. They had significantly better oxygenation and lower concentrations of lactate on arterial blood gas analysis than the GA group. Postoperative clinical and radiological complication rates were not significantly different. CONCLUSIONS: TEA combined with general anesthesia improved intraoperative ventilation/oxygenation. Although clinical and radiologic pulmonary complications were not significantly influenced, TEA can be considered an option for patients with limited reserve capacity or preexisting impairments of visceral blood flow.