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ObjectiveGeneral anaesthesia with tracheal intubation results in sore throat. We evaluated the influence of the two-handed jaw thrust on postoperative sore throat in patients who require tracheal intubation.MethodsIn this prospective, double-blind, single-centre, parallel-arm, and randomised trial, 92 patients who were scheduled for general anaesthesia for total hip arthroplasty were allocated to one of two groups. In the jaw thrust group (n = 46), the two-handed jaw thrust manoeuvre was applied at intubation. In the control group (n = 46), conventional intubation with sham jaw thrust was performed. Incidences of airway morbidities including sore throat, hoarseness, and cough at 2, 4, and 24 hours postoperatively were compared.ResultsDuring the postoperative 24 hours, the incidence of sore throat (8 [17%] vs. 20 [44%]) and hoarseness were lower in the jaw thrust group (8 [17%] vs. 18 [39%]) compared with the control group. The incidence of cough during the postoperative 24 hours was similar between the groups.ConclusionsThe jaw thrust manoeuvre significantly reduced sore throat and hoarseness in patients after general anaesthesia using tracheal intubation. Clinical trial registration: NCT 03568279.

Supplemental material, sj-pdf-1-imr-10.1177_0300060520961237 for Influence of two-handed jaw thrust during tracheal intubation on postoperative sore throat: a prospective randomised study by Hyub Huh, Doo Yeon Go, Jang Eun Cho, Jihoon Park, Jiwon Lee and Hyun-Chang Kim in Journal of International Medical Research

Background Phase lag entropy (PLE) is a novel anesthetic depth indicator that uses four-channel electroencephalography (EEG) to measure the temporal pattern diversity in the phase relationship of frequency signals in the brain. The purpose of the study was to evaluate the anesthetic depth monitoring using PLE and to evaluate the correlation between PLE and bispectral index (BIS) values during propofol anesthesia. Methods In thirty-five adult patients undergoing elective surgery, anesthesia was induced with propofol using target-controlled infusion (the Schneider model). We recorded the PLE value, raw EEG, BIS value, and hemodynamic data when the target effect-site concentration (Ce) of propofol reached 2, 3, 4, 5, and 6 μg/ml before intubation and 6, 5, 4, 3, 2 μg/ml after intubation and injection of muscle relaxant. We analyzed whether PLE and raw EEG data from the PLE monitor reflected the anesthetic depth as the Ce of propofol changed, and whether PLE values were comparable to BIS values. Results PLE values were inversely correlated to changes in propofol Ce (propofol Ce from 0 to 6.0 μg/ml, r2 = − 0.83; propofol Ce from 6.0 to 2.0 μg/ml, r2 = − 0.46). In the spectral analysis of EEG acquired from the PLE monitor, the persistence spectrogram revealed a wide distribution of power at loss of consciousness (LOC) and recovery of consciousness (ROC), with a narrow distribution during unconsciousness. The power spectrogram showed the typical pattern seen in propofol anesthesia with slow alpha frequency band oscillation. The PLE value demonstrated a strong correlation with the BIS value during the change in propofol Ce from 0 to 6.0 μg/ml (r2 = 0.84). PLE and BIS values were similar at LOC (62.3 vs. 61.8) (P > 0.05), but PLE values were smaller than BIS values at ROC (64.4 vs 75.7) (P Conclusions The PLE value is a useful anesthetic depth indicator, similar to the BIS value, during propofol anesthesia. Spectral analysis of EEG acquired from the PLE monitor demonstrated the typical patterns seen in propofol anesthesia. Trial registration This clinical trial was retrospectively registered at ClinicalTrials.gov at October 2017 (NCT03299621).

Artifacts in physiological signals acquired during intensive care have the potential to be recognized as critical pathological events and lead to misdiagnosis or mismanagement. Manual artifact removal necessitates significant labor-time intensity and is subject to inter- and intra-observer variability. Various methods have been proposed to automate the task; however, the methods are yet to be validated, possibly due to the diversity of artifact types. Deep belief networks (DBNs) have been shown to be capable of learning generative and discriminative feature extraction models, hence suitable for classifying signals with multiple features. This study proposed a DBN-based model for artifact elimination in pulse waveform signals, which incorporates pulse segmentation, pressure normalization and decision models using DBN, and applied the model to artifact removal in monitoring arterial blood pressure (ABP). When compared with a widely used ABP artifact removal algorithm (signal abnormality index; SAI), the DBN model exhibited significantly higher classification performance (net prediction of optimal DBN = 95.9%, SAI = 84.7%). In particular, DBN exhibited greater sensitivity than SAI for identifying various types of artifacts (motion = 93.6%, biological = 95.4%, cuff inflation = 89.1%, transducer flushing = 97%). The proposed model could significantly enhance the quality of signal analysis, hence may be beneficial for use in continuous patient monitoring in clinical practice.

Objective The efficacy of chlorhexidine- and silver sulfadiazine-coated central venous catheters (CSS-CVC) against catheter-related infection remains controversial. We hypothesized that the loss of silver nanoparticles may reduce the antibacterial efficacy of CSS-CVCs and that this loss could be due to the frictional force between the surface of the CVC and the bloodstream. The objective of this study was to investigate whether the antimicrobial effect of CSS-CVCs decreases with increasing exposure time in a bloodstream model and quantitatively assay the antimicrobial effect of CSS-CVCs compared with polyurethane and antiseptic-impregnated CVCs. Methods Each CVC was subjected to 120 hours of saline flow and analyzed at intervals over 24 hours. The analyses included energy-dispersive X-ray spectroscopy, scanning electron microscopy, and optical density after a Staphylococcus aureus incubation test. Results The weight percentage of silver in the CSS-CVCs significantly decreased to 56.18% (44.10% ± 3.32%) with 48-hour catheterization and to 18.88% (14.82% ± 1.33%) with 120-hour catheterization compared with the initial weight percentage (78.50% ± 6.32%). In the S. aureus incubation test, the antibacterial function of CSS-CVCs was lost after 48 hours [3 (N/D) of OD]. Similar results were observed in a pilot clinical study using 18 CSS-CVCs. Conclusions We found that the efficacy of CSS-CVCs decreased over time and that the antibacterial function was lost after 48 hours of simulated wear-out. Therefore, antibiotic-impregnated CVCs may be a better option when longer (>48 hours) indwelling is needed.

Purpose: Many studies have demonstrated the advantage of maintaining intraoperative deep neuromuscular block (NMB) with sugammadex. This trial is designed to evaluate the impact of muscle relaxation during laparoscopic subtotal gastrectomy on the oncological benefits, particularly in obese patients with gastric cancer. Materials and methods: This is a double-blind, randomized controlled multicenter prospective trial. Patients with clinical stage I–II gastric cancer with a body mass index of 25 and over, who undergo laparoscopic subtotal gastrectomy will be eligible for trial inclusion. The patients will be randomized into a deep NMB group or a moderate NMB group with a 1:1 ratio. A total of 196 patients (98 per group) are required. The primary endpoint is the number of harvested lymph nodes, which is a critical index of the quality of surgery in gastric cancer treatment. The secondary endpoints are surgeon's surgical condition score, patient's sedation score, and surgical outcomes including peak inspiratory pressure, operation time, postoperative pain, and morbidity. Discussion: This is the first study that compares deep NMB with moderate NMB during laparoscopic gastrectomy in obese patients with gastric cancer. We hope to show the oncologic benefits of deep NMB compared with moderate NMB during subtotal gastrectomy. Trial registration number: ClinicalTrials.gov (NCT03196791), date of registration: October 10, 2017.

BACKGROUND Chlorhexidine and silver sulfadiazine coated central venous catheters (CSS-CVC) may cause loss of antimicrobial efficacy due to friction between the CVC surface and sheer stress caused by the blood flow. Therefore, the aim of this study was to investigate the antibacterial efficacy of CSS-CVC at various flow rates using a bloodstream model. METHODS Each CVC was subjected to various flow rates (0.5, 1, 2, and 4 L/min) and wear-out times (0, 24, 48, 72, 96, and 120 hours), and the optical density (OD) 600 after a Staphylococcus aureus incubation test was used to determine the antibacterial effect of CSS-CVC. RESULTS In the 0.5 L/min group, there was no significant change in the OD600 value up to 120 hours compared with the baseline OD600 value for CSS-CVC (P > .467). However, the OD600 values of CSS-CVC in the 1 L/min (P

Various methods of assessing the depth of anesthesia (DoA) and reducing intraoperative awareness during general anesthesia have been extensively studied in anesthesiology. However, most of the DoA monitors do not include brain activity signal modeling. Here, we propose a new algorithm termed the cortical activity index (CAI) based on the brain activity signals. In this study, we enrolled 32 patients who underwent laparoscopic cholecystectomy. Raw electroencephalography (EEG) signals were acquired at a sampling rate of 128 Hz using BIS-VISTATM with standard bispectral index (BIS) sensors. All data were stored on a computer for further analysis. The similarities and difference among spectral entropy, the BIS, and CAI were analyzed. Pearson correlation coefficient between the BIS and CAI was 0.825. The result of fitting the semiparametric regression models is the method CAI estimate (−0.00995; P = .0341). It is the estimated difference in the mean of the dependent variable between method BIS and CAI. The CAI algorithm, a simple and intuitive algorithm based on brain activity signal modeling, suggests an intrinsic relationship between the DoA and the EEG waveform. We suggest that the CAI algorithm might be used to quantify the DoA.

Background: External applied pneumatic pressure is usually used for rapid transfusion of red blood cells (RBCs). However, increased shear stress can cause increased hemolysis and decreased RBC elongation indices. Therefore, the purpose of this study was to measure the degree of hemolysis and the alteration of RBC elongation indices under varying external pressure in fresh and aged blood. Methods: Venous blood samples were obtained from 20 healthy human volunteers. Each blood bag was divided into 2 subgroups (5 or 35 days of storage), and 5 levels of pressure were applied: 0, 150, 200, 250, and 300 mmHg. After infusion, a laboratory study was conducted. The percentages of irreversibly changed cells were evaluated using Bessis classification. RBC elongation indices were measured using a microfluidic ektacytometer. Results: There were no significant differences in the percentage of irreversibly changed RBCs between the pressures of 0 and 300 mmHg. Moreover, there were no significant differences in laboratory test results or elongation indices among all levels of pressure. Irreversibly changed RBCs and hemolysis were increased depending on the storage period. Conclusion: Irreversible changes in RBCs did not occur as a result of external pressure. The hemolysis and elongation indices of fresh RBCs were not influenced by external pneumatic pressure up to 300 mmHg. Only the storage period affected the irreversible changes in RBCs and hemolysis. Therefore, the application of external pressure to RBCs in variously aged blood is likely to be a safe procedure.

Organ transplant in humans is an established therapy for a variety of end-stage organ diseases. However, due to organ shortages and lack of donors, the need for xenotransplant has gradually increased. Xenotransplantation has great potential to solve many of the problems facing organ transplantation. Pigs are being developed as xenogeneic organ donors for use in humans. In this study, we propose a novel and simple method for tracheal intubation in a swine model using neuromuscular blocking agents and laryngeal mask airway.Eight Yorkshire pigs were used for the 2 separate experiments, which were conducted 1 week apart. In the first experiment, an anesthesiologist with no previous comparable experience performed endotracheal intubation of pigs. One week later, using the same pig, a second experiment was performed by an experienced anesthesiologist. Anesthesia was induced with intramuscular injection of a mixture of 1 mg/kg xylazine (Rompun, Bayer Korea Ltd., Seoul, Korea) and 7 mg/kg Zoletil (a mixture of tiletamine hydrochloride and zolazepam hydro-chloride, Virbac Laboratory, Carros, France). The laryngeal mask was then placed, and 0.15 mg/kg vecuronium bromide was injected intravenously. Tracheal intubation was attempted after mask removal. The duration and number of intubation attempts were recorded, and the degree of intubation difficulty was scored.In all cases, the laryngeal mask was easily inserted, and endotracheal intubation was successfully completed. Oxygen saturation did not fall below 95%, and there were no hypoxemia episodes. Degree of intubation difficulty and duration were not significantly different between the 2 anesthesiologists.Tracheal intubation in our swine model was successfully performed using neuromuscular blocking agents and laryngeal masks without resulting in hypoxemia, with even anesthesiologists who are unfamiliar with endotracheal intubation of pigs easily able to do so using our protocol. Therefore, our protocol will enable all investigators to perform successful tracheal intubation in swine models.

Background Anesthesia machines have been developed by the application of new technology for rapid and easier control of anesthetic concentration. In this study, we used a test lung to investigate whether the time taken to reach the target sevoflurane concentration varies with the rate of fresh gas flow (FGF) and type of anesthesia machine (AM). Methods We measured the times taken to reach the target sevoflurane concentration (2 minimum alveolar concentration = 4%) at variable rates of FGF (0.5, 1, or 3 L/min) and different types of AM (Primus®, Perseus®, and Zeus® [Zeus®-F; Zeus® fresh gas mode, Zeus®-A; Zeus® auto-mode]). Concomitant ventilation was supplied using 100% O2. The AMs were connected to a test lung. A sevoflurane vaporizer setting of 6% was used in Primus®, Perseus®, and Zeus®-F; a target end-tidal setting of 4% was used in Zeus®-A (from a vaporizer setting of 0%). The time taken to reach the target concentration was measured in every group. Results When the same AM was used (Primus®, Perseus®, or Zeus®-F), the times to target concentration shortened as the FGF rate increased (P

Objective To investigate the renoprotective effect of nicardipine in patients with pre-existing renal insufficiency undergoing robot-assisted laparoscopic radical prostatectomy (RALRP). Methods Men with preoperative renal insufficiency (estimated glomerular filtration rate [eGFR] 2) were enrolled and randomized to receive either 0.5 µg/kg per min nicardipine continuous infusion (nicardipine group) or normal saline (control group) during RALRP. Renal function was determined by eGFR and serum creatinine concentration. Results Serum creatinine levels on postoperative days (POD) 1 and 3 were significantly lower than baseline values in the nicardipine group ( n = 50). In the control group ( n = 50), eGFR was significantly higher on POD 3 than baseline, and was significantly higher than baseline on POD 1 and 3 in the nicardipine group. The change in eGFR from baseline to POD 1 was significantly higher in the nicardipine group than the control group. Conclusion Continuous infusion of nicardipine during RALRP improved postoperative renal function on POD 1 in patients with pre-existing renal insufficiency.

Malignant hyperthermia (MH) may lead to metabolic crisis of skeletal muscle in susceptible individuals following exposure to triggering agents such as volatile anesthetics or depolarizing muscle relaxants. MH is a rare and a potentially lethal disease, which can lead to cardiac arrest. We report a case of severe MH, in which the rapidly evolving signs of hypermetabolism eventually resulted in cardiac arrest. Despite conventional treatments following cardiopulmonary resuscitation, the patient's vital signs did not improve. Therefore, we applied extracorporeal membrane oxygenation for providing hemodynamic support.

Background. The lumen of novel threadlike structures (NTSs) is enclosed by a single layer of endothelial cells surrounded by extracellular matrix (ECM). We hypothesized that collagen may be a component of the ECM associated with lymphatic NTSs.Methods. Six female New Zealand white rabbits were anesthetized, and the NTS structures within lymphatic vessels were identified by contrast-enhanced stereomicroscopy or alcian blue staining. Isolated NTS specimens were stained with acridine orange, YOYO-1, and 1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine perchlorate (DiI). The structural and molecular composition of the ECM was investigated using transmission electron microscopy (TEM), electrospray ionization-mass spectrometry, and proteomic analysis.Results. The lymph vessel wall was stained red by DiI, and rod-shaped nuclei were stained green by YOYO-1. The area surrounding the NTS was also stained red and contained green rod-shaped nuclei. TEM images showed that the NTS consisted of many ECM fibers and the ECM fibers appeared to be ~100 nm in diameter and had narrowly spaced striated bands. Proteomic analysis of the lymphatic NTS-associated ECM identified 4 proteins: keratin 10, cytokeratin 3, cytokeratin 12, and soluble adenylyl cyclase.Conclusion. The TEM study suggested that the lymphatic NTS-associated ECM did not contain collagen. This was confirmed by proteomic analysis, which showed that keratin was the major component of the ECM.