Showing papers in "Journal of Anesthesia in 2016"
TL;DR: Anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by sugammadex and neuromuscular blocking agents, as well as recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anAPHylaxis with the use of sug Mammadex.
Abstract: Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
105 citations
TL;DR: The developing focus in CO monitoring devices appears to be shifting to tissue perfusion and microcirculatory flow and aimed more at markers that indicate the effectiveness of circulatory and micro Circulatory resuscitations.
Abstract: Although cardiac output (CO) by pulmonary artery catheterization (PAC) has been an important guideline in clinical management for more than four decades, some studies have questioned the clinical efficacy of CO in certain patient populations. Further, the use of CO by PAC has been linked to numerous complications including dysrhythmia, infection, rupture of pulmonary artery, injury to adjacent arteries, embolization, pulmonary infarction, cardiac valvular damage, pericardial effusion, and intracardiac catheter knotting. The use of PAC has been steadily declining over the past two decades. Minimally invasive and noninvasive CO monitoring have been studied in the past two decades with some evidence of efficacy. Several different devices based on pulse contour analysis are available currently, including the uncalibrated FloTrac/Vigileo system and the calibrated PiCCO and LiDCO systems. The pressure-recording analytical method (PRAM) system requires only an arterial line and is commercially available as the MostCare system. Transesophageal echocardiography (TEE) can measure CO by non-Doppler- or Doppler-based methods. The partial CO2 rebreathing technique, another method to measure CO, is marketed by Novametrix Medical Systems as the NICO system. Thoracic electrical bioimpedance (TEB) and electric bioreactance (EB) are totally noninvasive CO monitoring. Nexfin HD and the newer ClearSight systems are examples of noninvasive CO monitoring devices currently being marketed by Edwards Lifesciences. The developing focus in CO monitoring devices appears to be shifting to tissue perfusion and microcirculatory flow and aimed more at markers that indicate the effectiveness of circulatory and microcirculatory resuscitations.
90 citations
TL;DR: The importance of sarcopenia, especially ICU-AW, in ICU patients via related articles in Medline is examined, as well as a similar condition to sarc Openia in the ICU, calledICU-acquired weakness, which has been reported more frequently.
Abstract: Sarcopenia occurring as a primary consequence of aging and secondary due to certain medical problems including chronic disease, malnutrition and inactivity is a progressive generalized loss of skeletal muscle mass, strength and function. The prevalence of sarcopenia increases with aging (approximately 5-13 % in the sixth and seventh decades). However, data showing the prevalence and clinical outcomes of sarcopenia in intensive care units (ICUs) are limited. A similar condition to sarcopenia in the ICU, called ICU-acquired weakness (ICU-AW), has been reported more frequently. Here, we aim to examine the importance of sarcopenia, especially ICU-AW, in ICU patients via related articles in Medline.
79 citations
TL;DR: Perioperative administration of opioids, midazolam, ketamine, alpha-2 agonist sedatives, and nonsteroidal anti-inflammatory drugs has demonstrated efficacy in the prevention and treatment of EA.
Abstract: Emergence agitation (EA) in children is a major postoperative issue that increases the risk of patient self-harm, places a burden on nursing staff, and reduces parent satisfaction with treatment. Risk factors for EA include age, preoperative anxiety, patient personality, pain, anesthesia method, and surgical procedure. Sevoflurane and desflurane are widely used anesthetics due to their low blood/gas partition coefficients, but they have recently been posited as a cause of EA in children. The perioperative administration of opioids, midazolam, ketamine, alpha-2 agonist sedatives, and nonsteroidal anti-inflammatory drugs has demonstrated efficacy in the prevention and treatment of EA. Maintenance of anesthesia using propofol has also been shown to prevent EA. In children, anesthesia methods that are unlikely to cause EA should be selected, with the prompt adminstration of appropriate treatment in cases of EA.
61 citations
TL;DR: Continuous RLB was not inferior to PVB except for the first 24 h, and was satisfactory after mastectomy, and showed safe, low peak arterial levobupivacaine concentrations.
Abstract: Retrolaminar block (RLB) is a thoracic truncal block that can produce analgesia for the thoracic and abdominal wall. However, the characteristics of RLB are not well known. The aim of this study was to determine analgesic efficacy by measuring postoperative consume of patient-controlled analgesia (PCA), additional nonsteroidal antiinflammatory drug (NSAID) rescue, and opioid rescue. Our secondary analysis included assessment of the chronological change in arterial levobupivacaine concentrations after the block. This prospective, randomized, double-blinded study included 30 patients scheduled for modified radical mastectomy under general anesthesia. The patients were randomized to receive either a landmark-guided RLB or paravertebral block (PVB) catheter placement on T4. Continuous infusion with 4 ml/h of 0.25 % levobupivacaine was started for 72 h, after initial injection of 20 ml 0.375 % levobupivacaine before surgery. Postoperative pain was compared using the amount of block PCA (3 ml 0.25 % levobupivacaine with 30-min lockout), NSAID, and opioid rescue. Arterial blood was sampled for 120 min after the initial injection. The frequency of postoperative block PCA use was significantly high after RLB in 24 h [p = 0.01; 6 (3–12) vs. 2.5 (0.3–3) times, respectively]. There was no PCA use after 24 h in either group. There was no postoperative opioid rescue use throughout the study. After RLB and PVB, there was no significant difference in T
max (p = 0.14; 15 ± 8 vs. 15 ± 8 min, respectively) and C
max (p = 0.2; 0.9 ± 0.2 vs. 0.9 ± 0.3 µg/ml, respectively), and all the concentrations were below the threshold of local anesthetic systemic toxicity. Continuous RLB was not inferior to PVB except for the first 24 h, and was satisfactory after mastectomy. RLB showed safe, low peak arterial levobupivacaine concentrations.
57 citations
TL;DR: It is demonstrated that cuffed ETTs reduce the need for TT exchanges and do not increase the risk for postextubation stridor compared with uncuffed ET Ts, and the need to re-intubation following planned extubations and duration of tracheal intubation did not change.
Abstract: Cuffed endotracheal tubes (ETTs) have increasingly been used in small children. However, the use of cuffed ETTs in small children is still controversial. The goal of this meta-analysis is to assess the current evidence regarding the postextubation morbidity and tracheal tube (TT) exchange rate of cuffed ETTs compared to uncuffed ETTs in children. A systematic literature search in PubMed, Web of Science, Embase, and Cochrane Central Register of Controlled Trials up to November 2014 was conducted to identify randomized controlled trials (RCTs) and prospective cohort studies that compared the use of cuffed and uncuffed ETTs in children. The primary outcome was the incidence of postextubation stridor and the second outcomes were the TT exchange rate, need for re-intubation, and duration of tracheal intubation. All pooled data were estimated using random effects meta-analysis. Two RCTs and two prospective cohort studies including 3782 patients, in which 1979 patients for cuffed tubes and 1803 patients for uncuffed tubes, were included in our analysis. We found that the use of cuffed ETTs did not significantly increase the incidence of postextubation stridor (RR = 0.88; 95 % CI 0.67–1.16, p = 0.36), and the TT exchange rate was lower in patients receiving cuffed tubes intubation (RR, 0.07; 95 % CI 0.05–0.10, p < 0.00001). The need for re-intubation following planned extubations and duration of tracheal intubation did not differ significantly between the cuffed tube group and the uncuffed tube group. Our study demonstrates that cuffed ETTs reduce the need for TT exchanges and do not increase the risk for postextubation stridor compared with uncuffed ETTs.
51 citations
TL;DR: PVB using dexmedetomidine 1 µg/kg added to 0.5 % bupivacaine in patients undergoing major breast cancer surgery under GA provides analgesia of longer duration with decreased postoperative opioid consumption and lower incidence of nausea/vomiting compared to PVB with bupvacaine alone or no PVB.
Abstract: This study evaluated the analgesic efficacy of dexmedetomidine in combination with bupivacaine for single-shot paravertebral block (PVB) in patients undergoing major breast cancer surgery. This prospective, randomized double blind study was conducted in 45 ASA I/II/III females, aged ≥18 years, undergoing modified radical mastectomy or breast conservation surgery with axillary lymph node dissection. Patients in group PB (paravertebral–bupivacaine) received PVB with 0.5 % bupivacaine 0.3 ml/kg with 1 ml normal saline; group PBD (paravertebral–bupivacaine–dexmedetomidine) received PVB with 0.5 % bupivacaine 0.3 ml/kg and dexmedetomidine 1 μg/kg in a volume of 1 ml; and group C (control) patients were given a sham block (a subcutaneous injection with 2 ml normal saline) before receiving general anesthesia (GA). All patients received analgesia by fentanyl intraoperatively and morphine patient-controlled analgesia postoperatively. The control group patients required more intraoperative fentanyl than the other two groups. Patients receiving dexmedetomidine had lower morphine consumption (p < 0.001), pain scores and incidence of postoperative nausea/vomiting (p = 0.011); longer time to first analgesic request; earlier time to mobilize; and better satisfaction scores. Heart rate and blood pressure values during the intraoperative period were also lower at many time points in this group. However, the incidence of hypotension and bradycardia were statistically similar in all groups. PVB using dexmedetomidine 1 µg/kg added to 0.5 % bupivacaine in patients undergoing major breast cancer surgery under GA provides analgesia of longer duration with decreased postoperative opioid consumption and lower incidence of nausea/vomiting compared to PVB with bupivacaine alone or no PVB.
49 citations
TL;DR: Obive sleep apnea, higher ASA-PS scores and greater doses of intraoperative opioids were associated with naloxone administration during Phase I recovery, and patients administered nAloxone had increased adverse events after discharge from the recovery room and may benefit from a higher level of postoperative care.
Abstract: Purpose
To identify characteristics associated with postoperative respiratory depression that required naloxone intervention during Phase I recovery following general anesthesia. A secondary aim is to compare postoperative outcomes between patients who received naloxone and those who did not.
45 citations
TL;DR: Sevoflurane preconditioning protects pulmonary glycocalyx and reduces expression of leukocyte chemokines in an in-vivo model of pulmonary IR.
Abstract: The glycocalyx is a glycoprotein-polysaccaride layer covering the endothelium luminal surface, and plays a key regulatory role in several endothelial functions. Lung ischemia reperfusion (IR) is a clinical entity that occurs in everyday thoracic surgery and causes glycocalix destruction and a florid local and systemic immune response. Moreover, sevoflurane is able to modulate the inflammatory response triggered by IR lung injury. In this study, we evaluated the protective effects of sevoflurane on the pulmonary endothelial glycocalyx in an in-vivo lung autotransplant model in pigs. Sixteen Large White pigs underwent pneumonectomy plus lung autotransplant. They were divided into two groups depending on the hypnotic agent received (propofol or anesthetic preconditioning with sevoflurane). Glycocalyx components (syndecan-1 and heparan sulphate), cathepsin B, chemokines (MCP-1, MIP-1, and MIP-2) and adhesion molecules (VCAM and ICAM-1) were measured at four different timepoints using porcine-specific enzyme-linked immunosorbent assay (ELISA) kits. There were no differences between groups in weight or in surgical and one-lung ventilation time. Greater glycocalyx destruction and higher chemokine and adhesion molecule expression were observed in the group that did not receive sevoflurane. Heparan sulphate and serum syndecan levels were higher in the propofol group (P < 0.0001) after reperfusion, as was cathepsin B activity (P < 0.015). MCP-1, MIP-1, MIP-2, VCAM, and ICAM-1 levels were also higher in the propofol group (P < 0.006). Sevoflurane preconditioning protects pulmonary glycocalyx and reduces expression of leukocyte chemokines in an in-vivo model of pulmonary IR.
44 citations
TL;DR: The present study suggests that TKA patients who receive ACB can achieve similar or even better recovery of quadriceps strength and mobilization ability than those treated with FNB.
Abstract: Although several studies have compared the clinical efficacy of an adductor canal block (ACB) to that of a femoral nerve block (FNB) for analgesia after total knee arthroplasty (TKA), disputes mainly exist in the recovery of quadriceps strength and mobilization ability between the two methods. The aim of the present study was to compare, in a systematic review and meta-analysis, the clinical efficacy of ACB with that of FNB. We systematically searched randomized controlled trials comparing FNB with ACB for analgesia after TKA in Pubmed and the Cochrane Library from inception to April 30th 2015. There was no limitation of publication language. Trial quality was assessed using the modified Jadad scale, and eligible data were pooled for meta-analysis. Five studies of 348 patients were included. Outcomes showed that patients who received ACB had similar or better recovery of quadriceps strength and mobilization ability than those that underwent FNB. Similar efficacy was found between the two strategies regarding adductor strength, pain scores [at rest (p = 0.86), at or after knee flexion (p = 0.31)], opioid consumption (p = 0.99), opioid-associated adverse effects (p = 0.60), length of hospital stay (p = 0.42), patient satisfaction (p = 0.57), and success rate of blockade (p = 0.20). The present study suggests that TKA patients who receive ACB can achieve similar or even better recovery of quadriceps strength and mobilization ability than those treated with FNB. Taken as a whole, ACB may be a better analgesia strategy after TKA at present.
41 citations
TL;DR: The operating room logistics and postoperative complications between pre-ERABS and ERABS periods in an academic hospital were compared and the length of stay in hospital was significantly shortened.
Abstract: While the demand for bariatric surgery is increasing, hospital capacity remains limited. The ERABS (Enhanced Recovery After Bariatric Surgery) protocol has been implemented in a number of bariatric centers. We retrospectively compared the operating room logistics and postoperative complications between pre-ERABS and ERABS periods in an academic hospital. The primary endpoint was the length of stay in hospital. The secondary endpoints were turnover times—the time required for preparing the operating room for the next case, induction time (from induction of anesthesia until a patient is ready for surgery), surgical time (duration of surgery), procedure time (duration of stay in the operating room), and the incidence of re-admissions, re-operations and complications during admission and within 30 days after surgery. Of a total of 374 patients, 228 and 146 received surgery following the pre-ERABS and ERABS protocols, respectively. The length of hospital stay was significantly shortened from 3.7 (95 % confidence interval [CI] 3.1–4.7) days to 2.1 (95 % CI 1.6–2.6) days (P < 0.001). Procedure (surgical) times were shortened by 15 (7) min and 12 (5) min for gastric bypass and gastric sleeve surgery, respectively (P < 0.001 for both), by introducing the ERABS protocol. Induction times were reduced from 15.2 (95 % CI 14.3–16.1) min to 12.5 (95 % CI 11.7–13.3) min (P < 0.001).Turnover times were shortened significantly from 38 (95 % CI 44–32) min to 11 (95 % CI 8–14) min. The incidence of re-operations, re-admissions and complications did not change.
TL;DR: The performance of MEP monitoring was good for detecting postoperative paraplegia in TAA/TAAA open repair surgery and the cut-off point of all-or-none may be the best, according to a systematic review.
Abstract: Motor evoked potential (MEP) monitoring has been used to prevent neurological complications such as paraplegia in patients who underwent thoracic or thoracoabdominal aortic aneurysm (TAA/TAAA) surgery. The object of this study was making a systematic review to survey the performance of MEP monitoring during TAA/TAAA open repair surgery. We searched electronic databases for relevant studies. We summarized the diagnostic data with summary sensitivity, summary specificity and forest plots of pooled sensitivity, and conducted sub-group analysis. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We also surveyed the reporting rate of clinical key factors such as methods of anesthesia, surgery, and success rate of MEP. Nineteen studies met our criteria. The results of meta-analysis showed 89.1 % summary sensitivity (95 % confidence interval 47.9–98.6 %) and 99.3 % summary specificity (95 % confidence interval 96.1–99.9 %). Sub-group analysis of pooled sensitivity and specificity by all-or-none cut-off point were better than other cut-off points. The results of the QUADAS-2 were not good. The performance of MEP monitoring was good for detecting postoperative paraplegia in TAA/TAAA open repair surgery. The cut-off point of all-or-none may be the best, according to our review.
TL;DR: During the postoperative period patients differed in terms of pain intensity profiles and that these differences were associated with outcomes for up to 6 weeks following surgery, but pain trajectories were not predictive of persistent postoperative pain status at 6 months.
Abstract: Purpose
The aim of this study was to explore acute movement-evoked postoperative pain intensity trajectories over the first 5 days after total hip arthroplasty (THA) and to examine how these pain trajectories are associated with pain-related outcomes 6 weeks and 6 months later.
TL;DR: A simple and secure technique for blocking multiple anterior branches of intercostal nerves, named the parasternal inter costal nerve block (PSI block), is proposed and injected between the pectoral major muscle and the external intercostAL muscle is performed.
Abstract: We propose a simple and secure technique for blocking multiple anterior branches of intercostal nerves, named the parasternal intercostal nerve block (PSI block). To perform a PSI block, we inject a local anesthetic between the pectoral major muscle and the external intercostal muscle (Supplementary Figure). Because anterior branches of the intercostal nerve penetrate through these two muscles to innervate the internal mammary area, injection of a local anesthetic to this plane could block anterior branches of intercostal nerves.
TL;DR: Administration of dexmedetomidine before ischemia can provide a protection against lung IRI by re-installing the PI3K/Akt/HIF-1α signaling pathway.
Abstract: To evaluate the role of the phosphatidylinositol 3 kinase (PI3K)/protein kinase B (Akt)/hypoxia-inducible factor 1α (HIF-1α) signaling pathway in the protection by dexmedetomidine against lung ischemia–reperfusion injury (IRI) in rats. Forty-eight male Sprague–Dawley rats weighing 250–350 g were randomly divided into six groups (n = 8 each group): sham group, IRI group, low-dose dexmedetomidine group (LD group), high-dose dexmedetomidine group (HD group), combined low-dose dexmedetomidine and LY294002 group (LDL group), and combined high-dose dexmedetomidine and LY294002 group (HDL group). A 30-min ischemia was induced by occluding the hilum of the left lung, followed by a 120-min reperfusion by removing occlusion of the hilum. After the left lung was removed, the wet/dry weight ratio (W/D) of the lung tissues was determined. Pathological changes of lung tissues were evaluated by light and electron microscopes and the expression of p-Akt and HIF-1α in the lung tissues was determined by western blotting. Compared with the sham group, both the W/D ratio and lung injury were significantly increased, the p-Akt expression was down-regulated and HIF-1α expression was up-regulated in the five experimental groups. Compared with the LD and LDL groups, both the W/D ratio and lung injury were decreased, but the expression of p-Akt and HIF-1α was increased in the HD and HDL groups. Administration of dexmedetomidine before ischemia can provide a protection against lung IRI by re-installing the PI3K/Akt/HIF-1α signaling pathway.
TL;DR: The rate of persistent wound pain is higher when only general anesthesia was used during cesarean section than with regional anesthesia, and thus it is necessary to provide a sufficient postoperative analgesia using multimodal analgesia, including intravenous patient-controlled analgesia (IV-PCA), transversus abdominis plane (TAP) block, non-steroidal inflammatory drugs, and acetaminophen.
Abstract: In this review, we describe the current consensus surrounding general anesthetic management for cesarean section. For induction of anesthesia, rapid-sequence induction using thiopental and suxamethonium has been the recommended standard for a long time. In recent years, induction of anesthesia using propofol, rocuronium, and remifentanil have been gaining popularity. To prevent aspiration pneumonia, a prolonged preoperative fasting and an application of cricoid pressure during induction of anesthesia have been recommended, but these practices may require revision. Guidelines for difficult airway management were developed first in obstetric anesthesia, and the use of a supraglottic airway is now recognized as an effective rescue device. After the delivery of a fetus, switching from volatile anesthetics to intravenous anesthetics has been recommended to avoid uterine atony. At the same time, intraoperative awareness should be avoided. The rate of persistent wound pain is higher when only general anesthesia was used during cesarean section than with regional anesthesia, and thus it is necessary to provide a sufficient postoperative analgesia using multimodal analgesia, including intravenous patient-controlled analgesia (IV-PCA), transversus abdominis plane (TAP) block, non-steroidal inflammatory drugs, and acetaminophen.
TL;DR: The results suggest that the protective effect of curcumin on LPS-induced acute lung injury is associated with AMPK activation.
Abstract: Curcumin, a biphenolic compound extracted from turmeric (Curcuma longa), possesses potent anti-inflammatory activity The present study investigated whether curcumin could increase 5′ adenosine monophosphate-activated protein kinase (AMPK) activity in macrophages and modulate the severity of lipopolysaccharide (LPS)-induced acute lung injury Macrophages were treated with curcumin and then exposed (or not) to LPS Acute lung injury was induced by intratracheal administration of LPS in BALB/c mice Curcumin increased phosphorylation of AMPK and acetyl-CoA carboxylase (ACC), a downstream target of AMPK, in a time- and concentration-dependent manner Curcumin did not increase phosphorylation of liver kinase B1, a primary kinase upstream of AMPK STO-609, an inhibitor of calcium2+/calmodulin-dependent protein kinase kinase, diminished curcumin-induced AMPK phosphorylation, but transforming growth factor-beta-activated kinase 1 inhibitor did not Curcumin also diminished the LPS-induced increase in phosphorylation of inhibitory κB-alpha and the production of tumor necrosis factor alpha (TNF-α), macrophage inflammatory protein (MIP)-2, and interleukin (IL)-6 by macrophages Systemic administration of curcumin significantly decreased the production of TNF-α, MIP-2, and IL-6 as well as neutrophil accumulation in bronchoalveolar lavage fluid, and also decreased pulmonary myeloperoxidase levels and the wet/dry weight ratio in mice subjected to LPS treatment These results suggest that the protective effect of curcumin on LPS-induced acute lung injury is associated with AMPK activation
TL;DR: Intraoperative application of ketamine was associated with improved scores for depressed mood and increased serum BDNF levels in patients undergoing elective orthopedic surgery.
Abstract: A depressed mood frequently occurs in perioperative patients, negatively impacting patient recovery. Recent studies suggested that ketamine has a rapid, obvious, and persistent antidepressant effect. The purpose of this study was to investigate the impact of intraoperative application of ketamine on postoperative depressive mood in patients undergoing elective orthopedic surgery. This was a randomized, double-blind, controlled study. A total of 120 patients (ASA grade I–II) undergoing elective orthopedic surgery were divided randomly into a ketamine group (group K) and a control group (group C). In the K group, 0.5 mg/kg (0.05 ml/kg) ketamine was given at induction of anesthesia, followed by 0.25 mg/kg/h (0.025 ml/kg/h) continuous infusion for 30 min. In the C group, 0.05 ml/kg 0.9 % saline was used at induction of anesthesia, followed by 0.025 ml/kg/h continuous infusion of saline for 30 min. PHQ-9 score was recorded preoperatively (1 day before surgery) and postoperatively (on day 1 and day 5 following surgery). Blood at these time points was drawn for serum brain-derived neurotrophic factor (BDNF) level analysis. Intraoperative blood loss, surgery time, postoperative visual analog scale pain scores and perioperative complications were also recorded. There were no differences in age, sex, surgery time, blood loss, and preoperative PHQ-9 scores between the two groups (P > 0.05). There were no differences in PHQ-9 scores preoperatively and postoperatively for the C group (P > 0.05); however, the PHQ-9 postoperative scores were lower than the preoperative PHQ-9 scores in the K group (P 0.05). Compared with the preoperative BDNF levels of K group, postoperative BDNF levels in K group increased significantly (P < 0.01). An inverse correlation between PHQ-9 score and serum BDNF level was shown. Intraoperative application of ketamine was associated with improved scores for depressed mood and increased serum BDNF levels in patients undergoing elective orthopedic surgery.
TL;DR: To perform simulation-based airway management training effectively, not only are task trainers and high-fidelity simulators required but also instructors with rich experience inAirway management simulation training and optimal curriculum design are essential.
Abstract: Within the airway management field, simulation has been used as a tool of training for over 40 years. Simulation training offers a chance of active involvement for the trainees. It can effectively enhance and upgrade the knowledge and skills of the trainees in airway management, and subsequently decrease medical errors and improve patients' outcomes and safety through a variety of airway management training modalities, such as common airway skills, difficult airway management strategies, and crisis management skills. To perform simulation-based airway management training effectively, not only are task trainers and high-fidelity simulators required but also instructors with rich experience in airway management simulation training and optimal curriculum design are essential.
TL;DR: The purpose of this preliminary study is to establish the feasibility of applying eye-tracking technology as a measurement tool for comparing procedural expertise in UGRA and suggest a potential application of eye- tracking technology in the assessment of UG RA learning and performance.
Abstract: Ultrasound-guided regional anesthesia (UGRA) requires an advanced procedural skill set that incorporates both sonographic knowledge of relevant anatomy as well as technical proficiency in needle manipulation in order to achieve a successful outcome. Understanding how to differentiate a novice from an expert in UGRA using a quantifiable tool may be useful for comparing educational interventions that could improve the rate at which one develops expertise. Exploring the gaze pattern of individuals performing a task has been used to evaluate expertise in many different disciplines, including medicine. However, the use of eye-tracking technology has not been previously applied to UGRA. The purpose of this preliminary study is to establish the feasibility of applying such technology as a measurement tool for comparing procedural expertise in UGRA. eye-tracking data were collected from one expert and one novice utilizing Tobii Glasses 2 while performing a simulated ultrasound-guided thoracic paravertebral block in a gel phantom model. Area of interest fixations were recorded and heat maps of gaze fixations were created. Results suggest a potential application of eye-tracking technology in the assessment of UGRA learning and performance.
TL;DR: Urinary L-FABP appears to be a sensitive biomarker of AKI in patients undergoing abdominal aortic repair in patients with poor renal function, and ROC analysis showed urinary L- FABP to be more sensitive than SCr for early detection ofAKI.
Abstract: Purpose
Acute kidney injury (AKI) is common after cardiovascular surgery and is usually diagnosed on the basis of the serum creatinine (SCr) level and urinary output. However, SCr is of low sensitivity in patients with poor renal function. Because urinary liver-type fatty-acid-binding protein (L-FABP) reflects renal tubular injury, we evaluated whether perioperative changes in urinary L-FABP predict AKI in the context of abdominal aortic repair.
TL;DR: In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.
Abstract: Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors. Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade. Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24–48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02). In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.
TL;DR: It is thought that TRPV4 may be an important drug target based on its broad expression patterns and important physiological functions, and research progress that has been made toward the understanding of TRpV4 physiology is discussed.
Abstract: This review provides a summary of the physiological significance of the TRPV4 ion channel. Although TRPV4 was initially characterized as an osmosensor, we found that TRPV4 can also act as a thermosensor or a mechanosensor in brain neurons or epithelial cells in the urinary bladder. Here, we summarize the newly characterized functions of TRPV4, including the research progress that has been made toward our understanding of TRPV4 physiology, and discuss other recent data pertaining to TRPV4. It is thought that TRPV4 may be an important drug target based on its broad expression patterns and important physiological functions. Possible associations between diseases and TRPV4 are also discussed.
TL;DR: Maternal rCBV and rCBO decrease significantly during spinal anesthesia for cesarean section and may be associated with the severity of hypotension induced by subarachnoid sympathetic block with bupivacaine.
Abstract: During spinal anesthesia for cesarean section, cerebral oxygenation decreases may be related to an abrupt drop in cerebral blood flow due to hypotension. We measured the changes in maternal regional cerebral blood volume (rCBV) and oxygenation (rCBO) using near-infrared spectroscopy (NIRS) to evaluate whether a decrease in arterial blood pressure during spinal anesthesia diminishes rCBV and rCBO. Forty patients scheduled for elective cesarean section under spinal anesthesia were monitored for mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), and concentrations of oxy-hemoglobin (Hb), deoxy-Hb, total-Hb, and tissue oxygenation index (TOI), before spinal anesthesia (baseline) and for 20 min after intrathecal injection of bupivacaine. We investigated changes in the values from baseline and evaluated whether the maximum changes in total-Hb (Δ-total-Hb) and TOI (Δ-TOI) correlate with changes in MAP at the same time point. The mean oxy-Hb, total-Hb, TOI, and MAP significantly decreased from baseline after intrathecal injection of bupivacaine (P < 0.01). There were significant positive correlations between both Δ-total-Hb and Δ-TOI and the decrease in MAP (Δ-total-Hb: r = 0.53, P < 0.01; Δ-TOI: r = 0.59, P < 0.01). Maternal rCBV and rCBO decrease significantly during spinal anesthesia for cesarean section. Reductions in rCBV and rCBO may be associated with the severity of hypotension induced by subarachnoid sympathetic block with bupivacaine.
TL;DR: Sevoflurane maintains higher SjO2 levels than propofol during RALP and SctO2 does not accurately reflect SJO2, and a weak relationship between Sj O2 and SCTO2 is shown.
Abstract: Purpose
Steep Trendelenburg position and pneumoperitoneum during robotic-assisted laparoscopic prostatectomy (RALP) increase intracranial pressure (ICP) and may alter cerebral blood flow (CBF) and oxygenation. Volatile anesthetics and propofol have different effects on ICP, CBF, and cerebral metabolic rate and may have different impact on cerebral oxygenation during RALP. In this study, we measured jugular venous bulb oxygenation (SjO2) and regional oxygen saturation (SctO2) in patients undergoing RALP to evaluate cerebral oxygenation and compared the effects of sevoflurane and propofol. We also verified whether SctO2 may be an alternative to SjO2.
TL;DR: The time period involving both explantation and storage for ischaemia reperfusion injury and storage is an important therapeutic window for improving outcomes and other windows explored include treatment of IRI and improvement in immunosuppressive therapy.
Abstract: Renal transplantation remains an important therapy in treating renal failure and can be considered to be a curative treatment. The demand for renal grafts outstrips supply available each year, making it increasingly important to look at improving the treatment of both renal grafts and recipients, and thereby improving patient outcomes and increasing the pool of potential donor grafts. Important to this, however, is knowledge of the underlying mechanisms leading to damage to the graft and rejection from the recipient. This includes ischaemia and consequently the priming of the organ during storage for ischaemia reperfusion injury (IRI) on implantation and the importance of the innate immune system which can be activated via multiple pathways, often via TLR-4, and the consequent production of danger-associated molecular patterns. This makes the time period involving both explantation and storage an important therapeutic window for improving outcomes. Other windows explored include treatment of IRI and improvement in immunosuppressive therapy. The multiple windows of potential therapeutic input have spawned a large body of work exploring both the underlying mechanisms and also how to exploit these mechanisms to improve overall outcomes and to allow for more marginal organs to be used.
TL;DR: Three patients with severe respiratory dysfunction who underwent nonintubated VATS for pneumothorax using epidural anesthesia and DEX seem to be a promising strategy for nonint Tubed VATS in patients with respiratory dysfunction, as well as patients with normal respiratory function.
Abstract: Nonintubated video-assisted thoracoscopic surgery (VATS) has been reported to be safe and feasible for patients with various thoracic diseases, including those who have respiratory dysfunction. In nonintubated VATS, it is important to maintain spontaneous respiration and to obtain a satisfactory operating field through adequate collapse of the lung by surgical pneumothorax. Therefore, we need to minimize the patient's physical and psychological discomfort by using regional anesthesia and sedation. If analgesia and sedation are inadequate, conversion to intubated general anesthesia may be required. Dexmedetomidine (DEX) is a highly selective α2-adrenoceptor agonist that provides anxiolysis and cooperative sedation without respiratory depression. It seems to be a suitable sedative for nonintubated VATS, especially in high-risk patients for intubated general anesthesia, but there have been no report about its use combined with epidural anesthesia in nonintubated VATS for adult patients. Here, we report three patients with severe respiratory dysfunction who underwent nonintubated VATS for pneumothorax using epidural anesthesia and DEX. In all three patients, DEX infusion was started after placement of an epidural catheter and was titrated to achieve mild sedation, while maintaining communicability and cooperation. This seems to be a promising strategy for nonintubated VATS in patients with respiratory dysfunction, as well as patients with normal respiratory function.
TL;DR: The results suggest that the TNF-α or IL-1β/JNK pathway in the spinal dorsal horn may play a critical role in the development of painful peripheral neuropathy induced by BTZ.
Abstract: Bortezomib (BTZ), a widely used chemotherapeutic drug, is closely associated with the development of painful peripheral neuropathy, but the mechanism underlying the induction of this disorder by BTZ remains largely unclear. To examine this association, we have evaluated the activation of mitogen-activated protein kinase (MAPK) family members in the spinal dorsal horn and the role of tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1β) in BTZ-induced allodynia in rats. Male Sprague–Dawley rats were used as the model animals. The paw withdrawal test, in which mechanical stimuli (von Frey hairs) is applied to the plantar surface of the hindpaw, was used to determine any changes in the paw withdrawal threshold of the treated rats. A PE-10 catheter was placed intrathecally to deliver TNF-α neutralizing antibody, IL-1 receptor antagonist (IL-1ra) or the c-Jun N-terminal kinase (JNK) inhibitor SP600125. The mRNA levels of various cytokines were measured by real-time quantitative PCR. The expression of TNF-α, IL-1β and mitogen-activated protein kinase (MAPK) family members in the spinal dorsal horn was measured by western blot analysis and immunohistochemistry. All data were expressed as the mean ± standard error of the mean and analyzed using the SPSS version 13.0 software program. The BTZ treatment induced an upsurge in the mRNA and protein levels of TNF-α in the neurons and IL-1β in the astrocytes in the spinal dorsal horn. It also significantly upregulated the phosphorylation of JNK but not of extracellular signal-regulated kinases (ERK) and p38-MAPK in astrocytes of the spinal dorsal horn. Inhibition of TNF-α or IL-1β ameliorated JNK activation and mechanical allodynia induced by BTZ. Co-administration of thalidomide (TNF-α synthesis inhibitor) and IL-1ra prevented BTZ-induced mechanical allodynia. Our results suggest that the TNF-α or IL-1β/JNK pathway in the spinal dorsal horn may play a critical role in the development of painful peripheral neuropathy induced by BTZ.
TL;DR: Although fiberoptic bronchoscopy skills started to decay within 2 months, the re-training time was shorter and novices were successfully trained to proficiency skill level.
Abstract: Generally, novices are taught fiberoptic intubation on patients by attending anesthesiologists; however, this approach raises patient safety concerns. Patient safety should improve if novice learners are trained for basic skills on simulators. In this educational study, we assessed the time and number of attempts required to train novices in fiberoptic bronchoscopy and fiberoptic intubation on simulators. Because decay in skills is inevitable, we also assessed fiberoptic bronchoscopy and fiberoptic intubation skill decay and the amount of effort required to regain fiberoptic bronchoscopy skill. First, we established attempt- and duration-based quantitative norms for reaching skill proficiency for fiberoptic bronchoscopy and fiberoptic intubation by experienced anesthesiologists (n = 8) and prepared an 11-step checklist and a 5-point global rating scale for assessment. Novice learners (n = 15) were trained to reach the established skill proficiency in a Virtual Reality simulator for fiberoptic bronchoscopy skills and a Human Airway Anatomy Simulator for fiberoptic intubation skills. Two months later, novices were reassessed to determine decay in learned skills and the required time to retrain them to fiberoptic bronchoscopy proficiency level. Proficiency in fiberoptic bronchoscopy skill level was achieved with 11 ± 5 attempts and after 658 ± 351 s. After 2 months without practice, the time taken by the novices to successful fiberoptic bronchoscopy on the Virtual Reality simulator increased from 41 ± 8 to 68 ± 31 s (P = 0.0138). Time and attempts required to retrain them were 424 ± 230 s and 9.1 ± 4.6 attempts, respectively. Novices were successfully trained to proficiency skill level. Although fiberoptic bronchoscopy skills started to decay within 2 months, the re-training time was shorter.
TL;DR: Remifentanil IVPCA warrants one-to-one nursing monitoring, appropriate education of healthcare providers, continuous maternal oxygen saturation monitoring, end-tidal CO2 monitoring, and availability of both maternal and neonatal resuscitation equipment.
Abstract: Japan has seen significant developments in obstetric anesthesia in recent years, including the establishment of the Japanese Society of Obstetric Anesthesia and Perinatology. However, labor pain, which is one of the most important issues in obstetric practice, is still not treated aggressively. The rate of epidural administration for labor analgesia is very low in Japan as compared to other developed countries. Remifentanil has been used for labor analgesia, as part of general anesthesia for cesarean delivery, as well as for various fetal procedures around the world. Intravenous patient-controlled analgesia (IVPCA) with remifentanil is considered to be a reasonable option for labor pain relief. Several studies have demonstrated its efficacy with minimal maternal and neonatal adverse effects. On the other hand, reports of cases of maternal cardiac and respiratory arrest with remifentanil IVPCA within the past couple of years have redirected our attention to its safe use. Remifentanil IVPCA warrants one-to-one nursing monitoring, appropriate education of healthcare providers, continuous maternal oxygen saturation monitoring, end-tidal CO2 monitoring, and availability of both maternal and neonatal resuscitation equipment. This article provides an overview of knowledge and principles of using remifentanil IVPCA for labor analgesia and introduces its potential usage in Japan.