Bilateral erector spinae plane blocks using a small volume of local anesthetic for acute pain control after single-port laparoscopic surgery.

In the era of enhanced recovery after surgery, clinicians are encouraged to develop optimized programs for patients who require surgery. Minimal intervention with laparoscopic surgery and multimodal pain management mostly with peripheral nerve block are key components. We are developing a departmental program for enhanced recovery after surgery for single-port laparoscopic surgery. We applied an erector spinae plane block, a novel, newly recognized block, bilaterally at the T10 transverse process with a small dose (10 mL) of local anesthetic. This method was effective and safe and resulted in successful analgesia in a patient who received single-port surgery. This surgery requires a 3-5 cm horizontal or longitudinal periumbilical incision, which was performed in this case, and our results were promising and encouraging.

Comparison between the Trachway video intubating stylet and Macintosh laryngoscope in four simulated difficult tracheal intubations: A manikin study.

OBJECTIVES: It remains to be determined whether the TVI-4000 Trachway video intubating (TVI) stylet (Markstein Sichtec Medical Corp, Taichung, Taiwan), an airway device for novices, improves airway management practice by experienced anesthesiologists. The aim of this study was to evaluate the feasibility of using the TVI stylet in difficult tracheal intubation situations compared with that of using the Macintosh laryngoscope on an airway manikin. MATERIALS AND METHODS: Ten anesthesiologists (with 3-21 years' experience), including three senior residents, participated. We compared tracheal intubation in four airway scenarios: normal airway, tongue edema, cervical spine immobilization, and tongue edema combined with cervical spine immobilization. The time of tracheal intubation (TTI), success rate, and perceived difficulty of intubation for each scenario were compared and analyzed. RESULTS: The TTI was significantly shorter in both the tongue edema and combined scenarios with the TVI stylet compared with the Macintosh laryngoscope (21.60 ± 1.45 seconds vs. 24.07 ± 1.58 seconds and 23.73 ± 2.05 seconds vs. 26.6 ± 2.77 seconds, respectively). Success rates for both devices were 100%. Concomitantly, participants rated using the TVI stylet in these two scenarios as being less difficult. CONCLUSION: The learning time for tracheal intubation using the TVI stylet in difficult airway scenarios was short. Use of the TVI stylet was easier and required a shorter TTI for tracheal intubation in the tongue edema and combined scenarios.

The effect of different harvest strategies on the nucleated cell yields of bone marrow collection.

To improve bone marrow (BM) harvest of the volunteer donors in our institute, we changed from the single-hole needle to the multi-side-hole needle after March 2002, and examined the midway total nucleated cell (TNC) counts during collection after September 2004. The aims of this retrospective study were to evaluate BM harvest yields obtained through different strategies and to examine the correlation between final and midway BM harvests. The distribution of BM harvesting by different strategies was 235 donors with single-hole needles (group A), 389 donors with 5-side-hole needles (group B), and 365 donors with 5-side-hole needles and midway TNC counts (group C). The nucleated cell density of the collected BM was significantly improved by modifying the harvest strategy (0.202 × 10(8)/mL in group A, 0.219 × 10(8)/mL in group B, and 0.250 × 10(8)/mL in group C; P < .001). The percentage of unacceptable TNC dose (<2 × 10(8)/kg) was also decreased in all 3 groups (to 5.9%, 3.6%, and 0%, respectively; P < .001). Multiple regression analysis revealed that donor weight, white blood cell count, and harvest strategy were positively correlated with BM TNC density (P < .001), whereas harvested BM volume was negatively correlated with TNC density (P < .001). On linear regression analysis, highly significant correlations were noted between midway and final TNC densities (r = 0.8774; P < .001) as well as between harvested BM volume and TNC count (r = 0.7937; P < .001). Changing the harvesting needle and checking the midway TNC count improved the harvest outcome.

Quality improvements of antimicrobial prophylaxis in coronary artery bypass grafting.

BACKGROUND: Although the principles of antibiotics prophylaxis are well established, more than 60% of hospitals that joined the international quality indicator project failed to discontinue the use of prophylactic antibiotics within 24h after coronary artery bypass grafting (CABG). Our specific aims are to disseminate the gain obtained from breakthrough series model in knee arthroplasty and abdominal hysterectomy to increase the rate of prophylactic duration not longer than 24h in patients with CABG. METHODS: The control and intervention groups enrolled 55 and 78 patients with CABG before and after the project. Measurements were prophylactic interval and duration, surgical site infection, hospital and antibiotics costs. Two strategies were developed. The key cardiac surgeon was invited to attend quality improvement activities. Knowledge and rationale of medical quality indicators would thus be communicated. Secondly, we proposed a regional symposium in which a level of competition was subconsciously established, and practitioners would present their level of compliance. RESULTS: Instances of prophylactic interval within 1h prior to incision were significantly increased from 66.7% to 97.4%. Rates of prophylactic duration less than 24h were significantly increased from 2.8% to 66.1%. The average hospital cost was reduced by 16.4%, and antibiotics cost was reduced by 91.8%. No significant changes in surgical site infection within 30 d of CABG were observed. CONCLUSIONS: We successfully disseminated the gain of breakthrough project in improving antimicrobial prophylaxis to CABG. By implementing this model, we are able to optimize the timing and duration of antimicrobial prophylaxis in patients with CABG to a level above worldwide average.

Effects of propofol sedation during the early postoperative period in hemorrhagic stroke patients.

BACKGROUND: The early postoperative period is a critical time for patients after receiving a decompressive craniotomy. Prompt detection and early management of postoperative recurrent/residual hemorrhagic complications may dramatically improve clinical outcomes. METHODS: The present cohort retrospective study involved 135 patients who received decompressive craniotomy and intensive care unit (ICU) supervision as life-saving measures. The purpose of the study was to evaluate the effects of propofol sedation on the clinical outcome during the ICU stay. The patients' demographic data, hemodynamic variables, the dose of propofol used during the first 48 hours after surgery, residual/recurrent blood clot volume after surgery, and neurologic and clinical outcomes were reviewed. The propofol dosages used for sedation were further divided into three categories: < 0.66, 0.66-3.33 and > 3.33 mg/kg/hr, based on the doses infused during the first 12 hours after surgery. RESULTS: Our results indicated that the patients of the propofol-sedated group had a significantly smaller amount of residual/recurrent blood clot (p < 0.05) than did those of the non-sedated group. The 30-day mortality rate was significantly lower in the propofol-sedated group (p < 0.05) than in the non-sedated group. Among the propofol-sedated patients, those who received a dose of 0.66-3.33 mg/kg/hr in the first 12 hours after surgery achieved significantly improved clinical and neurologic outcomes than those who received either more than 3.33 mg/kg/hr or less than 0.66 mg/kg/hr of propofol. CONCLUSION: Our results support the use of propofol sedation during the early postoperative period after craniotomy in hemorrhagic stroke patients, because it improved both neurologic and clinical outcomes. However, early postoperative use of propofol sedation at larger dosages warrants special attention.

Endovascular repair of tracheo-innominate artery fistula.

Innominate arterial wall rupture with pseudoaneurysm formation was found during angiography in a 39-year-old woman 2 days after she had undergone percutaneous dilatational tracheostomy. Endovascular stent surgery and balloon angioplasty were performed but these procedures failed to control the massive bleeding resulting from an endoleak. We report the clinical presentations and describe the treatment of a tracheo-innominate artery fistula in our patient. We also reviewed the algorithms of management and the rescue options for treating a tracheo-innominate artery fistula.

Subthalamic deep brain stimulation after anesthetic inhalation in Parkinson disease: a preliminary study.

OBJECT: The authors of this preliminary study investigated the outcome and feasibility of intraoperative microelectrode recording (MER) in patients with Parkinson disease (PD) undergoing deep brain stimulation of the subthalamic nucleus (STN) after anesthetic inhalation. METHODS: The authors conducted a retrospective analysis of 10 patients with PD who received a desflurane anesthetic during bilateral STN electrode implantation. The MERs were obtained as an intraoperative guide for final electrode implantation and the data were analyzed offline. The functional target coordinates of the electrodes were compared preoperatively with estimated target coordinates. RESULTS: Outcomes were evaluated using the Unified Parkinson's Disease Rating Scale 6 months after surgery. The mean improvement in total and motor Unified Parkinson's Disease Rating Scale scores was 54.27 +/- 17.96% and 48.85 +/- 16.97%, respectively. The mean STN neuronal firing rate was 29.7 +/- 14.6 Hz. Typical neuronal firing patterns of the STN and substantia pars nigra reticulata were observed in each patient during surgery. Comparing the functional target coordinates, the z axis coordinates were noted to be significantly different between the pre- and postoperative coordinates. CONCLUSIONS: The authors found that MER can be adequately performed while the patient receives a desflurane anesthetic, and the results can serve as a guide for STN electrode implantation. This may be a good alternative surgical method in patients with PD who are unable to tolerate deep brain stimulation surgery with local anesthesia.

Impact of maternal and neonatal factors on CD34+ cell count, total nucleated cells, and volume of cord blood.

The engraftment outcome of UCB transplantation is highly dependent on cell number. It would be useful to predict CB cell content using information of donor-related variables before cell processing. In this study, CBs were obtained from 1312 single-birth term deliveries in the Buddhist Tzu Chi Stem Cells Center from January 2001 to June 2006. We evaluated whether maternal factors, such as age and race, have an effect on laboratory parameters of hematopoietic content, including CD34+ cell counts, TNCs, and cord blood volume. We also studied the impact of neonatal factors, such as delivery method, gestational age, sex, birth weight, and birth order on the same parameters. In multivariate analysis, babies delivered via Cesarean section had more CD34+ cells and volume, but lower TNCs. Similar results were found for either babies of shorter gestational age or in male infants. Babies with larger birth weight had higher CD34+ cell volume, and TNC, while mothers with fewer previous live births had CB with more TNCs. Maternal age and race had no effect on these laboratory parameters. To conclude, our results suggest that neonatal factors affect CB cell yields. TNCs tend to be more affected by different variables than CD34+ cell counts and volume. These findings may help in collecting CB efficiently and improve the CB transplantation rate.

Microbial contamination of the Tzu-Chi Cord Blood Bank from 2005 to 2006.

BACKGROUND: In total, 4502 units of cord blood (CB) were collected during a 2-year period from 2005 to 2006 by the Buddhist Tzu-Chi Stem Cells Center. The aim of this study was to analyze the incidence of microbial contamination and type of organism present in the cord blood. The clinical impact of microbial contamination on hematopoietic progenitor cell (HPC) grafts used for HPC transplantation is also discussed. METHODS: First and second specimens were obtained for microbial assessment. These were collected in laboratory after cord blood collection and after cord blood unit manipulation, respectively. The samples were cultured and the results reviewed. RESULTS: The overall incidence of microbiological contamination was 1.8% (82/4502). Three CB units were contaminated with two different organisms. Infectious organisms comprised 9.4% (8/85) of total isolated microbes. These infectious microorganisms were beta-Streptococci group B, Candida tropicalis and Staphylococcus aureus which were isolated in 6, 1 and 1 of CB units respectively. Escherichia coli, Bacteroides fragilis, Lactobacillus spp., Enterococcus, beta-Streptococcus Group B, Bacteroides valgatus, Corynebacterium spp., Klebsiella pneumonia and Peptococcus spp. were the most frequently encountered microorganisms. A higher contamination rate of the CB units was noted after vaginal delivery (2.16%) compared to caesarian section (0.85%) (p < 0.01). CONCLUSIONS: Extensive training in CB collection, good procedures and good protocols can decrease the rate of microbial contamination. The use of a closed collecting system and an ex utero method have the advantage of a lower contamination rate. In our cord blood bank, we use a closed system but an in utero method. Similar to other studies, most of microorganisms reported here as contaminants are non-pathogenic.

Uneven distribution of ethanol in rat brain following acute administration, with the highest level in the striatum.

OBJECTIVE: Following acute administration, ethanol has been assumed to be evenly distributed throughout the brain. However, some evidence exists for unequal extracellular levels of ethanol in different areas of the brain, suggesting the existence of locally elevated intracellular levels. The aim of this study was to investigate the relative tissue levels and rates of decline of ethanol in various regions of the brain and in the plasma of rats. METHOD: Adult male Wistar rats (250-300 g) were injected intraperitoneally with a 14% ethanol/water solution at a dose of 1 g/kg of body weight. Brain and plasma samples were analyzed by an enzymatic rate method 30, 60, 90, or 120 minutes after injection for ethanol content. RESULTS: The highest tissue and plasma concentrations of ethanol occurred 30 minutes after administration, with concentrations of ethanol being highest in the striatum. All regions of the brain and plasma followed zero-order kinetics of elimination of ethanol; however, the rate of elimination in the brain declined at a slower rate than in the plasma. The rate remained constant during the 90-minute period. Elimination was slower in the brain than in the plasma. CONCLUSIONS: Ethanol can accumulate to higher levels and can be eliminated more slowly from the brain than from the plasma, thus raising questions about blood alcohol testing as a measure of intoxication. The higher level of ethanol in the striatum, an area implicated in movement regulation and substance addiction, thus may have a significant bearing on the neurological effects and addictive properties of ethanol.

Adjuvant bupivacaine scalp block facilitates stabilization of hemodynamics in patients undergoing craniotomy with general anesthesia: a preliminary report.

STUDY OBJECTIVE: To evaluate the effect of 0.25% bupivacaine scalp block on alterations in hemodynamics and plasma catecholamine metabolites during general anesthesia in patients undergoing frontotemporal craniotomy. DESIGN: Prospective, clinical study. SETTING: Operating room of a university hospital. PATIENTS: 16 ASA physical status II and III patients who were scheduled for frontotemporal craniotomy. INTERVENTIONS: Patients were prospectively randomized to receive a saline control (C group) or bupivacaine scalp block (SB group) as an adjuvant to general anesthesia using isoflurane in 50% N(2)O-O(2). MEASUREMENTS: Routine monitoring of electrocardiogram, heart rate (HR), and mean arterial blood pressure (MAP) were recorded at two-minute intervals from the beginning of anesthesia until 10 minutes after incision, followed by 5-minute intervals throughout the remaining course of the surgery. By prospective design, increases in MAP or HR by 20% above the mean baseline values were treated with 2.5 mg/kg of thiopental combined with 2 mug/kg of fentanyl. Arterial blood was sampled at 5 minutes before and after skin incision and at the start of dural opening for measuring serum catecholamine metabolites by high-performance liquid chromatography. MAIN RESULTS: Only two patients in the SB group needed additional anesthetics for stabilizing their hemodynamics during the course of anesthesia. In contrast, all C group patients required supplemental anesthesia for controlling the abrupt rise in hemodynamic parameters. In addition, absolute MAP and HR values were significantly higher in the C group than in the SB group during the surgical period between incision and dural opening. The differences in hemodynamics observed between the two groups were, however, not accompanied with a significant change in plasma catecholamine metabolites at each predetermined time interval measured. CONCLUSIONS: Pretreatment with 0.25% bupivacaine scalp block appeared to be an effective adjuvant treatment for maintaining stable hemodynamics for patients undergoing craniotomy during general anesthesia especially at the time of skin incision and dural opening. This study design was unable to discern any correlation between elevation in hemodynamic parameters and a rise in serum catecholamine levels.

Comparison of the anesthesia profiles between sevoflurane-nitrous oxide and propofol-nitrous oxide conveyed by laryngeal mask airway in patients undergoing ambulatory gynecological surgery.

BACKGROUND: The major purpose of this study is to evaluate and compare the clinical characteristics of sevoflurane-nitrous oxide and propofol-nitrous oxide anesthesias conveyed by laryngeal mask airway (LMA) in patients for gynecological procedures. METHODS: Eighty female patients were randomly assigned to one of the two groups: Group I, inhalational induction at vital capacity with 8% sevoflurane and 67% nitrous oxide in oxygen; Group II, induction with intravenous propofol at 2 mg/kg followed by intravenous infusion at 6 mg/kg/hr. The LMA was inserted after loss of response to jaw thrusting. After successful insertion, in group I anesthesia was maintained with sevoflurane and 67% nitrous oxide in O2 and in group II anesthesia was maintained with propofol at 6 mg/kg/hr and nitrous oxide 67% in oxygen. Anesthetic profiles, including insertion event, postoperative nausea and vomiting, and hemodynamic alterations were compared. RESULTS: Demographic data were comparable in the two groups. After induction, in group II unconsciousness was produced 59 sec shorter than that in group I for placement of LMA. Group I had a higher statistically significant rate of cough upon induction, and by the same token postoperative nausea and vomiting. There were no significant differences in hemodynamic alterations, as well as time to open eyes on command, and time to regain orientation. CONCLUSIONS: Intravenous propofol in combination with 67% nitrous oxide in oxygen technique provided better clinical profiles, compared with sevoflurane-nitrous oxide technique through the use of LMA in gynecological patients undergoing ambulatory short procedures.

Effects of dopexamine on regional blood flow and leukotriene production in multiple splanchnic sites in endotoxemic rats.

BACKGROUND/AIMS: This work examines the effects of lipopolysaccharide (LPS) on splanchnic blood flow and tests the potential effect of dopexamine in preventing LPS-induced decrease in splanchnic blood flow, also analyzing its influence on regional leukotriene production. METHODOLOGY: Male Sprague-Dawley rats were grouped and subjected to i.v. administration (time 0) of the lipopolysaccharide (10mg/kg) or vehicles with some rats receiving dopexamine (2microg/kg/min) (times 2 hrs to 6 hrs) infusion and compared. Microdialysis collection for analyzing leukotrienes concentrations and direct splanchnic laser Doppler flowmetry were started at times 0 to 6 hrs. RESULTS: Mean arterial pressure decreased markedly in LPS-injected animals and it decreased further gradually during observation period. A marked increase in mean arterial pressure was noted following concomitant administration of dopexamine with LPS. CONCLUSIONS: Impaired splanchnic blood flow in the stomach, jejunum and ileum after LPS injection has been attenuated following infusion of dopexamine. The changes in regional blood flow in the specific splanchnic area correlate closely with the systemic mean arterial pressure in this early sepsis model. Increased leukotriene production following LPS injection also has been attenuated in the stomach, jejunum and ileum following dopexamine infusion, and the increase of leukotriene production also correlates closely with systemic mean arterial pressure.

Rossicasins A, B and rosicaside F, three new phenylpropanoid glycosides from Boschniakia rossica.

Three phenylpropanoid glycosides have been isolated, together with the known phenylpropanoid glycosides rossicaside A (4), B (5), E (6), and trans-p-coumaryl alcohol 1-O-beta-D-glucopyranosyl(1-->4)-alpha-L-rhamnopyranosyl(1-->3)-beta-D-glucopyranoside (7), and an acylated oligosaccharide beta-D-glucopyranosyl(1-->4)-alpha-L-rhamnopyranosyl-(1-->3)-(4-O-trans-caffeoyl)-D-glucopyranose) (8), from the aqueous extract of Boschniakia rossica (CHAM. et SCHLECH.) FEDTSCH. et FLEROV. Spectroscopic evidence led to the assignments of their structures as trans-p-coumaryl-(6'-O-beta-D-xylopyranosyl)-O-beta-D-glucopyranoside (1), trans-p-coumaryl-(6'-O-alpha-L-arabinopyranosyl)-O-beta-D-glucopyranoside (2) and 2-(3,4-dihydroxyphenyl)-R,S-2-ethoxy-ethyl-O-beta-D-glucopyranosyl(1-->4)-alpha-L-rhamnopyranosyl(1-->3)(4-O-trans-caffeoyl)-beta-D-glucopyranoside (3), designated as rossicasin A, rossicasin B, and rossicaside F, respectively. Compound 7 was identified from the degradation reaction and this is the first isolation from a natural source.

Blockade of spinal nitric oxide synthase on blood pressure variability and hepatic microcirculation.

BACKGROUND: We previously demonstrated that intrathecal administration of N(G)-nitro-L-arginine methyl ester (L-NAME), a nitric oxide synthase inhibitor, increased systemic arterial blood pressure in a dose-dependent manner in rats. The aim of the study was to investigate the participation of autonomic nervous system on L-NAME-induced hypertension and also illuminate its effects on hepatic microcirculation in rats. METHODS: Eight Spraque-Dawley rats were used and initially anesthetized with ketamine 120 mg/kg, intraperitoneally supplemented by intravenous infusion of ketamine at 30 mg/kg/h for maintenance. Surgical preparations included cannulations of right femoral artery and vein to obtain systemic arterial pressure signals and administer anesthetic drug. A mini-laparotomy was made to facilitate the insertion of a microdialysis probe and attachment of a laser Doppler probe to the middle lobe of the liver. On experiment, L-NAME was administered via the previously placed intrathecal catheter at 0, 0.37, 0.74, and 1.48 micromol in sequence at a 2-h interval. RESULTS: The results showed that the arterial blood pressure increased in a dose-dependent manner. By the same token, the power density of very low frequency (VLF) also increased. The low frequency (LF): high frequency (HF) ratio shifted toward parasympathetic dominance. Blood flow to the liver was unchanged except slightly decreased in the animals receiving 0.37 micromol. The levels of monoethylglycinexylidide (MEGX), an index of hepatic metabolism, were unchanged throughout the experiment. CONCLUSIONS: We concluded that the blockade of spinal nitric oxide synthase by intrathecal administration of L-NAME significantly increased vasomotor tone in a dose-dependent manner and as a consequence induced a reflex sympathetic inhibition. Hepatic microcirculation was stable with the applied doses.

Effect of esmolol on positive-pressure ventilation-induced variations of arterial pressure in anaesthetized humans.

Positive-pressure ventilation-induced variations in arterial pressure have been related to cardiac sympathetic activity in animals. However, the effect of beta-adrenoceptor blockade on these variations in anaesthetized humans under positive-pressure ventilation has not yet been investigated. In the present study, RAPV (respiratory-related arterial pressure variability) and %SPV (percentile systolic pressure variation) were determined before and after esmolol treatment in ten mechanically ventilated patients. RAPV and %SPV decreased significantly after intravenous esmolol (1 mg/kg of body weight) treatment (maximal decrease of RAPV, 50% and %SPV, 35%). Linear regression analysis of RAPV and %SPV before and after esmolol treatment both revealed high correlation (r = 0.93 and 0.91 respectively). The amplitudes of RAPV and %SPV also significantly increased in a graded way with higher tidal volumes. Thus we propose that esmolol suppresses the variations in arterial pressure induced by positive-pressure mechanical ventilation, and we suggest that RAPV and %SPV may be alternative choices for monitoring cardiac sympathetic regulation in anaesthetized patients under positive-pressure ventilation.

A dose ranging study of dexamethasone for preventing patient-controlled analgesia-related nausea and vomiting: a comparison of droperidol with saline.

UNLABELLED: We designed this study to determine the minimum dose of dexamethasone for preventing nausea and vomiting associated with the use of morphine by patient-controlled analgesia (PCA). Two hundred forty female patients were randomly assigned to receive dexamethasone 2, 4, 8, or 12 mg IV immediately before induction of anesthesia. Droperidol (0.1 mg/mL with morphine 1 mg/mL in PCA pump) and saline were used as controls. The complete response (no postoperative nausea and vomiting and no need for rescue antiemetic for a 24-h postoperative period) rates for dexamethasone 8 mg (72.2%) and 12 mg (78.9%) were significantly more than for saline (42.9%) (P < 0.05). Patients who received dexamethasone 12 or 8 mg also reported higher patient satisfaction than those who received saline (P < 0.05). These results were as effective as adding droperidol 0.1 mg/mL to the morphine PCA without causing drowsiness, restlessness, or arrhythmias. Smaller doses of dexamethasone (4 or 2 mg) were not effective for this propose. The results suggest that dexamethasone 8 mg IV is the minimum effective dose for the reduction of PCA morphine-related nausea and vomiting. IMPLICATIONS: Morphine administration by patient-controlled analgesia (PCA) is often associated nausea and vomiting. In this double-blind study, the minimum effective dose of dexamethasone for reducing this complication was 8 mg. This was as effective as adding droperidol 0.1 mg/mL to the morphine PCA without causing drowsiness, restlessness or arrhythmias.

Delayed hypoxemia after bone cement insertion during total hip replacement under spinal anesthesia--a case report.

We report a case of delayed hypoxemia in an aged healthy male patient, which developed 2 hours after cementation of the prosthesis in total hip replacement (THR) under spinal anesthesia. The patient was doing well throughout the operation but unfortunately, progressive tachypnea was noted 1 h after he was transferred to the recovery room (i.e. 2 h after the application of bone cement into the femur). An hour further, distinct wheeze was heard bilaterally on auscultation, which signified bronchospasm. Arterial blood gases analysis revealed a low PaO2 of 71 mmHg and a decrease of oxygen saturation to 91% with supplement of fractional oxygen of 35%. Aerosolization of bronchodilator with terbutaline was administered and supplemental fractional oxygen was increased to 50%. Although wheezing soon subsided, tachypnea and desaturation persisted. He was then transferred to the surgical intensive care unit for further management. Ventilation-perfusion lung scan was performed, which was suggestive of multiple pulmonary embolism.