Slow advancement of the endotracheal tube during fiberoptic-guided tracheal intubation reduces the severity of postoperative sore throat.

Although fiberoptic-guided tracheal intubation is a gentler method than using a direct laryngoscope, injury may occur owing to impingement between the distal edge of the endotracheal tube and the glottis. This study aimed to investigate the effects of endotracheal tube advancement speed during fiberoptic-guided intubation on airway symptoms postoperatively. We randomized patients scheduled for laparoscopic gynecological surgery to either Group C or S. When advancing the tube over the bronchoscope, the operator advanced the tube at a normal speed in Group C and at a slower speed in Group S. The speed in Group S was approximately half that in Group C. The target outcomes were the severity of postoperative sore throat, hoarseness, and cough. Patients in Group C experienced a more severe sore throat than those in Group S at 3 and 24 h postoperatively (p = 0.001 and p = 0.012, respectively). However, the severity of hoarseness and cough postoperatively were not significantly different between the groups. In conclusion, the slow advancement of the endotracheal tube during fiberoptic-guided intubation can reduce sore throat severity.

Sudden arrhythmia in the prone position during spinal surgery: A case report.

RATIONALE: The prone position is the most commonly required position during spinal surgery. Decreasing lumbar lordosis is necessary to facilitate the accessibility of the surgical field. And this can affect the hemodynamic circulation of the patients. The Jackson spine table is one of the most preferred methods, known to have minimal effects on cardiac function. PATIENT CONCERNS: We report a case of sudden arrhythmia that developed during the prone position using a Jackson spine table. It occurred 30 minutes after the positional change. DIAGNOSES: Arrhythmia showed bizarre P and QRS waves. Ectopic P, bundle branch block, or both was suspected. INTERVENTIONS: Because it was difficult to define the exact type or cause of this sudden arrhythmia and considering that other vital signs remained stable, we decided to keep close observation during the operation rather than applying uncertain antiarrhythmic medication. OUTCOMES: Arrhythmia spontaneously developed and subsided repeatedly. And it recovered to normal sinus rhythm immediately after the positional change to the supine position. Therefore, increased intrathoracic pressure caused by the prone position was highly suspected to be the cause of this event. LESSONS: Although the Jackson spine table is known to have the least effect on cardiac function, the patient experienced arrhythmia in our case. Hence, to achieve better clinical outcomes, an understanding of physiological alterations and possible complications caused by the prone position is necessary for earlier diagnosis and management.

Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial.

BACKGROUND: During fiberoptic-guided tracheal intubation, impingement between the distal tip of the endotracheal tube and the airway tissue can cause difficulties in tube insertion or tissue damage during the tube advancement over the bronchoscope. This randomized controlled study aimed to investigate the effects of the endotracheal tube's bevel direction on the complications associated with airway injury when performing fiberoptic-guided tracheal intubation. METHODS: The study subjects were divided into 2 groups: L (control) and D (study). When advancing the tube over the bronchoscope, the tube's bevel was facing the patients' left in Group L and the dorsal direction in Group D. According to the degree of resistance at the time of tube advancement, the insertion score was graded in 3 stages; the severity of the patients' sore throat and hoarseness was evaluated and recorded postoperatively. RESULTS: The severity of postoperative sore throat was higher in Group L than in Group D 3 hours and 24 hours after surgery. (P = .008, P = .023, respectively). The tube insertion score was comparable between the groups. The severity of postoperative hoarseness did not vary significantly between the groups. CONCLUSION: Endotracheal tube insertion with the bevel facing the dorsal direction of the patient during fiberoptic-guided tracheal intubation reduced the severity of postoperative sore throat in patients undergoing laparoscopic gynecologic surgery.

Sildenafil and beraprost combination therapy in patients with pulmonary hypertension undergoing valvular heart surgery.

BACKGROUND AND AIM OF THE STUDY: Sildenafil and beraprost, as orally available pulmonary vasodilators, are used increasingly to treat pulmonary hypertension (PH). An evaluation was made, in patients with PH undergoing valvular heart surgery, as to whether preoperative combined oral sildenafil and beraprost treatment could induce synergistic and prolonged pulmonary vasodilation, or result in a loss of pulmonary selectivity. METHODS: Fifty patients scheduled for valvular heart surgery with a mean pulmonary arterial pressure (PAP) > 30 mmHg were randomly assigned to receive either 50 mg oral sildenafil + 40 microg beraprost, or a placebo, 15 min before the induction of anesthesia. Hemodynamic variables were measured intraoperatively. RESULTS: The treatment group had a significantly lower systemic vascular resistance index at 60 min after medication. No other significant intergroup differences in hemodynamic variables were observed. In addition, significantly more patients in the treatment group required vasopressor therapy. In both groups, the PAP was significantly reduced by general anesthesia, and almost normalized after valvular heart surgery. CONCLUSION: Preoperative oral sildenafil and beraprost treatment resulted in a loss of pulmonary selectivity, and did not provide any additional pulmonary vasodilation or favorable perioperative hemodynamics in patients with PH undergoing valvular heart surgery.

Cardiac Perforation Caused by Bone Cements as a Complication of Cement Augmented Pedicle Screw Fixation Using the Fenestrated Pedicle Screw: A Case Report.

Cement-augmented fenestrated pedicle screw fixation is becoming more popular for osteoporotic patients. Although several reports have been published on leakage-related problems with bone cement, no cases of cardiac perforation after cement-augmented pedicle screw fixation have been reported. We present a case of cardiac perforation after cement-augmented fenestrated pedicle screw fixation. A 67-year-old female was admitted to our hospital with complaints of dyspnea and chest pain after lumbar surgery. She had been treated with L4-5 lumbar interbody fusion and percutaneous pedicle screw fixation with bone cement augmentation seven days earlier for degenerative spondylolisthesis. The right chest pain was observed a day after the surgery; she was treated conservatively but it did not improve for 7 days after surgery. Chest computed tomography (CT) revealed a hemothorax and a large sharp bone cement fragment that perforated the right atrium. Bone cement can be removed with thoracotomy surgery. We have to be aware of cement leakage through the normal venous drain system around the vertebral body. We also have to consider a detailed cardiac workup, which may include chest CT or echocardiography, if a patient complains of chest pain or dyspnea after cement augmentation.

Role of Remote Ischemic Preconditioning in Hepatic Ischemic Reperfusion Injury.

The effect of remote ischemic preconditioning (RIPC) has been proposed that mediates the protective response in ischemia reperfusion injury (IRI) of various organs. In this study, we investigated the effect of RIPC in hepatic IRI, by assessing biomarker of oxidative stress and inflammatory cytokines. Moreover, we intended to demonstrate any such protective effect through nitric oxide (NO). Twenty-five rats were divided into the 5 groups: (1) Sham; (2) RIPC; (3) hepatic IRI; (4) RIPC + hepatic IRI; (5) C-PTIO, 2-(4-carboxyphenyl)-4,5dihydro-4,4,5,5-tetramethyl-1H-imidazolyl-1-oxy-3oxide, + RIPC + hepatic IRI. RIPC downregulated the level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), histologic damage, and activity of Malondialdehyde (MDA). However, there was no significant reduction in the level of tumor necrosis factor-alpha (TNF-α) and nuclear factor kappa B (NF-κB). AST and ALT levels, and hepatic tissue morphology in the C-PTIO group showed a significant improvement compared to those of the RIPC + hepatic IRI group. The application of RIPC before hepatic ischemia downregulated the oxidative stress, not the inflammatory cytokines. Moreover, these protective effect of RIPC would be mediated through the activation of NO as well as anti-oxidant effect.

Effects of early vital capacity maneuver on respiratory variables during multivessel off-pump coronary artery bypass graft surgery.

OBJECTIVES: Despite avoiding cardiopulmonary bypass, similar degrees of pulmonary impairment compared with on-pump coronary artery bypass surgery have been demonstrated in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) compared with on-pump coronary artery bypass surgery. To investigate the effects of an early vital capacity maneuver (VCM) on intrapulmonary shunt (Qs/Qt), oxygenation, and pulmonary outcome in OPCAB. DESIGN: Prospective, randomized, controlled, double-blind clinical trial. SETTING: Cardiothoracic operating room and intensive care unit (ICU) of a university hospital. PATIENTS: Fifty patients scheduled for OPCAB were randomized to treatment with VCM or none. INTERVENTIONS: After sternotomy, VCM was performed by inflating the lungs to 40 cm H2O and holding this pressure for 10 seconds. MEASUREMENTS AND MAIN RESULTS: Qs/Qt, Pao2/Fio2 (P/F) ratio, and dynamic and static pulmonary compliances were measured before induction of anesthesia (T0), 15 minutes after tracheal intubation (T1), during Y-graft construction (T2), 15 minutes after completion of grafting (T3), 15 minutes after sternal closure (T4), and 3 hours after arrival at the ICU (T5). Qs/Qt was lower and P/F ratio was higher in the VCM group at T2 through T5. Pulmonary compliances were also higher in the VCM group at T4 and T5. Patients in the VCM group were extubated earlier. CONCLUSIONS: The beneficial effects of an early VCM on Qs/Qt persisted into the period of ICU care, with an improvement in P/F ratio and preserved pulmonary compliances, leading to a shorter time to extubation.

Predictors of ineffectual radial arterial pressure monitoring in valvular heart surgery.

BACKGROUND AND AIM OF THE STUDY: Unexpected sustained underestimation of the central aortic pressure by the radial arterial pressure commonly develops following cardiopulmonary bypass (CPB) in valvular heart surgery (VHS), leading to an inappropriate use of vasopressors. The study aim was to identify clinical predictors leading to a sustained inappropriate difference between the radial and femoral arterial pressure (IDRF) in VHS. METHODS: A total of 200 patients undergoing VHS was studied prospectively. Those patients who developed sustained IDRF (systolic IDRF > or =10 mmHg and/or mean IDRF > or =5 mmHg) from immediately after discontinuation of CPB until the end of the surgery were compared with patients who did not develop any IDRF. RESULTS: Data from seven patients who required second aortic cross-clamping and re-CPB were excluded from the analysis; thus, data from 193 patients were analyzed. In total, 53 patients (27.5%) developed sustained IDRF, whereas 80 patients (41.4%) did not develop any IDRF. In multivariate analysis, female gender, the presence of atrial fibrillation and diuretic use were identified as independent preoperative predictors; longer-duration aortic cross-clamping and use of larger amounts of vasopressin during CPB were identified as independent operative risk factors of the sustained IDRF. CONCLUSION: When an erroneously low radial arterial pressure is suspected following CPB in this subset of patients undergoing VHS, monitoring of the femoral or axillary arterial pressure should be considered to guide hemodynamic management, as there is an increased risk of persistence of this phenomenon.

Stabilized infective endocarditis and altered heparin responsiveness during cardiopulmonary bypass.

BACKGROUND: Although active infective endocarditis (IE) is known as a risk factor for decreased heparin responsiveness during cardiopulmonary bypass (CPB), evidence is lacking in patients with stabilized IE. We investigated whether heparin responsiveness was still altered in stabilized IE patients undergoing cardiac surgery in a prospective, controlled trial. METHODS: A total of 16 patients with stabilized IE without signs of active inflammation (IE group) and 48 patients without systemic infection (control group) undergoing valve surgery were included. Heparin responsiveness was assessed using the heparin sensitivity index (HSI), whereas heparin resistance was defined as an activated clotting time (ACT) occurring less than 400 s after the initial heparinization. RESULTS: Preoperative antithrombin III activity was lower and fibrinogen level was higher in the IE group. ACT after initial heparinization was shorter in the IE group. The HSI was lower and the number of patients with HSI <1.0 was greater in the IE group. Heparin resistance occurred more frequently in the IE group. CONCLUSIONS: Heparin responsiveness during CPB was significantly reduced in the IE group, and it seems to be associated with preoperative hypercoagulability and reduced antithrombin III activity. Therapeutic measures such as the administration of antithrombin III concentrate should be considered in these patients even when they are in a stabilized condition without active inflammation.

Failure to awaken from general anesthesia due to infratentorial hemorrhage after cervical spine surgery: A case report.

RATIONALE: Emergence is not simply the reverse process of induction. Many dynamic situations could occur in this period by distinct neurobiology as recent studies indicated. Herein we report a rare case of failure of emergence from general anesthesia after cervical spine surgery. PATIENT CONCERNS: Despite the perioperative vital signs and laboratory results were unremarkable, the patient could not recover his mental status and spontaneous breathing during emergence. 20 minutes after cessation of anesthetic drug administration, his blood pressure suddenly began to decrease requiring transfusion and vasopressor. DIAGNOSIS: After thorough inspection of intraoperative alterations of hemodynamic and metabolic values, which showed no significant changes except possible signs of delayed volume loss, cerebrovascular bleeding was most suspected as the cause of the event. Computed tomography was performed and infratentorial hemorrhage after cervical spine surgery was checked. INTERVENTIONS: Decompression operation was required for removing the hemorrhage. However, the patient's family refused further management considering his limited life expectancy. OUTCOMES: The patient expired on postoperative day 5. LESSONS: Failure to awaken is a relatively rare event. It could be confused with simple delayed emergence, which is often caused by residual drug effect. However, when it occurs, the result could be devastating. Therefore, appropriate recognition and prompt response are required to decrease the mortality and morbidity of the patient.

Traumatic severe tricuspid regurgitation diagnosis after the progression of right ventricle function deterioration.

Traumatic tricuspid regurgitation is a rare complication of blunt cardiac injury and frequently misdiagnosed during the initial assessment. Unfortunately, it may be diagnosed after deterioration of right ventricle function, which may be fatal to the patient. Here, we report a case of a patient with blunt chest injury complicated by a diagnosis of traumatic severe tricuspid regurgitation after deterioration of the right ventricle function even after the patient was subjected to serum cardiac enzyme normalization. The patient was a driver and admitted to the hospital owing to multiple traumatic injuries. Echocardiography was performed suspicious of blunt cardiac injury, which revealed no abnormal findings. Initial cardiac enzyme levels were high, but after serial follow-up, the levels improved. However, on day 4 of hospitalization, hemodynamic deterioration occurred owing to severe tricuspid regurgitation and delayed right ventricle dysfunction. Immediate tricuspid valve replacement was performed, however, the patient had a pronged recovery period. We believe that it is important to take into account the nature of the accident and the presentation of clinical signs and symptoms and not be blinded by laboratory test results alone; it is also important to consider performing repeated serial echocardiographic examinations for blunt cardiac injury patients.

Prediction of cognitive dysfunction and patients' outcome following valvular heart surgery and the role of cerebral oximetry.

OBJECTIVE: Postoperative cognitive dysfunction (POCD) commonly develops after cardiac surgery affecting patients' outcome. Cerebral oximetry noninvasively measures regional cerebral oxygen saturation (rSO(2)) and significant correlation has been reported between intraoperative cerebral desaturation and POCD, as well as patients' outcome following coronary artery bypass grafting. However, evidence is limited in valvular heart surgery (VHS). We investigated the relationship of intraoperative rSO(2) values with POCD and length of postoperative hospitalization in patients undergoing VHS. METHODS: One hundred patients undergoing elective VHS were enrolled. Neurocognitive evaluation was performed with Mini-Mental State Examination, Trail-Making Test (Part A), and Grooved Pegboard Test at 1 day before and 7th day after surgery. During surgery, rSO(2) was continuously monitored and the incidence and duration of decrease in rSO(2) values for five consecutive minutes were recorded as follows; (1) decrease in absolute rSO(2) values to less than 50%, (2) 40%, and (3) a 20% decrease compared to baseline value. RESULTS: Twenty-three patients (23%) demonstrated POCD. We could not observe any significant differences in either the incidence or duration of decrease in rSO(2) values between patients with and without POCD. Low education level and higher baseline temperature had significant correlation with POCD. Patients with cerebral desaturation required significantly longer postoperative hospitalization. CONCLUSION: In patients undergoing VHS, POCD could not be predicted with cerebral oximetry. However, patients with intraoperative cerebral desaturation required significantly longer postoperative hospitalization and cerebral oximetry appears to be promising in terms of monitoring the brain as the index organ for systemic perfusion and improving patients' outcome.

Beneficial Role of Hydrogen Sulfide in Renal Ischemia Reperfusion Injury in Rats.

PURPOSE: Hydrogen sulfide (H2S) is an endogenous gaseous molecule with important physiological roles. It is synthesized from cysteine by cystathionine γ-lyase (CGL) and cystathionine ß-synthase (CBS). The present study examined the benefits of exogenous H2S on renal ischemia reperfusion (IR) injury, as well as the effects of CGL or CBS inhibition. Furthermore, we elucidated the mechanism underlying the action of H2S in the kidneys. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats were randomly assigned to five groups: a sham, renal IR control, sodium hydrosulfide (NaHS) treatment, H2S donor, and CGL or CBS inhibitor administration group. Levels of blood urea nitrogen (BUN), serum creatinine (Cr), renal tissue malondialdehyde (MDA), and superoxide dismutase (SOD) were estimated. Histological changes, apoptosis, and expression of mitogen-activated protein kinase (MAPK) family members (extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38) were also evaluated. RESULTS: NaHS attenuated serum BUN and Cr levels, as well as histological damage caused by renal IR injury. Administration of NaHS also reduced oxidative stress as evident from decreased MDA, preserved SOD, and reduced apoptotic cells. Additionally, NaHS prevented renal IR-induced MAPK phosphorylation. The CGL or CBS group showed increased MAPK family activity; however, there was no significant difference in the IR control group. CONCLUSION: Exogenous H2S can mitigate IR injury-led renal damage. The proposed beneficial effect of H2S is, in part, because of the anti-oxidative stress associated with modulation of the MAPK signaling pathways.

Treatment of radiation-induced cystitis and vulvodynia via a ganglion impar block using a lateral approach under computed tomography guidance: a case report.

Adjuvant radiation therapy (RT) after colorectal cancer surgery can prevent local recurrence, but has several side effects. Precise injection of drugs into the affected areas is complicated by radiation-induced fibrosis of soft or connective tissue. A 48-year-old woman experienced severe intractable perineal pain, dysuria, urinary urgency, and frequent urination after rectal cancer surgery and adjuvant RT, and was diagnosed with radiation-induced cystitis and vulvodynia. Her symptoms persisted despite two fluoroscopy-guided ganglion impar blocks. Fluoroscopy revealed atypical needle tip positioning and radiolucent dye distribution, presumably due to radiation-induced fibrosis in the target region. We performed two computed tomography (CT)-guided ganglion impar blocks by using a lateral approach, which allowed more accurate po-sitioning of the needle tip. Her pain visual analog score decreased from 9 to 3, and she recently resumed sexual intimacy. CT guidance is a viable alternative to fluoroscopy guidance when performing ganglion impar blocks in fibrotic areas.

Identification of human-generated forces on wheelchairs during total-body extensor thrusts.

BACKGROUND: Involuntary extensor thrust experienced by wheelchair users with neurological disorders may cause injuries via impact with the wheelchair, lead to the occupant sliding out of the seat, and also damage the wheelchair. The concept of a dynamic seat, which allows movement of a seat with respect to the wheelchair frame, has been suggested as a potential solution to provide greater freedom and safety. Knowledge of the human-generated motion and forces during unconstrained extensor thrust events is of great importance in developing more comfortable and effective dynamic seats. The objective of this study was to develop a method to identify human-generated motions and forces during extensor thrust events. This information can be used to design the triggering system for a dynamic seat. METHODS: An experimental system was developed to automatically track the motions of the wheelchair user using a video camera and also measure the forces at the footrest. An inverse dynamic approach was employed along with a three-link human body model and the experimental data to predict the human-generated forces. FINDINGS: Two kinds of experiments were performed: the first experiment validated the proposed model and the second experiment showed the effects of the extensor thrust speed, the footrest angle, and the seatback angle. The proposed method was tested using a sensitivity analysis, from which a performance index was deduced to help indicate the robust region of the force identification. INTERPRETATION: A system to determine human-generated motions and forces during unconstrained extensor thrusts was developed. Through experiments and simulations, the effectiveness and reliability of the developed system was established.

Non-Anastomotic Rupture of a Woven Dacron Graft in the Descending Thoracic Aorta Treated with Endovascular Stent Grafting.

The intrinsic structural failure of a Dacron graft resulting from the loss of structural integrity of the graft fabric can cause late graft complications. Late non-anastomotic rupture has traditionally been treated surgically via open thoracotomy. We report a case of the successful use of thoracic endovascular repair to treat a Dacron graft rupture in the descending aorta. The rupture occurred 20 years after the graft had been placed. Two stent grafts were placed at the proximal portion of the surgical graft, covering almost its entire length.

Inhibition of reactive oxygen species downregulates the MAPK pathway in rat spinal cord after limb ischemia reperfusion injury.

INTRODUCTION: We examined the activity of mitogen-activated protein kinase (MAPK) family members, extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38, in rats pinal cord after hind limb ischemia reperfusion (IR) and analyzed the role of reactive oxygen species (ROS) as mediators of MAPK signaling under these conditions. METHODS: In experiment 1, hind limb IR rats were treated intraperitoneally with one of following agents at 30 min before reperfusion: allopurinol (4, 40 mg/kg), superoxide dismutase (SOD, 4000 U/kg), N-nitro-l-arginine methyl ester (l-NAME, 10 mg/kg), or SOD (4000 U/kg) + l-NAME (10 mg/kg). In experiment 2, 5,10,15,20-tetrakis (N-methyl-4'-pyridyl) porphyrinato iron (III) (FeTMPyP) was administered intraperitoneally (1, 3, or 10 mg/kg) 30 min before reperfusion. After 3 d reperfusion period, the spinal cord (L4-6) was harvested to investigate MAPK signaling activity. RESULTS: In experiment 1, p-ERK and p-JNK levels were significantly higher in the IR group than sham group. Administration of allopurinol, SOD, l-NAME, or SOD + l-NAME significantly reduced the IR-induced increase in p-ERK and p-JNK levels. There were no significant differences in p-p38 levels. In experiment 2, FeTMPyP significantly reduced the IR-induced increase in p-ERK and p-JNK levels in a dose-dependent manner. CONCLUSIONS: Activation of ERK and JNK in the spinal cord was induced by hind limb IR and was not accompanied by p38 activation. IR-induced MAPK phosphorylation was reduced by inhibition of superoxide, nitric oxide, and peroxynitrite, indicating that ROS produced by hind limb IR mediate the activation of these signaling pathways in the spinal cord, potentially affecting distant organs.

Abnormal origin of the left subclavian artery from the left pulmonary artery in a patient with double outlet right ventricle.

Anomalous aortic origin of the left subclavian artery (LSCA) from the left pulmonary artery (LPA) is a rare congenital cardiac malformation. We describe a case of LSCA from the LPA via ductus arteriosus in association with a double-outlet right ventricle, which never has been reported previously in Korea.

Treatment of large arteriovenous malformation in right lower limb.

A 10-year-old boy with arteriovenous malformation (AVM) of the right lower limb was scheduled for an amputation of the affected limb. Limb amputation was necessary because of the ineffectiveness of previous sclerotherapy and the rapid progression of AVM causing pain and heart failure. Right hip disarticulation was considered the best option to improve his quality of life. To prevent congestive heart failure and uncontrollable hemorrhage during surgery, the disarticulation was done under a partial cardiopulmonary bypass. The patient underwent surgery successfully without complications.

Massive hemothorax immediately after removal of central venous catheter -A case report-.

Hemothorax is a possible immediate complication of central venous catheterization. We experienced a patient who suffered from massive hemothorax 72 hours after right subclavian venous catheterization. A 29-year-old female patient with Marfan's syndrome underwent the Bentall's operation and aortic arch replacement with an artificial graft, which was performed uneventfully. She recovered favorably in the intensive care unit and was transferred to the general ward on postoperative day 3. Immediately after the removal of the catheter in the general ward, massive hemothorax developed and emergent thoracotomy should have been performed to control bleeding. We report this case to re-emphasize the careful monitoring even after removal of central venous catheter and the need for ultrasound guidance during insertion of central venous catheters.