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Title: Association of multilevel thoracic retrolaminar paravertebral blocks for MIDCAB surgery through left anterior small thoracotomy (LAST) with decreased opioid consumption: 2 case reports.Background and aims: Recently, Society for Enhanced Recovery After Cardiac Surgery (ERACS) has been developed with a mission to u201ca multimodal, opioid-sparing, pain management plan is recommended postoperatively.u201d We hypothesized that patients receiving multilevel thoracic retrolaminar paravertebral blocks (TRB) would have decreased peri- and postoperative opioid consumption.Methods: Two consecutive patients with normal EF undergoing MIDCAB surgery through LAST without CPB were evaluated. Ipsilateral (left) TRB was performed upon general anesthesia induction completion with 20 ml levobupivacaine (0.25%) for each lamina of the T4 and T5 vertebrae. Postoperative pain was controlled with standardized acetaminophen and/or pentazocine boluses after surgery. Pain was graduated using the numerical rating scale (NRS). The NRS score ranges from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable.Results: Two patients received injection fentanyl 0.15 mg for induction. Intraoperative remifentanil was infused continuously at a rate of 4 ml/hr (2mg/20ml) and no increased remifentanil infusions were used between skin incision and closure during surgery. In both patients, peak of the NRS score was 8 on postoperative day (POD) 2. A first required rescue analgesics at 24 hours (h) post-TRB were intravenous (IV) acetaminophen (1000 mg) in both patients. Additional required analgesics at 30 and 36h post-TRB were IV pentazocine (15 mg) in Case1 and at 47h post-TRB was IV acetaminophen (1000 mg) in Case2. From POD3 onwards both patients had less pain (NRS < 2) and required no pain medication.Conclusions: In both patients, preoperative multilevel TRB was associated with decreased peri- and postoperative opioid consumption.

Retrospective analysis of comparison between intraoperative infusion of Dexmedetomidine and Propofol for postoperative delirium in elderly cardiac surgery on cardiopulmonary bypassSTUDY OBJECTIVE:To determine whether using dexmedetomidine intraoperatively is associated with fewer postoperative delirium (POD) in elderly cardiac surgery on cardiopulmonary bypass (CPB).DESIGN:Retrospective study.SETTING:Urban academic hospital.MEASUREMENTS:Thirty-four eligible elderly patients (> 70-years-old) who underwent elective cardiac surgery on CPB between December 2014 and October 2015 were randomly divided prospectively into two group. Patients received either intraoperative infusion of dexmedetomidine (DEX group; 0.4-0.6u03bcg/kg/hr, n=17) or propofol (PRO group; 3-5 mg/kg/hr, n=17) and carotid ultrasound scanning were performed preoperatively in both group. Intraoperative cerebral oxygenation was assessed by the tissue oxygenation index (TOI) using near-infrared spectroscopy (NIRS). The absolute value of the difference (mean value of right TOI during CPB minus mean value of left TOI during CPB) (R-L mD) were calculated in both group. Delirium was assessed with the Confusion Assessment Method (CAM) for ICU.RESULTS:Patients suffered from a carotid stenosis (CS) in 8 (47.1%) and 3 (17.6%) cases in DEX and PRO groups, respectively. There was no difference in the incidence of POD between the DEX group (8 of 17 patients, 47.06%) and the PRO groups (5 of 17 patients, 29.41%) (P>0.05). However, in the POD group, patients with CS were present in 4 of 8 (50%) and 0 of 3 (0%) patients in DEX and PRO groups, respectively. It seems that this disadvantage of carotid stenosis is directly related to POD in the DEX group. In contrast, increased u201cR-L mDu201d values were significantly associated with POD (P=0.024). In particular, it was found to be significantly increased the u201cR-L mDu201d values in the PRO group. CONCLUSION: This study suggests that intraoperative infusion of DEX is not associated with significantly lower rates of POD in elderly cardiac surgery on CPB. Instead, using DEX intraoperatively correlated significantly with POD in elderly patients who suffered from a CS. References: Djaiani G1, Silverton N, Fedorko L, Carroll J, Styra R, Rao V, Katznelson R. Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology. 2015 Nov 16. Park JB, Bang SH, Chee HK, Kim JS, Lee SA, Shin JK. Efficacy and safety of dexmedetomidine for postoperative delirium in adult cardiac surgery on cardiopulmonary bypass. Korean J Thorac Cardiovasc Surg. 2014 Jun;47(3):249-54.

Title:Association of interhemispheric oxygenation difference during cardiopulmonary bypass with postoperative delirium incidence in elderly cardiac surgery.OBJECTIVE:We investigated whether cerebral interhemispheric difference in prefrontal tissue oxygenation (IHSD) during cardiopulmonary bypass (CPB) are associated with the postoperative delirium (POD) incidence in elderly cardiac surgery.Materials and Methods:In total, 34 elderly patients (70-years-old or more, 20 males/14 females) who underwent elective cardiac surgery with CPB (including underwent either deep hypothermic cardiac arrest (HCA) and/or selective cerebral perfusion (SCP)) were enrolled in this retrospective study. The bilateral cerebral tissue oxygenation index (cTOI) were measured simultaneously by near-infrared spectroscopy (NIRS, NIRO-200; Hamamatsu Photonics KK; Japan). The absolute value of an IHSDcpb [(the average of right cTOI during CPB) - (the average of left cTOI during CPB)] was calculated in each patient. Delirium was assessed with the Confusion Assessment Method (CAM) for ICU. The differences between groups (patients with POD and patients without POD) were checked by Fisheru2019s exact test for categorical variables or by Mann-Whitneyu2019s U test for continuous variables. A difference was considered significant if the P value was less than 0.05.Results and Discussion:POD was present in 13 of 34 (38.2%) patients. The average of IHSDcpb in all eligible elderly patients was 4.5%. The patients with an IHSDcpb 4.5% or more was present in 9 of 13 (69.2%) patients with POD. Compared with patients with an IHSDcpb < 4.5%, patients with an IHSDcpb of 4.5% or more was found to be higher prevalence of POD. Patients with POD were significantly lower BMI (P=0.0365), IHSDcpb 4.5% or more (P=0.0337) and higher IHSDcpb (P=0.0244) when compared with patients without POD.Conclusion:An IHSDcpb of 4.5% or more and lower BMI were significantly correlated with the POD incidence in elderly cardiac surgery with CPB. Detection of an IHSD during CPB may provide one of the useful methods of detecting elderly patients at increased risk of POD.