Addition of Preoperative Ultrasound-Guided Suprascapular Nerve Block and Axillary Nerve Block to Parecoxib Is More Effective in Early Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Study.

PURPOSE: To prospectively compare pain intensity and patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only. METHODS: Sixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n = 30) or control group (group C, n = 31). Two patients in group C were excluded because of miscommunication. All patients were administered 40 mg of parecoxib intravenously prior to induction of anesthesia. SSNB and ANB were performed after general anesthesia in group N, whereas no nerve block was performed in group C. Pain intensity was compared before surgery, as well as immediately, 24 hours, and 2 weeks after surgery. PROs, including the Oxford Shoulder Score, University of California-Los Angeles shoulder score, and Single Assessment Numeric Evaluation score, were compared before and 6 months after surgery. RESULTS: The numerical rating scale (NRS) score for resting pain was significantly lower in group N (4.9 ± 3.1 vs 7.6 ± 2.5, P < .001) immediately after surgery, but no difference was noted 24 hours after surgery. The resting pain NRS score 2 weeks after surgery was significantly lower in group N (1.4 ± 1.6 vs 2.7 ± 2.7, P = .03), but the scores for movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after surgery in both groups, but there was no difference between the 2 groups. CONCLUSIONS: The addition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after surgery. LEVEL OF EVIDENCE: Level II, prospective randomized controlled trial.

Total intravenous anesthesia for geriatric hip fracture with severe systemic disease.

PURPOSE: Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery. METHODS: We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics. RESULTS: There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates. CONCLUSION: Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

Effects of phthalates on normal human breast cells co-cultured with different fibroblasts.

Whether or not phthalates play a role in breast carcinogenesis remains to be determined. The goal of this study was to explore the effects of phthalates on the growth of normal MCF-10A breast cells modulated by breast fibroblasts. Fibroblasts were derived from normal mammary tissue adjacent to both estrogen receptor (ER) positive and negative primary breast cancers, which were grown separately from nontumorigenic MCF-10A epithelial cells. MCF-10A co-culture cells were treated with 10 nM 17ß-estradiol (E2), Butyl benzyl phthalate (BBP), di(n-butyl) phthalate (DBP), and di(20ethylhexyl) phthalate (DEHP) (10 and 100 nM). After incubation for 120 hours, the cells were harvested and extracted for MTT assay. Western blot analysis was used to evaluate the proliferative pathway proteins and the effects on ER α. Only fibroblasts from ER (+) breast cancer significantly stimulated proliferation of MCF-10A cells. Exposure of the co-culture to E2, BBP, DBP, DEHP, and E2 combined with one of these phthalates resulted in significantly increased cell proliferation, as well as proliferating cell nuclear antigen (PCNA) and ER α expressions. The present study demonstrates that phthalates express a significant influence in fibroblast-epithelial interactions, similarly to the effects of E2 on breast cells. The effects of phthalates on normal breast cells depend upon ER modulating actions. In breast carcinogenesis, phthalates should be considered as having endocrine disrupting potential, even at low concentrations.

Intravenous leiomyomatosis with extension to the heart: echocardiographic features: a case report.

A 40-year-old female was admitted to the hospital for an operation with a presumptive diagnosis of right atrial myxoma. She had had a hysterectomy for leiomyoma 8 months earlier and has since experienced progressive dyspnea on exertion, pedal edema, and two syncope episodes in the past 2 months. Cardiac murmur was detected and two-dimensional echocardiography was arranged. A mobile right atrial mass was discovered, which was thought to be a myxoma. The patient subsequently received open heart surgery. Histologic examination of the resected mass confirmed intravenous leiomyomatosis. Magnetic resonance imaging performed on the eighth postoperative day revealed an intravascular mass from the right common iliac vein to the upper abdominal inferior vena cava. The patient underwent a second operation one and half months after the first operation, with resection of the tumor mass in the inferior vena cava and resection of multiple uterine myoma. She recovered well. Repeat magnetic resonance imaging 6 months following the second operation showed that the inferior vena cava and right atrium were clear of tumor.

Labetalol pretreatment reduces blood pressure instability during surgical resection of pheochromocytoma.

BACKGROUND: To evaluate the effect of pretreatment with the mixed alpha- and beta-adrenergic blocker, labetalol, on blood pressure instability during surgical resection of pheochromocytoma. METHODS: Blood pressure stability and surgical results were compared between patients in the saline (n = 11) and labetalol (n = 15) groups. Anesthesia was induced with fentanyl, sodium thiopental and atracurium, and maintained with isoflurane in a 50% oxygen/nitrous oxide mixture. Intravenous labetalol was administered in the labetalol group before surgical incision, with the maximal dose being 1.2 mg/kg, while normal saline was administered to patients in the control, saline, group. Supplemental intravenous sodium nitroprusside (SNP) infusion was administered whenever systolic blood pressure exceeded 180 mmHg. The number of patients with intraoperative hypertension or hypotension, dosage of SNP administered, number of intraoperative hypertension episodes, use of fluid and blood transfusion, and heart rate (defined as the mean of heart rate every 5 minutes throughout the operation) were compared between these two groups. RESULTS: The number of patients with intraoperative hypertension, number of patients receiving SNP, dose of SNP administered, and number of hypertension episodes were significantly lower in patients who received labetalol pretreatment than in control patients. CONCLUSION: This study has demonstrated that labetalol pretreatment (1.2 mg/kg) with supplemental SNP provides more favorable blood pressure control during surgical resection of pheochromocytoma than with SNP alone.

Red Man's syndrome following administration of vancomycin in a patient under spinal anesthesia--a case report.

Prophylactic antibiotics are frequently administered during anesthesia to reduce the incidence of infection. The most common organisms revealed in wound infections are staphylococci. Vancomycin is the antibiotic of choice for resistant staphylococcal infections and bacterial endocarditis in patient allergic to penicillin. We had a case of tibial osteomyelitis, while undergoing removal of implants under spinal anesthesia developed hypotensions, bradycardia, consciousness change and skin erythematous macular rash after 0.1% vancomycin slow infusion for 10 min. After appropriate management, the patient recovered well and was discharged on the following day. Our report is intended to alert our colleagues that vancomycin can cause hypotension secondary to histamine release, direct myocardial depression and direct peripheral vasodilation. Even cardiac arrest had been reported in the literatures.

Effects of estradiol and progestogens on human breast cells: regulation of sex steroid receptors.

OBJECTIVES: To examine the effects of 17ß-estradiol (E2) and progestogens, used in hormone therapy, on estrogen receptors (ER), progesterone receptors (PR), and human breast tumor cell growth. MATERIALS AND METHODS: MCF-7 cells were incubated in pure E2 (1 nM and 10 nM) as well as in E2 in conjunction with 10 nM progestogens, including progesterone (P4), medroxyprogesterone acetate (MPA), norethisterone acetate (NET), and cyproterone acetate (CPA). Cell proliferation, apoptosis, expression of caspase-3, and both ER and PR isoforms were evaluated. RESULTS: Caspase-3 was significantly diminished in cultures with only E2, whereas ERα significantly increased. A significant increase of caspase-3 in addition to the entire abolishment of E2-induced augmentation of ERα was observed in 1 nM E2 plus MPA and 10 nM E2 plus NET, whereas PR isoform B (PRB) was significantly increased. The ratios of apoptosis: proliferation significantly increased in 1 nM E2 plus progestogens (except P4) and 10 nM E2 plus NET. The changes of the PRA/PRB ratio were inversely related to the changes of the apoptosis to proliferation ratio. Significant increase of ERß and PRB was noted in the E2 plus MPA or NET, in addition to a significant increase of ERα and decrease of PRA in the E2 plus CPA, as well as an increase of ERα and decrease of PRA and PRB in the E2 plus P4. CONCLUSIONS: The combination of E2 and various progestogens resulted in diverging effects on ERs and PRs expressions, which induced different effects on MCF-7 cell growth. Compared with P4, aberrant hormone and biological activity of synthetic progestin, by way of altered receptor expression, may be an important factor in affecting breast cell growth.

Unexpected upper airway obstruction due to disseminated human papilloma virus infection involving the pharynx in a parturient.

Human papilloma virus has been implicated as the cause of juvenile-onset recurrent respiratory papillomatosis in first-born children. Thus, cesarean section is strongly recommended by obstetricians to avoid direct contact with papilloma in an infected birth canal. We report a parturient with silent hypopharyngeal papilloma, which was associated with severe clinical problems at the induction of general anesthesia. The anesthesiologist considered general anesthesia for this case because of disseminated skin warts and secondary pus across the patient's body. Although the patient's breathing was smooth before starting general anesthesia, it was difficult to maintain positive pressure ventilation despite administration of a muscle relaxant. High air-way resistance without chest wall motion was noted, despite the insertion of an oral airway. Therefore, direct laryngoscopy was immediately performed and an obstructing mass was found. This mass acted as a check valve during positive ventilation. Our report should remind clinicians that human papilloma virus infection, although benign, can be disastrous in certain circumstances, as in our case where it resulted in airway obstruction and distal spread during cesarean section. Its presence necessitated preoperative laryngoscopic evaluation and aggressive treatment.

Prosthetic mitral leaflet malfunction due to inappropriate size of implant.

We report a case of unexpected malfunction of prosthetic mitral leaflets, discovered by transesophageal echocardiography (TEE) immediately after implantation, due to selection of an inappropriate size of prosthesis; the problem was amended immediately by surgical revision. The subject was a 48-year-old man admitted for mitral valve replacement because of severe mitral stenosis. He had undergone mitral commissurotomy 21 years previously. Preoperative echo findings showed severe mitral stenosis with regurgitation and a huge thrombus in the left atrial chamber. During operation, the surgeon also discovered severe calcification over the mitral valve with rheumatic changes in both leaflets and the chordae. Because the posterior leaflet had totally fused with the annulus, resection could not be performed. A 33-mm Edwards-Carpentier porcine xenograft was then installed and sutured onto the approximate annular position. The posterior chordae were also not resected, and the atriotomy was closed. Once the aortic cross-clamp was removed and the patient was re-warmed, the left atrium distended rapidly. No ventricular wall motion was seen. Immediate TEE evaluation demonstrated that the prosthetic valve was dysfunctional and the leaflets were immobile. Total cardiopulmonary bypass was then resumed. A smaller 29-mm valve was reimplanted in the same anatomic position. The 33-mm tissue valve was then re-examined and checked for any structural abnormality or functional inadequacy. The prosthetic valve stent was intact and the leaflets were mobile upon gross inspection. The patient was successfully weaned from cardiopulmonary bypass with high dose inotropic agents and intra-aortic balloon pump support. In conclusion, TEE can provide us with immediate, accurate and detailed information to evaluate an unexpected circumstance and disclose an operative misadventure during or after cardiac surgery.

Anesthetic management of a parturient undergoing cesarean section with a tracheal tumor and hemoptysis.

Anesthetic management of a parturient with respiratory failure associated with hemoptysis, dyspnea, and orthopnea is difficult. An anesthesiologist should realize that the patient's major problem is not solved during the surgery. This circumstance is similar to a patient with associated cardiac disease scheduled for non-cardiac surgery. General anesthesia with endotracheal intubation can provide safe oxygenation for both the parturient and the fetus, but with possible unexpected massive hemoptysis and tumor seeding. Prolonged intubation may delay the patient's pulmonary treatment course. Laryngeal mask anesthesia can provide an airway, but must not be secured due to the risk of aspiration. The need of high doses of inhalation drugs may hinder uterine contractions. The addition of a muscle relaxant will change the patient's respiratory patterns and physiology. Regional anesthesia alone might not be tolerated. A decrease in cough strength, as well as dyspnea, orthopnea, and hyperventilation may be harmful to both the parturient and the fetus. However, we successfully managed this case using epidural anesthesia combined with assisted mask ventilation instead of spontaneous breathing usually provided by a simple mask in almost all American Society of Anesthesiology (ASA) class I-II parturients during cesarean section. The anesthetic level was maintained at T8 with 18 ml of 2% Xylocaine mixed with 2 ml of 7% sodium bicarbonate with 1:200,000 epinephrine epidurally and with the patient in a supine position with the head up at 30 degrees to prevent cephalic spreading and to ensure better pulmonary ventilation.

Vascular injury during a lumbar laminectomy.

A lumbar laminectomy is a common and routine operation. Damage to abdominal vascular structures during surgery is a relatively infrequent complication; however, when it does occur, it is sudden and life-threatening. We herein report on 2 cases of abdominal vascular injury which occurred during lumbar microdiscectomies. The first case was a 34-year-old man. A bloody surgical field was noted 45 min into the operation along with an increase in heart rate and a decrease in blood pressure. After fluid resuscitation and an ephedrine injection, his vital signs stabilized. The patient was then sent to the surgical intensive care unit for observation. An emergent abdominal computer tomography scan revealed right retroperitoneal hematoma, and an urgent exploratory laparotomy was performed to check for bleeding and to remove the hematoma. The second case was a 61-year-old woman with recurrent disc herniation. The operation was proceeding smoothly for 90 min, when a large amount of fresh blood suddenly gushed out. Her blood pressure immediately dropped to that of a state of shock. The patient was turned back to a supine position, and an emergent laparotomy was done to repair the injured vessels. Both patients had uneventful recoveries.

Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report.

PURPOSE: To report a case where failure to provide adequate one-lung ventilation during transbronchial intubation resulted in a potentially fatal mishap. CLINICAL FEATURES: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube. Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO2 to around 95% allowed completion of surgery. CONCLUSIONS: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation.

High frequency jet ventilation in exploration of tracheostomy--a case report.

Exploration of tracheostomy is not uncommon, however, in case a patient with a facial reconstruction flap, trouble may arise because of difficulty in intubation. We hereby report a patient who had a fresh facial reconstruction flap after radical resection of buccal carcinoma, sustained bleeding around the tracheostomy and was scheduled for exploration of tracheostomy. Fiberoptic oral intubation was failed because of profuse secretion and edematous oral mucosa; high frequency jet ventilation (HFJV) was thus applied and made possible with a suction catheter put through the tracheostomy tube. Exploration was performed following withdrawal of the tracheostomy tube. The tracheostomy tube was reinserted under the guidance of the in-place suction tube after uneventful exploration. The probable concomitant complications and contraindications of using HFJV are discussed here. With thorough preparation and careful monitoring, and under the supervision of experienced physicians, transtracheal HFJV can substitute fiberoptic intubation for ventilation in case of exploration of tracheostomy.