Role of oxygen reserve index monitoring in patients undergoing robot-assisted radical prostatectomy: a retrospective study.

PURPOSE: Robot-assisted radical prostatectomy (RARP) is a common surgical procedure for the treatment of prostate cancer. Although beneficial, it can lead to intraoperative hypoxia due to high-pressure pneumoperitoneum and Trendelenburg position. This study explored the use of oxygen reserve index (ORi) to monitor and predict hypoxia during RARP. METHODS: A retrospective analysis was conducted on 329 patients who underwent RARP at the Seoul National University Bundang Hospital between July 2021 and March 2023. Various pre- and intraoperative variables were collected, including ORi values. The relationship between ORi values and hypoxia occurrence was assessed using receiver operating characteristic curves and logistic regression analysis. RESULTS: Intraoperative hypoxia occurred in 18.8% of the patients. The receiver operating characteristic curve showed a satisfactory area under the curve of 0.762, with the ideal ORi cut-off value for predicting hypoxia set at 0.16. Sensitivity and specificity were 64.5% and 75.7%, respectively. An ORi value of < 0.16 and a higher body mass index were identified as independent risk factors of hypoxia during RARP. CONCLUSIONS: ORi monitoring provides a non-invasive approach to predict intraoperative hypoxia during RARP, enabling early management. Additionally, the significant relationship between a higher body mass index and hypoxia underscores the importance of individualized patient assessment.

Remimazolam to prevent hemodynamic instability during catheter ablation under general anesthesia: a randomized controlled trial.

PURPOSE: Maintaining hemodynamic stability during cardiac ablation under general anesthesia is challenging. Remimazolam, a novel ultrashort-acting benzodiazepine, is characterized by maintaining comparatively stable blood pressure and does not influence the cardiac conduction system, which renders it a reasonable choice for general anesthesia for cardiac ablation. We aimed to evaluate whether remimazolam is associated with a decreased incidence of intraoperative hypotension compared with desflurane. METHODS: In this single-centre, parallel-group, prospective, single-blind, randomized clinical trial, we randomized patients (1:1) into a remimazolam group (remimazolam-based total intravenous anesthesia) or desflurane group (propofol-induced and desflurane-maintained inhalational anesthesia) during cardiac ablation procedures for arrhythmia. The primary outcome was the incidence of intraoperative hypotensive events, defined as mean arterial pressure of < 60 mm Hg at any period. RESULTS: Overall, we enrolled 96 patients between 2 August 2022 and 19 May 2023 (47 and 49 patients in the remimazolam and desflurane groups, respectively). The remimazolam group showed a significantly lower incidence of hypotensive events (14/47, 30%) than the desflurane group (29/49, 59%; relative risk [RR], 0.5; 95% confidence interval [CI], 0.31 to 0.83; P = 0.004). Remimazolam was associated with a lower requirement for bolus or continuous vasopressor infusion than desflurane was (23/47, 49% vs 43/49, 88%; RR, 0.56; 95% CI, 0.41 to 0.76; P < 0.001). No between-group differences existed in the incidence of perioperative complications such as nausea, vomiting, oxygen desaturation, delayed emergence, or pain. CONCLUSIONS: Remimazolam was a viable option for general anesthesia for cardiac ablation. Remimazolam-based total intravenous anesthesia was associated with significantly fewer hypotensive events and vasopressor requirements than desflurane-based inhalational anesthesia was, without significantly more complications. STUDY REGISTRATION: ClinicalTrials.gov (NCT05486377); first submitted 1 August 2022.

RéSUMé: OBJECTIF: Le maintien de la stabilité hémodynamique lors d'une ablation cardiaque sous anesthésie générale est un défi. Le remimazolam, une nouvelle benzodiazépine à action ultra-courte, se caractérise par le maintien d'une tension artérielle relativement stable et son absence d'influence sur le système de conduction cardiaque, ce qui en fait un choix raisonnable pour l'anesthésie générale pour l'ablation cardiaque. Nous avons cherché à déterminer si le remimazolam est associé à une diminution de l'incidence d'hypotension peropératoire comparativement au desflurane. MéTHODE: Dans cette étude clinique randomisée, prospective, en simple aveugle, en groupes parallèles et monocentrique, nous avons randomisé des patient·es (1:1) dans un groupe remimazolam (anesthésie intraveineuse totale à base de remimazolam) et un groupe desflurane (anesthésie volatile induite par propofol et maintenue par desflurane) pendant des interventions d'ablation cardiaque pour arythmie. Le critère d'évaluation principal était l'incidence d'événements hypotensifs peropératoires, définis comme une tension artérielle moyenne de < 60 mm Hg à n'importe quelle période. RéSULTATS: Au total, nous avons recruté 96 patient·es entre le 2 août 2022 et le 19 mai 2023 (47 et 49 personnes dans les groupes remimazolam et desflurane, respectivement). Le groupe remimazolam a montré une incidence significativement plus faible d'événements hypotensifs (14/47, 30 %) que le groupe desflurane (29/49, 59 %; risque relatif [RR], 0,5; intervalle de confiance [IC] à 95 %, 0,31 à 0,83; P = 0,004). Le remimazolam a été associé à des besoins plus faibles de bolus ou de perfusion continue de vasopresseurs que le desflurane (23/47, 49 % vs 43/49, 88 %; RR, 0,56; IC 95 %, 0,41 à 0,76; P < 0,001). Il n'y avait pas de différences entre les groupes dans l'incidence des complications périopératoires telles que les nausées, les vomissements, la désaturation en oxygène, l'émergence retardée ou la douleur. CONCLUSION: Le remimazolam a constitué une option viable pour l'anesthésie générale en vue d'une ablation cardiaque. L'anesthésie intraveineuse totale à base de remimazolam a été associée à un nombre significativement plus faible d'événements d'hypotension et de besoins en vasopresseurs que l'anesthésie par inhalation à base de desflurane, sans complications significativement plus nombreuses. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05486377); soumis pour la première fois le 1er août 2022.

Artificial intelligence model predicting postoperative pain using facial expressions: a pilot study.

PURPOSE: This study aimed to assess whether an artificial intelligence model based on facial expressions can accurately predict significant postoperative pain. METHODS: A total of 155 facial expressions from patients who underwent gastric cancer surgery were analyzed to extract facial action units (AUs), gaze, landmarks, and positions. These features were used to construct various machine learning (ML) models, designed to predict significant postoperative pain intensity (NRS ≥ 7) from less significant pain (NRS < 7). Significant AUs predictive of NRS ≥ 7 were determined and compared to AUs known to be associated with pain in awake patients. The area under the receiver operating characteristic curves (AUROCs) of the ML models was calculated and compared using DeLong's test. RESULTS: AU17 (chin raising) and AU20 (lip stretching) were found to be associated with NRS ≥ 7 (both P ≤ 0.004). AUs known to be associated with pain in awake patients did not show an association with pain in postoperative patients. An ML model based on AU17 and AU20 demonstrated an AUROC of 0.62 for NRS ≥ 7, which was inferior to a model based on all AUs (AUROC = 0.81, P = 0.006). Among facial features, head position and facial landmarks proved to be better predictors of NRS ≥ 7 (AUROC, 0.85-0.96) than AUs. A merged ML model that utilized gaze and eye landmarks, as well as head position and facial landmarks, exhibited the best performance (AUROC, 0.90) in predicting significant postoperative pain. CONCLUSION: ML models using facial expressions can accurately predict the presence of significant postoperative pain and have the potential to screen patients in need of rescue analgesia. TRIAL REGISTRATION NUMBER: This study was registered at ClinicalTrials.gov (NCT05477303; date: June 17, 2022).

Modified Thoracoabdominal Nerves Block Through Perichondral Approach: A Systematic Review and Meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to investigate the postoperative analgesic efficacy and safety of the modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) in abdominal surgeries. DESIGN: Systematic review and meta-analysis. METHODS: We searched electronic databases to identify relevant studies comparing M-TAPA with conventional analgesic techniques. The primary outcome was the requirement for rescue analgesia at 12 and 24 hours postsurgery. Secondary outcomes included the 11-point numerical rating scale pain scores at 0, 1, 2, 4, 6, 8, 12, and 24 hours following surgery, global quality of recovery scores, and postoperative adverse events. FINDINGS: Five randomized controlled trials involving 308 patients were analyzed. M-TAPA showed no significant difference in the requirement for rescue analgesia at 12 hours (relative risk [RR]: 0.87; 95% confidence interval [CI]: 0.62, 1.22; P = .424; I2 = 40.7%; Ph = .185) and 24 hours (RR: 0.67; 95% CI: 0.22, 1.99; P = .252; I2 = 90.3%; Ph < .001) postsurgery compared to non-M-TAPA. No significant differences in numerical rating scale pain scores or global quality of recovery scores were found between the two groups (all P < .05). However, M-TAPA was associated with a lower occurrence of nausea (RR: 0.37; 95% CI: 0.22, 0.68; P < .001; I2 = 0%; Ph = .834), vomiting (RR: 0.32; 95% CI: 0.17, 0.62; P < .001; I2 = 0%; Ph = .884), and itching (RR: 0.38; 95% CI: 0.21, 0.70; P = .002; I2 = 0%; Ph = .826). CONCLUSIONS: There was no significant difference in analgesic efficacy and safety between M-TAPA and non-M-TAPA techniques.

The Involvement of the Hypothalamus-Pituitary-Adrenal Axis in the Development of Hyperalgesia during the Early Postoperative Period.

INTRODUCTION: Hyperalgesia frequently occurs after surgery and is associated with adverse effects on surgical outcomes. Thus, we aimed to examine whether the hypothalamus-pituitary-adrenal (HPA) axis function after surgery is involved in the development of postoperative hyperalgesia. METHODS: Surgery- and pain-related variables were measured 24 and 48 h after the first and second total knee arthroplasties (TKAs) in postmenopausal patients undergoing 1-week-interval staged bilateral TKA. Two sets of saliva samples were consecutively collected from patients before (pre-T1) and 1 week after (post-T1) the first TKA (n = 69). HPA axis function was analyzed in a subgroup of 20 patients with a typical cortisol awakening response (CAR) in both the sets of saliva samples. RESULTS: Surgery-related variables were comparable between the first and second TKAs. However, pain-related variables (pain ratings and the amount of opioid analgesics consumed) were greater after the second than the first TKA. Cortisol and dehydroepiandrosterone (DHEA) secretion during the post-awakening period (CARauc and Daucawk, respectively) was higher at post-T1 than at pre-T1, but the molar CARauc/Daucawk ratio was comparable between the time points examined. No relationship was observed between the pre-T1 CARauc and pain ratings after the first TKA. However, post-T1 CARauc showed a positive correlation with pain ratings after the second TKA. Postoperative pain ratings were negatively correlated with Daucawk and positively correlated with the molar CARauc/Daucawk ratio at all examined time points. DISCUSSION/CONCLUSION: The results suggest that adrenocortical steroidogenic activity favoring the production of cortisol over DHEA after surgery may contribute to the development of hyperalgesia during the early postoperative period.

Comparison between ketorolac- and fentanyl-based patient-controlled analgesia for acute kidney injury after robot-assisted radical prostatectomy: a retrospective propensity score-matched analysis.

PURPOSE: It is unclear whether ketorolac-based patient-controlled analgesia (PCA) leads to acute kidney injury (AKI) after robot-assisted radical prostatectomy (RARP) in patients susceptible to AKI. We compared the postoperative AKI incidence with ketorolac- and fentanyl-based PCA after RARP. METHODS: After medical record review, eligible patients were divided in ketorolac and fentanyl groups. We conducted propensity score matching of 3239 patients and assigned 641 matched patients to each group, and compared the AKI incidence. We investigated potential risk factors for postoperative AKI, defined according to the Kidney Disease Improving Global Outcomes criteria. We collected preoperative data (age, height, weight, body mass index, American Society of Anesthesiologists physical status, medical history, creatinine level, estimated glomerular filtration rate, and hemoglobin level) and intraoperative data (maintenance anesthetics, surgery duration, anesthesia duration, crystalloid amount, colloid use, total amount of fluid administered, estimated blood loss, norepinephrine use, phenylephrine use, and PCA type). RESULTS: The postoperative AKI incidence was significantly higher in the ketorolac than in the fentanyl group, both before (31.1% vs. 20.4%; p < 0.001) and after (31.5% vs. 22.6%; p < 0.001) matching. In the univariate analysis, ketorolac was significantly associated with postoperative AKI, both before (odds ratio [OR], 1.762; 95% confidence interval [CI], 1.475-2.105; p < 0.001) and after (OR, 1.574; 95% CI, 1.227-2.019; p < 0.001) matching. In the multivariate analysis, ketorolac-based PCA was independently associated with development of postoperative AKI in the matched groups (OR, 1.659; 95% CI, 1.283-2.147; p < 0.001). CONCLUSION: Ketorolac-based PCA may increase postoperative AKI incidence after RARP; thus, renal function should be monitored in these patients.

Blood transfusion had no influence on the 5-year biochemical recurrence after robot-assisted radical prostatectomy: a retrospective study.

BACKGROUND: Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot-assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy. METHODS: This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence. RESULTS: A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4-5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5-3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8-3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5-2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence. CONCLUSIONS: RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Effects of magnesium on the dose of rocuronium for deep neuromuscular blockade: A randomised controlled trial.

BACKGROUND: Magnesium is known to enhance the effect of rocuronium, but the extent is not quantified. OBJECTIVES: We aimed to quantify the effect of magnesium on the dose of rocuronium for deep neuromuscular blockade. DESIGN: A randomised controlled study. SETTING: A single tertiary care hospital. PATIENTS: Seventy males scheduled to undergo robot-assisted laparoscopic prostatectomy, aged between 20 and 80 years with American Society of Anesthesiologists physical status classification 1 or 2, were enrolled. INTERVENTIONS: Patients were randomised to either the magnesium group or control group. The magnesium group were infused with 50 mg kg-1 of magnesium, followed by a continuous intra-operative infusion at 15 mg kg-1 h-1 while the control group were infused with the same volumes of 0.9% saline. Deep neuromuscular blockade was maintained with a continuous infusion of rocuronium and was reversed using sugammadex. MAIN OUTCOME MEASURES: The primary outcome was the dose of rocuronium administered to maintain deep neuromuscular blockade. The secondary outcomes were recovery time, defined as the time from the administration of sugammadex to train-of-four ratio 0.9, and the incidence of postoperative nausea and vomiting. RESULTS: The dose of rocuronium administered to maintain deep neuromuscular blockade was significantly lower in the magnesium group (7.5 vs. 9.4 µg kg-1 min-1, P = 0.01). There was no difference in recovery time or the incidence of nausea and vomiting. CONCLUSION: Magnesium reduced the dose of rocuronium required for deep neuromuscular blockade by approximately 20% without affecting the recovery time after administration of sugammadex. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04013243.

Association of neuromuscular reversal by sugammadex and neostigmine with 90-day mortality after non-cardiac surgery.

BACKGROUND: Reversing a neuromuscular blockade agent with sugammadex is known to lessen postoperative complications by reducing postoperative residual curarization. However, its effects on 90-day mortality are unknown. Therefore, this study aimed to compare the effects of sugammadex and neostigmine in terms of 90-day mortality after non-cardiac surgery. METHODS: This retrospective cohort study analyzed the medical records of adult patients aged 18 years or older who underwent non-cardiac surgery at a single tertiary care hospital between 2011 and 2016. Propensity score matching and Cox regression analysis were used to investigate the effectiveness of sugammadex and neostigmine in lowering 90-day mortality after non-cardiac surgery. RESULTS: A total of 65,702 patients were included in the analysis (mean age: 52.3 years, standard deviation: 15.7), and 23,532 of these patients (35.8%) received general surgery. After propensity score matching, 14,179 patients (3906 patients from the sugammadex group and 10,273 patients from the neostigmine group) were included in the final analysis. Cox regression analysis in the propensity score-matched cohort showed that the risk of 90-day mortality was 40% lower in the sugammadex group than in the neostigmine group (hazard ratio: 0.60, 95% confidence interval: 0.37, 0.98; P = 0.042). These results were similar in the multivariable Cox regression analysis of the entire cohort (hazard ratio: 0.62, 95% confidence interval: 0.39, 0.96; P = 0.036). CONCLUSIONS: This retrospective cohort study suggested that reversing rocuronium with sugammadex might be associated with lower 90-day mortality after non-cardiac surgery compared to neostigmine. However, since this study did not evaluate quantitative neuromuscular function in the postoperative period due to its retrospective design, the results should be interpreted carefully. Future prospective studies with quantitative neuromuscular monitoring in the postoperative period should be performed to confirm these results.

Postoperative residual neuromuscular blockade after reversal based on a qualitative peripheral nerve stimulator response: A randomised controlled trial.

BACKGROUND: Incomplete recovery of neuromuscular blockade is a common postoperative adverse event in the postanaesthesia care unit. OBJECTIVE: We examined and compared the incidence of residual neuromuscular blockade when the recommended dose of neostigmine or sugammadex was administered according to a qualitative nerve stimulator response. DESIGN: A randomised controlled trial. SETTING: A tertiary care hospital in South Korea from September 2017 to November 2017. PATIENTS: Eighty patients aged between 18 and 69 years were included in this study. All were patients scheduled to undergo elective laparoscopic cholecystectomy and who had an American Society of Anaesthesiologists physical status of one or two were eligible. INTERVENTIONS: Patients were allocated randomly to receive neostigmine or sugammadex at the end of surgery. The doses of the reversal agents were based on the response to peripheral nerve stimulation, which was discontinued after administration of the reversal agent. MAIN OUTCOME MEASURES: The primary outcome was the incidence of postoperative residual neuromuscular blockade. The secondary outcomes were the incidences of symptoms or signs of residual neuromuscular blockade such as hypoxaemia, inability to maintain head-lift for 5 s and diplopia. RESULTS: The incidence of residual neuromuscular blockade on arrival in the recovery room was 44.4% in the neostigmine group and 0% in the sugammadex group (P < 0.0001, relative risk = 1.80, 95% confidence interval 1.36 to 2.41). The incidences of adverse events in the recovery room were low and comparable between the groups. CONCLUSION: The incidence of residual neuromuscular blockade on arrival in the recovery room was significantly higher in the neostigmine group than that in the sugammadex group. However, the incidence of adverse events was similar in the neostigmine and sugammadex groups. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03292965.

Retrospective Comparison between the Effects of Propofol and Inhalation Anesthetics on Postoperative Recurrence of Early- and Intermediate-Stage Hepatocellular Carcinoma.

OBJECTIVE: Previous studies have reported that propofol has antitumor, anti-inflammatory, and antioxidant effects in addition to its anesthetic properties. To confirm this, a retrospective investigation was conducted to determine whether different anesthetic agents, particularly propofol and inhalation anesthetics, have an effect on the recurrence of hepatocellular carcinoma (HCC) in patients who were diagnosed with primary HCC and underwent laparoscopic hepatectomy. SUBJECTS AND METHODS: Patients with Barcelona Clinic Liver Cancer stages 0, A, and B HCC, who underwent laparoscopic hepatic resection, were enrolled in this study. Post-operative HCC recurrence, which was determined from postoperative liver CT, was evaluated 24 months postoperatively with respect to the main anesthetic agents. The characteristics of HCC and other patient-related or surgery-related variables were evaluated together. RESULTS AND CONCLUSION: During the 24-month period after hepatic resection, less HCC patients in the propofol group than in the inhalation group recurred (p = 0.046). The mean time to recurrence was 20.8 months (95% CI, 19.7-22.0) and 19.1 months (95% CI, 17.8-20.4) in the propofol group and the inhalation group, respectively. In addition, multivariable Cox proportional regression analysis revealed that the propofol group showed significantly decreased recurrence versus the inhalation group (hazard ratio, 0.57; 95% CI, 0.47-0.69; p = 0.029). When propofol was used as the main general anesthetic agent for laparoscopic hepatic resection, the postoperative 2-year recurrence rate decreased in early- and intermediate-stage HCC.

Retrospective analysis of 30-day unplanned readmission after major abdominal surgery with reversal by sugammadex or neostigmine.

BACKGROUND: Sugammadex is associated with fewer postoperative complications, but its impact on 30-day unplanned readmission is unclear. METHODS: This was a single-centre retrospective observational study of patients after major abdominal surgery between 2010 and 2017, where rocuronium was the only neuromuscular blocker used. The primary endpoint was the difference in incidence of 30-day unplanned readmission between reversal with sugammadex or neostigmine. The secondary endpoints were the length of hospital stay after surgery and related hospital charges (total charges excluding those related to surgery and anaesthesia). Analysis included propensity score matching and generalised mixed-effects modelling. RESULTS: Mixed-effects logistic regression analysis of 1479 patients (sugammadex: 355; neostigmine: 1124) showed that the incidence of 30-day unplanned readmission was 34% lower (odds ratio [OR]: 0.66, 95% confidence interval [CI]: 0.46-0.96, P=0.031), the length of hospital stay was 20% shorter (exponential regression coefficient: 0.80, 95% CI: 0.77-0.83, P<0.001), and related hospital charges were 24% lower (exponential regression coefficient: 0.76, 95% CI: 0.67-0.87, P<0.001) in the sugammadex group than in the neostigmine group. For patients living ≥50 km from the hospital, the incidence of 30-day unplanned readmission was 68% lower in the sugammadex group than in the neostigmine group (OR: 0.32, 95% CI: 0.13-0.79, P=0.014), while it was not significant for patients living <50 km from the hospital (P=0.319). CONCLUSIONS: Compared with neostigmine, reversal of rocuronium with sugammadex after major abdominal surgery was associated with a lower incidence of 30-day unplanned readmission, a shorter hospital stay, and lower related hospital charges.

Comparison of standard versus 90° rotation technique for LMA Flexible™ insertion: a randomized controlled trial.

BACKGROUND: Insertion of a flexible laryngeal mask airway (LMA Flexible) is known to be more difficult than that of a conventional laryngeal mask airway. The 90° rotation technique can improve the success rate with a conventional laryngeal mask airway but its effect with the LMA Flexible remains unknown. We assessed whether the 90° rotation technique increased the first-attempt success rate of LMA Flexible insertion versus the standard technique. METHODS: In total, 129 female patients undergoing breast surgery were analyzed. The primary endpoint was success at the first attempt. The insertion time, number of trials, number of manipulations required, and oropharyngeal leak pressure were also evaluated. Heart rate and mean blood pressure were recorded 1 min before and 1 min after insertion. Blood staining on the LMA Flexible after removal and postoperative sore throat were checked. RESULTS: The first-attempt success rates were comparable between the groups (93% vs. 98.3%, P = .20). The insertion time, number of trials and manipulations, hemodynamic variables, and complications, such as blood staining and sore throat, did not differ between the groups. CONCLUSIONS: The 90° rotation technique is a good alternative to the standard technique for insertion of the LMA Flexible. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03028896 ). It was registered retrospectively at Jan 19th, 2017.

The effect of an immersive virtual reality tour of the operating theater on emergence delirium in children undergoing general anesthesia: A randomized controlled trial.

BACKGROUND AND AIMS: An immersive virtual reality tour of the operating theater could reduce preoperative anxiety. This study was designed to determine whether a preoperative immersive virtual reality tour demonstrates a reduction in emergence delirium through reducing the preoperative anxiety in children undergoing general anesthesia. METHODS: Eighty-six children were randomly allocated into either the control or virtual reality group. The control group received conventional education regarding the perioperative process. The virtual reality group watched a 4-minute virtual reality video showing the operating theater and explaining the perioperative process. Incidence and severity of emergence delirium were the main outcomes. Secondary outcomes included preoperative anxiety using modified Yale Preoperative Anxiety Scale and postoperative behavioral disturbance. RESULTS: Eighty children completed the final analysis (control group = 39, virtual reality group = 41). The incidence (risk ratio [95% CI]: 1.1 [0.5-2.8], P = 0.773) and severity of emergence delirium (mean difference [95% CI]: -0.2 [-2.7 to 2.2], P = 0.791) were similar in the two groups. After the intervention, children in the virtual reality group had a significantly lower modified Yale Preoperative Anxiety score than those in the control group (mean difference [95% CI]: 9.2 [0.3-18.2], P = 0.022). No difference was observed regarding postoperative behavioral disturbance between the two groups at postoperative 1 day (mean difference [95% CI]: -0.1 [-0.3 to 0.1], P = 0.671) and 14 day (mean difference [95% CI]: -0.0 [-0.1 to 0.0], P = 0.329). CONCLUSION: Preoperative immersive virtual reality tour of the operating theater did not reduce the incidence and severity of emergence delirium, although it was effective in alleviating preoperative anxiety in children.

Association Between Perioperative Fluid Balance and 30-Day Unplanned Readmission After Major Abdominal Surgery.

Perioperative positive fluid balance (FB) increases postoperative complication and length of hospital stay. We aimed to investigate 30-day unplanned readmission after major abdominal surgery based on perioperative FB (%) on postoperative days (POD) 0 to 3. This retrospective cohort study analyzed medical records of patients who underwent elective major abdominal surgery (surgery time >2 hours, estimated blood loss >500 mL) at a single tertiary academic hospital from January 2010 to December 2017. Cumulative FB was calculated by total input fluid - output fluid in liters × weight (kg)-1 on admission × 100 during POD 0 (24 hours), 0 to 1 (48 hours), 0 to 2 (72 hours), and 0 to 3 (96 hours). Of the 3650 patients in the final analysis, 503 (13.8%) had unplanned readmission within 30 days. In the multivariable logistic regression analysis, FB on POD 0 (24 hours), 0 to 1 (48 hours), 0 to 2 (72 hours), and 0 to 3 (96 hours) showed no significant association with 30-day unplanned readmission (all P > .05). However, an increase of 10 000 points in the total relative value unit scores was associated with 5% increase in 30-day unplanned readmission (odds ratio = 1.05, 95% confidence interval = 1.02-1.07; P = .001), and 1-hour increase in surgery time was associated with 10% increase in 30-day unplanned readmission (odds ratio = 1.10, 95% confidence interval = 1.05-1.15; P < .001). This study showed that perioperative FB is not associated with 30-day unplanned readmission rate after a major abdominal surgery. Total relative value unit scores and duration of surgery were significantly associated with 30-day unplanned readmission rate after major abdominal surgery in a single tertiary academic hospital.

Abilities of Pre- and Postoperative High-Sensitivity C-Reactive Protein Levels to Predict 90-Day Mortality After Surgery for Abdominal and Thoracic Cancers.

BACKGROUND: Elevated high-sensitivity C-reactive protein (hsCRP) levels are known to be associated with a poor prognosis for cancer patients, but inadequate data exist regarding whether pre- or postoperative hsCRP levels have better predictive value after oncologic surgery. This study evaluated the associations between pre- and postoperative hsCRP levels and 90-day postoperative mortality among patients who underwent surgery for abdominal or thoracic cancers. METHODS: This retrospective cohort study included 7933 patients who underwent elective surgery between January 2010 and December 2016. Cox regression analysis and receiver operative characteristic curve analyses were used to evaluate the prognostic values of preoperative hsCRP (< 1 month before surgery) and postoperative hsCRP (< 3 days after surgery). RESULTS: For predicting 90-day mortality, the area under the receiver operating characteristic curve was significantly larger for preoperative hsCRP than for postoperative hsCRP [0.76; 95% confidence interval (CI) 0.71-0.81 vs 0.65 95% CI 0.57-0.72; P < 0.001]. The optimal cutoff values were 0.5 mg/dL for preoperative hsCRP and 9.7 mg/dL for postoperative hsCRP. Based on these cutoff values, increased risks of 90-day mortality were significantly associated with preoperative hsCRP levels higher than 0.5 mg/dL [hazard ratio (HR) 7.60; 95% CI 4.43-13.03; P < 0.001] and postoperative hsCRP levels higher than > 9.7 mg/dL (HR 1.83; 95% CI 1.12-2.98; P = 0.016). CONCLUSION: Both elevated pre- and postoperative hsCRP levels were associated with increased risks of 90-day mortality after surgery for thoracic and abdominal cancer. However, preoperative hsCRP had better prognostic value than postoperative hsCRP.

Chronic hyperglycemia with elevated glycated hemoglobin level and its association with postoperative acute kidney injury after a major laparoscopic abdominal surgery in diabetes patients.

BACKGROUND: The relationship between preoperative hyperglycemia and postoperative acute kidney injury (AKI) occurrence in non-cardiac surgery including laparoscopic surgery remains unclear. This study aimed to assess the relationship between preoperative chronic hyperglycemia and postoperative AKI occurrence after a major laparoscopic abdominal surgery. METHODS: We retrospectively reviewed medical records of diabetic patients (≥ 20 years old) who underwent elective major laparoscopic abdominal surgery procedures between 2010 and 2016. Patients were divided into two groups based on a cut-off value of hemoglobin A1c (HbA1c) at 6%. Serum creatinine value was used for the diagnosis of AKI, and all assessments and diagnoses of postoperative AKI were performed on 0-3 postoperative days (POD) using the criteria of Kidney Disease: Improving Global Outcomes. RESULTS: In all, 1885 patients were included in the final analysis, and patients were divided into the following groups: < 6.0% group with 1257 patients (66.7%), and ≥ 6.0% group with 628 patients (33.3%). Sixty-nine patients (3.7%) were diagnosed with postoperative AKI within 3 POD. Multivariable logistic regression analysis showed no significant difference in the incidence rate of postoperative AKI between the HbA1c ≥ 6.0% group and the < 6.0% group (odds ratio 1.10, 95% confidence interval 0.57-2.15; P = 0.770). In addition, there was no significant interaction between preoperative HbA1c group and exposure to acute hyperglycemia (serum glucose > 200 mg/dL) for incidence of AKI on POD 0-3 (P = 0.181). CONCLUSIONS: In diabetic patients, preoperative chronic hyperglycemia is not associated with postoperative AKI occurrence within 3 POD after a major laparoscopic abdominal surgery.

Association of Preoperative Serum Total Cholesterol Level with Postoperative Pain Outcomes after Laparoscopic Surgery for Gastric Cancer.

BACKGROUND: Opioid usage is reportedly increased in patients with advanced cancer and low total cholesterol (TC). The aim of this study was to determine the effects of preoperative serum TC levels on postoperative opioid usage in patients undergoing laparoscopic gastric cancer surgery. METHODS: We retrospectively analyzed the medical records of patients with gastric cancer who underwent laparoscopic gastrectomy at our institution between January 1, 2011 and July 31, 2017. We investigated the correlation between TC levels in the month before surgery and numeric rating scale (NRS) scores and opioid consumption on postoperative days (PODs) 0 to 3. The patients were stratified according to preoperative TC level (< 160 mg/dL, low; 160 to 199 mg/dL, medium; ≥ 200 mg/dL, high). RESULTS: TC and NRS scores (PODs 0, 1) for 1,919 eligible patients showed weak but significant positive coefficients (0.074 and 0.098 on POD 0 and POD 1, respectively, P < 0.01). After adjusting for confounders, there were no significant differences in postoperative NRS scores on PODs 0, 1, 2, or 3 or in oral morphine equivalents on PODs 0 to 3 according to TC level. CONCLUSION: Preoperative serum TC levels have no effect on pain outcomes in the 3 days following laparoscopic gastric surgery.

Randomized Clinical Trial of Moderate Versus Deep Neuromuscular Block for Low-Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy.

BACKGROUND: The beneficial effects of deep blockade are not fully known. In this study, we evaluated the effect of deep neuromuscular blockade on surgical conditions during laparoscopic cholecystectomy under low-pressure pneumoperitoneum. METHODS: Patients undergoing elective laparoscopic cholecystectomy were randomized to either the moderate group (train-of-four count of 1 or 2) or deep group (posttetanic count of 1 or 2). Neuromuscular blockade was induced and maintained with rocuronium; it was reversed with sugammadex in the deep group and with neostigmine in the moderate group. At the beginning of surgery, the intra-abdominal pressure was set at 8 mmHg. The surgeon rated the surgical condition on a 4-point scale (1 = excellent, 2 = good, 3 = acceptable, 4 = poor) and was allowed to increase the pressure to 12 mmHg if it was determined that the surgical conditions were inadequate for the operation. RESULTS: A total of 64 patients completed the study. The rate of increasing intra-abdominal pressure to maintain optimal surgical conditions was 34.4 % in the moderate group and 12.5 % in the deep group (P = 0.039). The proportion of patients with a surgical condition score of 1 or 2 (excellent or good) was 34.4 % in the moderate group and 68.8 % in the deep group (P = 0.006). CONCLUSION: The maintenance of intraoperative deep neuromuscular blockade was associated with a lower rate of conversion to standard pressure and higher surgeon satisfaction with the surgical conditions than was moderate blockade in patients undergoing low-pressure pneumoperitoneum laparoscopic cholecystectomy.

The involvement of protein kinase C-ε in isoflurane induced preconditioning of human embryonic stem cell--derived Nkx2.5(+) cardiac progenitor cells.

BACKGROUND: Anesthetic preconditioning can improve survival of cardiac progenitor cells exposed to oxidative stress. We investigated the role of protein kinase C and isoform protein kinase C-ε in isoflurane-induced preconditioning of cardiac progenitor cells exposed to oxidative stress. METHODS: Cardiac progenitor cells were obtained from undifferentiated human embryonic stem cells. Immunostaining with anti-Nkx2.5 was used to confirm the differentiated cardiac progenitor cells. Oxidative stress was induced by H2O2 and FeSO4. For anesthetic preconditioning, cardiac progenitor cells were exposed to 0.25, 0.5, and 1.0 mM of isoflurane. PMA and chelerythrine were used for protein kinase C activation and inhibition, while εψRACK and εV1-2 were used for protein kinase C -ε activation and inhibition, respectively. RESULTS: Isoflurane-preconditioning decreased the death rate of Cardiac progenitor cells exposed to oxidative stress (death rates isoflurane 0.5 mM 12.7 ± 9.3%, 1.0 mM 12.0 ± 7.7% vs. control 31.4 ± 10.2%). Inhibitors of both protein kinase C and protein kinase C -ε abolished the preconditioning effect of isoflurane 0.5 mM (death rates 27.6 ± 13.5% and 25.9 ± 8.7% respectively), and activators of both protein kinase C and protein kinase C - ε had protective effects from oxidative stress (death rates 16.0 ± 3.2% and 10.6 ± 3.8% respectively). CONCLUSIONS: Both PKC and PKC-ε are involved in isoflurane-induced preconditioning of human embryonic stem cells -derived Nkx2.5(+) Cardiac progenitor cells under oxidative stress.