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BACKGROUND The quick Sequential Organ Failure Assessment (qSOFA) is intended for the assessment of the prognosis and risk of sepsis. It may also help predict the mortality risk of nonseptic patients. OBJECTIVE This study investigated the relationship between pre-operative qSOFA scores and 30-day mortality after major surgery. It also evaluated the predictive value of qSOFA scores combined with the American Society of Anesthesiologists (ASA) physical status and Charlson comorbidity index (CCI). DESIGN A retrospective observational study. SETTING Single tertiary academic hospital. PATIENTS Medical records of patients who underwent major surgery (estimated blood loss >500 ml; surgery time >2 h) between January 2010 and December 2017 were examined. MAIN OUTCOME MEASURES The qSOFA score was measured within 24 h before surgery, and its association with 30-day mortality was analysed using multivariable logistic regression. A receiver-operating characteristic curve analysis was used to investigate the predictive power of the pre-operative qSOFA scores combined with the ASA physical status and with CCI. RESULTS A total of 6336 patients were included in the final analysis, and 91 (1.4%) died within 30 days. The multivariable logistic regression analysis including all covariates indicated that 30-day mortality was 2.43-times higher for the score 1 group than for the score 0 group (P = 0.002), and it was 3.54-times higher for the score at least 2 group than for the score 0 group (P

In terms of antinociceptive action, the main mode of action of magnesium involves its antagonist action at the N-methyl-d-aspartate (NMDA) receptor, which prevents central sensitization and attenuates preexisting pain hypersensitivity. Given the pivotal function of NMDA receptors in pain transduction, magnesium has been investigated in a variety of pain conditions. The oral and parenteral administration of magnesium via the intravenous, intrathecal, or epidural route may alleviate pain and perioperative anesthetic and analgesic requirements. These beneficial effects of magnesium therapy have also been reported in patients with neuropathic pain, such as malignancy-related neurologic symptoms, diabetic neuropathy, postherpetic neuralgia, and chemotherapy-induced peripheral neuropathy. In addition, magnesium treatment is reportedly able to alleviate fibromyalgia, dysmenorrhea, headaches, and acute migraine attacks. Although magnesium plays an evolving role in pain management, better understanding of the mechanism underlying its antinociceptive action and additional clinical studies is required to clarify its role as an adjuvant analgesic.

Background The effort to improve tracheal intubation process is clinically valuable. We hypothesized that a preoperative brief exercise therapy would increase mouth opening and neck extension, enhancing intubation conditions during general anesthesia. Methods Patients undergoing general anesthesia were randomized into two groups. The exercise group performed the exercise regimen including masseter muscle massage and stretching of jaw and neck joints before anesthetic induction, while the control did not. Before (baseline) and after the intervention, we evaluated Mallampati score, mouth aperture size, and sternomental distance. After tracheal intubation, intubation difficulty scale with direct laryngoscope and oropharyngeal soft tissue injury were also evaluated. Results A total of 138 patients completed the analysis (control = 68, exercise = 70). Baseline characteristics did not differ between groups. At anesthetic induction, there was a significant difference in Mallampati score between the two groups (P = 0.039) and the incidence of Mallampati scores of 1 was higher in the exercise group (odds ratio [95% CI]: 2.1 [1.0–4.3], P = 0.043). Mouth opening after the intervention was greater in the exercise group than in the control group (estimated difference [95% CI]: − 2.4 [− 4.8 – -0.1], P = 0.042) and sternomental distance was similar between the two groups (estimated difference [95% CI]: − 3.7 [− 9.0–1.7, P = 0.175). The exercise group showed less soft tissue injuries (odds ratio [95% CI]: 0.2 [0.1–0.8], P = 0.009), however, intubation difficulty scale did not differ between the study groups (P = 0.112). Conclusions The brief pre-anesthetic exercise improved intubation conditions and enabled faster tracheal intubation with less injury to oropharyngeal soft tissue. Trial registration Clinical Research Information Service (registration number: KCT0002618), registered at December 28, 2017.

Rapid response systems (RRSs) have been introduced into hospitals to help reduce the incidence of sudden cardiopulmonary arrest (CPA). This study evaluated whether an RRS reduces the incidence of in-hospital postoperative CPA. This retrospective before-and-after analysis evaluated data collected from electronic medical records during a pre-intervention (January 2008 to September 2012) and post-intervention (implementation of an RRS) interval (October 2012 to December 2016) at a single tertiary care institution. The primary outcome was a change in the rate of CPA in surgical patients recovering in a general ward. A Poisson regression analysis adjusted for the Charlson Comorbidity Index (CCI) was used to compare CPA rates during these two intervals. Of the 207,054 surgical procedures performed during the study period, mean (95% confidence interval [CI]) CPA events per 10,000 cases of 7.46 (5.72 to 9.19) and 5.19 (3.85 to 6.52) were recorded before and after RRS intervention, respectively (relative risk [RR], 0.73; 97.5% CI, 0.48 to 1.13; P = 0.103). Cardiopulmonary arrest incidence was reduced during RRS operational hours of 07:00–22:00 Monday-Friday and 07:00–12:00 Saturday (RR, 0.56; 97.5% CI, 0.31 to 1.02; P = 0.027) but was unchanged when the RRS was not operational (RR, 0.86; 97.5% CI, 0.52 to 1.40; P = 0.534). The CCI-adjusted RR of CPA after RRS implementation was lower than before RRS intervention (0.63; 97.5% CI, 0.41 to 0.98; P = 0.018) but this reduction was still only apparent during RRS operational hours (RR, 0.48; 97.5% CI, 0.27 to 0.89; P = 0.008 vs RR, 0.85; 97.5% CI, 0.45 to 1.58; P = 0.55). Implementation of an RRS reduced the incidence of postoperative CPA in patients recovering in a general ward. Furthermore, this reduction was observed only during RRS operational hours.

OBJECTIVES Patients with pancreatic cancer generally experience increasing pain as their disease progresses, making the titration of opioids difficult. This study aimed to determine a correlation between prescribed opioid doses and survival time in patients with unresectable pancreatic cancer. METHODS This retrospective observational cohort study in a tertiary care institution reviewed the medical records of patients diagnosed with unresectable pancreatic cancer and treated over a 10-year period. RESULTS We screened 1152 patients with unresectable pancreatic cancer, and 566 were eligible for inclusion in this study. There was a statistically significant negative correlation between initial opioid dose and survival time from initial opioid dose (correlation coefficient, -0.184; P < 0.01) and survival time from initial pancreatic cancer diagnosis (correlation coefficient, -0.177; P < 0.01). In addition, there were 0.8% and 0.6% increases in initial opioid dosage (morphine equivalent daily dose) and rate of increasing opioid dose (morphine equivalent daily dose per month), respectively, associated with the risk of early death (≤180 days, P < 0.05). CONCLUSIONS Correlations between patient survival, initial opioid dose, final opioid dose, and the rate of increase of opioid dosage could provide useful information for clinicians treating unresectable pancreatic cancer patients.

Serum albumin and conventional BMI (cBMI) are commonly used indices of malnutrition status. Because cBMI does not reflect fluid accumulation, modified body mass index (mBMI, serum albumin × cBMI) is a more accurate measure of malnutrition status. This study investigated the association between preoperative mBMI and postoperative 1-year mortality, in comparison with serum albumin and cBMI. Medical records of 80,969 adult patients who underwent surgical procedures in a tertiary care hospital between 1 January, 2011 and 31 December, 2015 were retrospectively reviewed. Postoperative 1-year mortality increased with reduction in cBMI, mBMI, and albumin separately (P P P > 0.05). Adjusted area under the curve (AUC) was highest (0.885) in the overall model (cBMI + albumin + cBMI * albumin); adjusted AUC between mBMI and albumin did not differ significantly (P = 0.558). Low albumin is the strongest independent predictor of postoperative 1-year mortality among the three variables (albumin, cBMI, mBMI). Adding cBMI to albumin does not increase the validity of the AUC of albumin.

Controversy exists as to whether the physician turnover affects patient outcome in academic hospitals. In-hospital cardiopulmonary resuscitation (CPR) is an important indicator of in-hospital mortality. This study aimed to investigate whether the physician turnover is associated with the in-hospital CPR rate. This retrospective cohort study was conducted at a single center; all in-hospital CPR cases among in-patients from 1 January 2007 to 31 December 2016 were analyzed. The turnover period was defined as the changeover of the trainee workforce in March, May, and November. The primary outcome was any variation in the monthly in-hospital CPR events (per 1000 admissions). The secondary outcomes were return of spontaneous circulation (ROSC), CPR in intensive care unit (ICU), monthly in-hospital deaths per 1000 admissions, and average length of hospital stay. A total of 2182 in-hospital CPR cases were included in the analysis. Monthly in-hospital CPR rates were greater during the turnover period when compared to the non-turnover period (4.66 ± 1.02 vs. 4.18 ± 1.56, P = 0.027). There was no significant difference in ROSC rate, CPR in ICU rate, monthly in-hospital deaths per 1000 admissions, or average length of hospital stay between the two periods. Our findings indicate that physician turnover may be associated with in-hospital CPR rate. However, physician turnover was not associated with ROSC rate, rate of CPR in the ICU, in-hospital death, or length of hospital stay.

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.

Reduced lung volumes are unavoidable after lung resection surgery. Magnesium sulphate (MgSO4) administration has been reported to reduce the requirement for neuromuscular blocking drugs and postoperative analgesics in surgical patients.To investigate the effect of MgSO4 on pulmonary function after video-assisted thoracoscopic surgery (VATS).A randomised, double-blind, placebo-controlled trial.A university tertiary care centre.Sixty-six patients scheduled for pulmonary lobectomy or segmentectomy via VATS.Patients were allocated to one of two groups: the Mg (MgSO4 50 mg kg intravenously for 10 min, followed by a continuous infusion of 15 mg kg h during surgery) or the control (same volume of 0.9% saline).Pulmonary function tests [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and peak expiratory flow rate] were measured before surgery and at three time points after surgery (2, 24 and 48 h postoperatively) using a portable spirometer. Twelve months after surgery, pulmonary function test values were repeated at a regular outpatient follow-up visit.FEV1 at 24 (1.7 ± 0.6 vs. 1.3 ± 0.5 l, P = 0.033) and 48 h (1.7 ± 0.6 vs. 1.4 ± 0.5 l, P = 0.021) and FVC at 24 (2.0 ± 0.8 vs. 1.6 ± 0.6 l, P = 0.038) and 48 h (2.2 ± 0.8 vs. 1.7 ± 0.7 l, P = 0.008) after surgery were significantly greater in the Mg group. Patients in the Mg group required less rocuronium than those in the control group (64.2 ± 19.9 vs. 74.9 ± 20.3 mg, respectively; P = 0.041). Consumption of postoperative patient-controlled analgesia was also significantly less at 24 and 48 h after surgery in the Mg group (P = 0.022 and 0.015, respectively), although pain scores and rescue analgesics were comparable. Five patients in the control group were diagnosed with postoperative pneumonia using clinical and radiological criteria before discharge. FEV1 and FVC at 12 months after surgery were not different between the two groups.Intraoperative administration of MgSO4 improved pulmonary function and reduced the need for rocuronium and postoperative analgesics in patients who underwent VATS.cris.nih.go.kr identifier: KCT0001410.

This randomized trial investigated whether a 2-dose administration of intravenous ramosetron (5-hydroxytryptamine type 3 receptor antagonist) is more effective than a single-dose administration in preventing postoperative nausea and vomiting (PONV) in 89 patients who were scheduled to undergo laparoscopic operation for benign gynecologic diseases and to receive intravenous patient-controlled analgesia for relief of postoperative pain. After assignment at a ratio of 1:1, intravenous ramosetron (0.3 mg) was initially administered at the end of skin closure in all patients. Thereafter, ramosetron (0.3 mg) and placebo were administered to the study and control groups, respectively, at 4 hours after the operation. The baseline and operative characteristics were similar between the groups. The incidence of PONV during the 24-hour period after operation which was assessed as the primary endpoint did not differ between the groups. No serious adverse events occurred in either group. A 2-dose administration of intravenous ramosetron may not be superior to a single-dose administration in preventing PONV in patients undergoing laparoscopic operation for benign gynecologic diseases.

Background Cholesterol plays an important role in the action of opioid analgesics, but its association with postoperative pain has not been clarified. Our study examined the association of pre- and postoperative total serum cholesterol (TSC), and change between the pre- and postoperative TSC levels with postoperative pain outcomes in patients with non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy. Methods We retrospectively reviewed medical records of patients with NSCLC who underwent VATS lobectomy at the Seoul National University Bundang Hospital in South Korea. We sought to determine the association between preoperative TSC, TSC on postoperative day (POD) 0–1, and pre- and postoperative changes in TSC by comparing numeric rating scale (NRS) scores on POD 0, 1, and 2 and total morphine equivalent consumption on POD 0–2. Multivariate linear regression analyses were used, and P < 0.05 was considered statistically significant. Results A total of 1,720 patients with NSCLC who underwent VATS lobectomy were included in the analysis. The change in TSC, preoperative TSC, and postoperative TSC showed no associations with morphine equivalent consumption on POD 0–2 (P > 0.05). In addition, the changes in TSC, preoperative TSC, and postoperative TSC were not associated with postoperative NRS pain score on POD 0, 1, and 2 (P > 0.05). Conclusions Our results indicated that no significant association was observed between pre- and postoperative TSC level and postoperative pain outcome after VATS lobectomy of the lung.

OBJECTIVE We assessed and compared two landmarks (conventional vs. high approach) used in internal jugular vein (IJV) cannulation with respect to the degree of overlap with the carotid artery (CA) and the cross-sectional area (CSA) of the IJV using ultrasonography. PATIENTS AND METHODS Forty-eight adult patients were included. Using ultrasonography, the percentage overlaps with the CA and the CSA of both IJVs were measured in the supine and Trendelenburg positions using conventional and high approaches. With the conventional approach, the IJV is penetrated at the apex of Sedillot's triangle, formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid muscle. The high approach involves the midpoint between the sternal notch and the mastoid process. RESULTS The degree of overlap with the CA was 30.5 (7.5-69.4)% [median (interquartile range)] and 0.0 (0.0-25.4)% with the conventional and high approaches, respectively, for the right IJV (P

This retrospective study evaluated the association between maximum clot firmness of FIBTEM (MCFFIB) and blood loss, and determined a cutoff value of MCFFIB that may predict massive bleeding in total hip replacement arthroplasty (THRA). Seventy-two adult patients undergoing THRA for avascular necrosis of the femoral head or degenerative arthritis of the hip were included. Patients' medical records were reviewed to collect pre and postoperative laboratory data, as well as the amount of intra and postoperative blood loss (IBL and PBL). Each pre and postoperative fibrinogen level had a significant correlation with the pre and postoperative MCFFIB, respectively (ρ = 0.289, P = 0.014 and ρ = 0.286, P = 0.015). IBL had significant correlations with pre and postoperative MCFFIB (ρ = -0.305, P = 0.010 and ρ = -0.297, P = 0.013, respectively), and PBL also showed significant correlations with the pre and postoperative MCFFIB (ρ = -0.471, P < 0.001 and ρ = -0.475, P < 0.001, respectively). A respective pre or postoperative MCFFI cutoff value of 16 mm or less or 10 mm or less showed the highest sensitivity and specificity for predicting IBL 1000 ml or above or PBL 400 ml or above. Postoperative transfusion was performed more frequently in patients showing postoperative MCFFIB 10 mm or less (31 vs. 3.3%, P = 0.005). MCFFIB correlated well with the amount of IBL or PBL. In addition, a particular value of pre or postoperative MCFFIB could offer the predictive standard for massive bleeding in THRA.

Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission. This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012–2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24 h), 0–1 (48 h), and 0–2 (72 h)] and was categorized as positive (≥ 5%), mild to moderate positive (5–10%), severe positive (> 10%), normal (0–5%), or negative (

To assess the association between physician turnover, mortality, and length of hospital stay after non-cardiac surgery in South Korea. This retrospective cohort study is based on analysis of the medical records of patients who underwent non-cardiac surgery between January, 2010 and December, 2016. The primary outcomes were the differences in 30-day, 90-day, and overall mortality between non-cardiac surgery performed during the turnover period and that performed during the non-turnover period. The subjects of the analysis were 106,832 patients who underwent non-cardiac surgery. Among them, 17,788 patients underwent surgery during the turnover period and 89,044 underwent surgery during the non-turnover period. Multivariable Cox regression analysis revealed no significant differences in postoperative 30-day mortality (P = 0.427), 90-day mortality (P = 0.854), or overall mortality (P = 0.928) between surgery conducted during the turnover period and that conducted during the non-turnover period. Surgery performed during the physician turnover period was associated with a 0.21-day increase compared with surgery performed during the non-turnover period (coefficient: 0.21, 95% confidence interval: 0.00–0.42, P = 0.038). Physician turnover was not associated with postoperative 30-day, 90-day, or overall mortality after non-cardiac surgery. However, the length of hospital stay was slightly longer for patients who underwent non-cardiac surgery in the turnover period.

Background In addition to propofol, dexmedetomidine is a suitable alternative for intraoperative sedation in procedures requiring regional anesthesia. To date, however, little is known about the influences of each drug on upper airway patency. Accordingly, the authors investigated differences between dexmedetomidine and propofol sedation in the occurrence of upper airway obstruction and requirements for airway intervention in patients with mild obstructive sleep apnea. Methods Patients with an apnea/hypopnea index of 5–14/h according to Watch-PAT 200 analysis were enrolled in this study. Spinal anesthesia was routinely performed for surgery. Intraoperative sedation was initiated using either dexmedetomidine or propofol infusion at a level of modified observer’s assessment of alertness/sedation scale 3. The primary outcome was the proportion of patients exhibiting signs of upper airway obstruction. A sign of upper airway obstruction was defined as no detection of end-tidal carbon dioxide for at least 10 s despite respiratory efforts. Results A total of 50 patients were included in the final analysis (dexmedetomidine [n = 26]; propofol [n = 24]). During the intraoperative sedation period, there was a significantly lower proportion of patients exhibiting signs of upper airway obstruction in the dexmedetomidine group than in the propofol group (11.5% vs. 41.7%, P = 0.035). An artificial airway was inserted in 1 patients (3.8%) and 5 patient (20.8%) in the dexmedetomidine and propofol groups, respectively (P = 0.093). Conclusion Dexmedetomidine sedation was associated with a lower incidence of upper airway obstruction than propofol sedation in patients with mild obstructive sleep apnea. Trial registration number Clinical trials.gov (NCT02993718): Retrospectively registered.

Background The relationship between statin use and incidence of postoperative delirium (POD) is controversial. We investigated the association between perioperative statin use and occurrence of delirium after total knee arthroplasty (TKA) under spinal anesthesia. Methods We retrospectively reviewed the electronic medical records of patients who underwent TKA under spinal anesthesia at single tertiary care hospital between January 2005 and October 2017. POD incidence was recorded for patients who received statins continuously from 1 month before surgery until discharge and for patients who did not receive any statins. Univariable and multivariable logistic regression analyses were conducted to investigate an association between occurrence of POD and perioperative statin use. Results In total, 6,020 procedures were included, and 992 (16.4%) were associated with perioperative statin use. POD was confirmed for 304 (5.0%) procedures. The statin group showed a 1.7% significant lower incidence ( P =0.017) of POD (35/992, 3.5%) than the no-statin group (1,420/5,028, 5.4%). In multivariable logistic regression analysis, the POD incidence in the statin group was 34% lower than that in the no statin group [odds ratio (OR), 0.66; 95% confidence interval (CI), 0.45–0.97; P = 0.036] Moreover, the POD incidence was decreased by 37% (OR, 0.63; 95% CI, 0.40–0.99; P = 0.047), and 79% (OR, 0.21; 95% CI, 0.05-0.88; P = 0.033) respectively, when atorvastatin and simvastatin were administered. Conclusions Continuous perioperative statin use may be associated with a significantly lower risk of delirium after TKA under spinal anesthesia; simvastatin was the most effective statin for POD prevention.

The current study aimed to measure the effects of Plasma-Lyte 148 solution on the blood coagulation profile according to the hemodilution level using rotational thromboelastometry (ROTEM) tests. Venous blood was collected from 12 healthy volunteers and divided into four specimen bottles, which were diluted at different levels with Plasma-Lyte 148 (0, 20, 40, and 60%). Following this, ROTEM tests were performed on the study samples. We found that as the hemodilution level increased, the ROTEM values showed a hypocoagulable pattern. The change rate of the maximum clot firmness (MCF) of INTEM was greater in the 40 (P = 0.015) and 60% (P

The short-term effects of magnesium sulfate infusion during surgery are well known. However, the long-term outcomes of intraoperative magnesium sulfate infusion remain unknown. Medical records of patients aged ≥20 years who underwent non-cardiac surgical procedures at Seoul National University Bundang Hospital between January, 2010 and October, 2016 were analyzed. After propensity score matching, 12,652 patients were included in the final analysis, 6326 each in the magnesium and non-magnesium groups. There were no significant differences in 30-day or 1-year mortality between subjects [30-day mortality, hazard ratio (HR): 1.31, 95% CI: 0.64–2.69, P = 0.465; 1-year mortality, HR: 1.20, 95%CI: 0.94–1.53, P = 0.136]. Intraoperative magnesium sulfate infusion was not significantly associated with postoperative 30-day or 1-year mortality.

This study was conducted to evaluate the effect of scalp blocks using levobupivacaine on recovery profiles including postoperative pain, patient-controlled analgesia (PCA) consumption, postoperative nausea and vomiting (PONV), and other adverse events in patients undergoing frontoparietal craniotomy for aneurysm clipping.Fifty-two patients scheduled for elective frontoparietal craniotomy for unruptured aneurysm clipping were enrolled. After surgery, scalp blocks were performed using normal saline (group C, n = 26) or 0.75% levobupivacaine (group L, n = 26). Postoperative pain scores and PCA consumption were recorded for 72 hours after recovery of consciousness. The time from patient recovery to the first use of PCA drug and rescue analgesics, the requirement for vasoactive agents, and adverse effects related to PCA and local anesthetics also were recorded.Postoperative pain scores and PCA consumption in group L were lower than in group C (P.05). The time intervals from patient recovery to the first use of PCA drug (P.001) and rescue analgesics (P = .038) was longer in group L than in group C. Additionally, less antihypertensive agent was required (P = .017), and PONV occurred less frequently (P = .039) in group L than in group C.Scalp blocks with 0.75% levobupivacaine improved recovery profiles in that it effectively lowered postoperative pain and PCA consumption without severe adverse events and also reduced the requirement for a postoperative antihypertensive agent and the incidence of PONV in patients who underwent frontoparietal craniotomy for aneurysm clipping.

To evaluate the effect of a part-time rapid response system on the occurrence rate of cardiopulmonary arrest by comparing the times of rapid response system operation versus nonoperation.Retrospective cohort study.A 1,360-bed tertiary care hospital.Adult patients admitted to the general ward were screened. Data were collected over 36 months from rapid response system implementation (October 2012 to September 2015) and more than 45 months before rapid response system implementation (January 2009 to September 2012).None.The rapid response system operates from 7 AM to 10 PM on weekdays and from 7 AM to 12 PM on Saturdays. Primary outcomes were the difference of cardiopulmonary arrest incidence between pre-rapid response system and post-rapid response system periods and whether the rapid response system operating time affects the cardiopulmonary arrest incidence. The overall cardiopulmonary arrest incidence (per 1,000 admissions) was 1.43. Although the number of admissions per month and case-mix index were increased (3,555.18 vs 4,564.72, p0.001; 1.09 vs 1.13, p = 0.001, respectively), the cardiopulmonary arrest incidence was significantly decreased after rapid response system (1.60 vs 1.23; p = 0.021), and mortality (%) was unchanged (1.38 vs 1.33; p = 0.322). After rapid response system implementation, the cardiopulmonary arrest incidence significantly decreased by 40% during rapid response system operating times (0.82 vs 0.49/1,000 admissions; p = 0.001) but remained similar during rapid response system nonoperating times (0.77 vs 0.73/1,000 admissions; p = 0.729).The implementation of a part-time rapid response system reduced the cardiopulmonary arrest incidence based on the reduction of cardiopulmonary arrest during rapid response system operating times. Further analysis of the cost effectiveness of part-time rapid response system is needed.

Progesterone is an important sex hormone for pregnancy and also has neuroprotective and anticonvulsant effects. It is well-known that full-term parturients become more susceptible to volatile anesthetics. Glutamate transporters are important for preventing neurotoxicity and anesthetic action in the central nervous system. We investigated the effects of progesterone on the activity of glutamate transporter type 3 (EAAT3), the major neuronal EAAT. EAAT3 was expressed in Xenopus laevis oocytes by injecting its mRNA. Oocytes were incubated with diluted progesterone for 72 h. Two-electrode voltage clamping was used to measure membrane currents before, during, and after applying 30 μM L-glutamate. Progesterone (1–100 nM) significantly increased EAAT3 activity in a dose-dependent manner. Our kinetic study showed that the V max was increased in the progesterone group compared with that in the control group (2.7±0.2 vs. 3.6±0.2 μC for control group vs. progesterone group; n =18–23; P K m was unaltered (46.7±10.2 μM vs. 55.9±10.5 μM for control group vs. progesterone group; n =18–23; P >0.05). P horbol-12-myristate-13-acetate, a protein kinase C (PKC) activator, did not change progesterone-enhanced EAAT3 activity. Inhibitors of PKC or phosphatidylinositol 3-kinase (PI3K) abolished the progesterone-induced increases in EAAT3 activity. Our results suggest that progesterone enhances EAAT3 activity and that PKC and PI3K are involved in mediating these effects. These effects of progesterone may contribute to its anticonvulsant and anesthesia-related properties.

Caffeine has been known to trigger seizures, however, the precise mechanism about the proconvulsive effect of caffeine remains unclear. Glutamate transporters play an important role to maintain the homeostasis of glutamate concentration in the brain tissue. Especially, dysfunction of excitatory amino acid transporter type 3 (EAAT3) can lead to seizures. We investigated the effects of caffeine on the activity of EAAT3 and the involvement of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K). Rat EAAT3 was expressed in Xenopus oocytes by injecting EAAT3 mRNA. l- Glutamate (30 μM)-induced inward currents were recorded via the two-electrode voltage clamp method. Caffeine decreased EAAT3 activity in a dose-dependent manner. Caffeine (30 μM for 3 min) significantly reduced V max , but did not alter K m value of EAAT3 for glutamate. When preincubated oocytes with phorbol-12-myristate-13-acetate (PMA, a PKC activator) were exposed to caffeine, PMA-induced increase in EAAT3 activity was abolished. Two PKC inhibitors (chelerythrine and staurosporine) significantly reduced basal EAAT3 activity. Whereas, there were no significant differences among the PKC inhibitors, caffeine, and PKC inhibitors + caffeine groups. In similarly fashion, wortmannin (a PI3K inhibitor) significantly decreased EAAT3 activity, however no statistical differences were observed among the wortmannin, caffeine, and wortmannin + caffeine groups. Our results demonstrate that caffeine attenuates EAAT3 activity and this reducing effect of caffeine seems to be mediated by PKC and PI3K.

Postoperative sore throat (POST) is a common complaint after general anesthesia, especially following thyroidectomy.We examined the effect of adjusting the endotracheal tube cuff pressure during thyroidectomy on the incidence of airway complications. Ninety patients scheduled for elective thyroidectomy were randomized into two groups: control (group A, n = 45) and experimental (group B, n = 45). All patients underwent total intravenous anesthesia with propofol and remifentanil. In group A, the cuff pressure was set to 25 cm H2O initially and then monitored continuously without adjustment during thyroidectomy. In group B, the cuff pressure was maintained at approximately 25 cm H2O throughout the operation. The incidences and the severity of POST, hoarseness, dysphagia, and cough were recorded at 2 and 24 h postoperatively.Cuff pressures in group A changed significantly over time (P 0.05) and were higher than those of group B during thyroidectomy (P 0.05). The incidences of POST were lower in group B than in group A at 2 and 24 h postoperatively (P 0.05), and there was a significant difference in the severity of POST at 2 h postoperatively between the two groups. There were no differences in the incidences of hoarseness, dysphagia, and cough between the two study groups (P 0.05). Adjusting the endotracheal cuff pressure during thyroidectomy decreased the incidence and degree of POST.Intraoperative monitoring and adjustment of the cuff pressure can reduce POST in patients undergoing thyroidectomy.

Laryngoscopy and tracheal intubation (LTI) after induction of general anesthesia often cause hypertension and tachycardia. Labetalol and nicardipine have been used to prevent and treat acute cardiovascular responses to LTI.The goal of this study was to compare the preventive and therapeutic effects of labetalol 0.4 mg/kg IV and nicardipine 20 μg/kg IV on hypertensive responses to LTI during induction of general anesthesia.Patients undergoing general anesthesia were randomly allocated to 4 groups. In part I (prevention), 80 patients were randomized to receive either 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) 4 minutes before LTI. In part II (treatment), patients were randomized to receive 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) after LTI if hypertension occurred. The number of additional study drug doses required by patients with hypertension (parts I and II) and time to return to normotension (part II) were recorded. Mean arterial pressure and heart rate were monitored, and rate-pressure product was calculated. Adverse events were also monitored.A total of 130 patients (72 patients in part I and 58 patients in part II) were included in the analysis. In parts I and II, the number of patients who required additional doses of the study drug because of persistent hypertension was lower in the nicardipine groups than in the labetalol groups (P0.05). Mean arterial pressure was lower and heart rate was significantly higher over time in the nicardipine groups compared with the labetalol groups (P0.05) in parts I and II. In part II, time to return to normotension was shorter in the nicardipine treatment group than in the labetalol treatment group (61 [21] vs 130 [46] seconds; P = 0.01). No statistical differences were observed in the incidence of adverse events except for tachycardia in part I (2 cases in the labetalol prevention group vs 18 cases in the nicardipine prevention group; P = 0.01).Patients who received nicardipine were less likely to require additional doses for either the prevention or treatment of hypertensive responses to LTI and responded to the study drug more rapidly than patients who received labetalol for the treatment of hypertensive responses to LTI. However, labetalol was associated with a lower incidence of tachycardia and less of an increase in rate-pressure product when used for the prevention of hypertension during LTI.

Background Patients undergoing general anesthesia for laparoscopic cholecystectomy have a high risk of postoperative nausea and vomiting (PONV) with incidences up to 75%. Ramosetron, a serotonin subtype 3 (5-HT 3 ) antagonist, has been shown to be effective as an antiemetic after chemotherapy and surgery. Consensus guidelines recommend a combination of antiemetic therapies in high-risk groups. Until now, no published data have been available on the use of combination oral plus intravenous ramosetron. Objective The goal of this prospective, randomized, double-blind study was to compare the efficacy and tolerability of intravenous, oral, and the combination of oral and intravenous ramosetron for PONV prophylaxis in patients undergoing laparoscopic cholecystectomy. Methods Patients scheduled for laparoscopic cholecystectomy were double-randomly allocated to 1 of 3 groups. Patients were randomly allocated to receive either 0.3 mg of intravenous ramosetron (group A), 0.1 mg of oral ramosetron (group B), or the combination of 0.1 mg of oral ramosetron and 0.3 mg of intravenous ramosetron (group C). All patients received standardized balanced anesthesia with desflurane and remifentanil. Postoperative nausea, retching, vomiting, pain, and adverse effects were assessed at 0 to 2, 2 to 24, and 24 to 48 hours after surgery. Results A total of 124 Korean patients (67 women, 57 men; age range, 25–65 years) were randomized to 1 of 3 study groups (42 in group A [mean age, 49.8 years], 41 in group B [mean age, 47.4 years], and 41 in group C [mean age, 48.9 years]). No statistical differences were observed among the 3 groups with regard to patient characteristics and information on surgery and anesthesia. During postoperative period 0 to 2 hours, complete response occurred in 31 (74%) patients in group A, 27 (66%) in group B, and 37 (90%) in group C. During the postoperative period of 2 to 24 hours, complete response was observed in 36 (86%), 33 (80%), and 40 (98%) patients in groups A, B, and C, respectively; there was a statistically significant difference in group C compared with group A or group B. During the postoperative period of 0 to 48 hours, incidences of rescue antiemetic use were 13 (31%), 14 (34%), and 3 (7%) in groups A, B and C, respectively. Common adverse effects (headache, dizziness, and drowsiness) were observed, but there was no significant difference in the incidences of adverse effects among the 3 groups ( P > 0.05). Conclusions The combination of 0.1-mg oral and 0.3-mg intravenous ramosetron was more effective than either 0.3-mg intravenous ramosetron or 0.1-mg oral ramosetron alone for the prophylaxis of nausea and vomiting after laparoscopic cholecystectomy during the first 24 hours after surgery. In addition, differences did not reach the level of statistical significance between 0.1 mg of oral ramosetron and 0.3 mg of intravenous ramosetron for the prevention of PONV in this patient population. Oral, intravenous, and combined oral and intravenous ramosetron appears well tolerated in the population studied. ClinicalTrials.gov identifier: NCT 01041183.

BACKGROUND AND OBJECTIVE Arterial hypoxaemia remains a problem during one-lung ventilation (OLV). We determined whether a preemptive alveolar recruitment strategy (ARS) before OLV improves arterial oxygenation during OLV in patients undergoing thoracic surgery. METHODS Forty-two patients were allocated randomly to receive either a tidal volume of 10 ml kg(-1) (group C) or ARS of 10 manual breaths with a peak inspiratory pressure of 40 cmH2O followed by positive end-expiratory pressure (PEEP) of 15 cmH2O until OLV commenced (group P). The dependent lung was ventilated with a tidal volume of 6 ml kg(-1) and PEEP of 5 cmH2O during OLV in both groups. Arterial blood gas data were recorded before ARS (baseline), after 15, 30, 45, 60 min of OLV, and at the end of OLV. RESULTS Baseline paO2 in group P was similar to that in group C (29.9 +/- 3.9 vs. 30.0 +/- 3.5 kPa). However, paO2 was significantly higher in group P than in group C during OLV (38.9 +/- 15.0 vs. 28.8 +/- 14.4 kPa after 15 min of OLV, 39.6 +/- 13.3 vs. 31.2 +/- 13.9 kPa after 60 min of OLV and 45.5 +/- 12.1 vs. 34.3 +/- 12.0 kPa before an air leakage test, P < 0.05). The alveolar-arterial oxygen gradient was significantly lower in group P than in group C after 15 min of OLV and at the end of OLV (46.1 +/- 14.4 vs. 55.9 +/- 14.7, 39.7 +/- 12.4 vs. 50.7 +/- 12.3 kPa, P < 0.05). CONCLUSION Preemptive ARS before OLV is effective in improving arterial oxygenation during the entire period of OLV.

Glucocorticoids can increase the extracellular concentrations of glutamate, the major excitatory neurotransmitter. We investigated the effects of corticosterone on the activity of a glutamate transporter, excitatory amino acid carrier 1 (EAAC1; also called excitatory amino acid transporter type 3 [EAAT3]), and the roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in regulating these effects. Rat EAAC1 was expressed in Xenopus oocytes by injecting mRNA. L-Glutamate (30 μM)-induced membrane currents were measured using the two-electrode voltage clamp technique. Exposure of these oocytes to corticosterone (0.01-1 μM) for 72 h decreased EAAC1 activity in a dose-dependent fashion, and this inhibition was incubation time-dependent. Corticosterone (0.01 μM for 72 h) significantly decreased the V(max), but not the K(m), of EAAC1 for glutamate. Furthermore, pretreatment of oocytes with staurosporine, a PKC inhibitor, significantly decreased EAAC1 activity (1.00±0.06 to 0.70±0.05 μC; P

To determine the effect-site target concentration (C(et)) of remifentanil that provides optimal conditions for patients and operators during cataract surgery during monitored anesthesia care using a target controlled infusion (TCI) of propofol and remifentanil.Prospective, randomized, double-blinded study.Operating room and postoperative recovery area of a university-affiliated hospital.66 adult, ASA physical status I, II, and III patients undergoing cataract surgery.Group I received C(et) of remifentanil 0.5 ng/mL; Group 2 received C(et) of remifentanil one ng/mL; and Group 3 received C(et) of remifentanil 1.5 ng/mL. After giving TCI propofol (C(et); one μg/mL)-remifentanil, an ophthalmologist administered topical anesthesia.Intraoperative hemodynamics, pain scores, sedation scores, patient satisfaction scores, and operators' satisfaction scores regarding surgical conditions were recorded. No statistical differences in heart rate or mean blood pressure were detected among the three groups during surgery. Pain scores (Group 1: 31.9 ± 17.9 vs. Group 2: 11.8 ± 7.7 and Group 3: 11.8 ± 7.7; P0.05) were higher and patient satisfaction scores (Group 1: 4.7 ± 0.8 vs. Group 2: 5.4 ± 0.4 and Group 3: 5.5 ± 0.4; P0.05) were lower in Group 1 than Groups 2 and 3. On the other hand, surgeon satisfaction was lowest in Group 3 (Group 3: 2.9 ± 1.3 vs. Group 1: 4.7 ± 0.4 and Group 2: 4.6 ± 0.7; P0.05) due to ocular movement.C(et) values of remifentanil and propofol of one ng/mL and one μg/mL, respectively, appear to provide optimal conditions for patients and operators during cataract surgery using monitored anesthesia care with TCI.

Statins are known for their anticancer effects, and many studies have shown the effectiveness of statins for cancer prevention and improvement of cancer-related long-term oncologic outcome. However, their effectiveness on recurrence or survival of non-small cell lung cancer (NSCLC) after curative resection remains unknown. This was a retrospective cohort study that assessed the medical records of patients who were diagnosed with NSCLC and treated with curative resection at a tertiary care hospital between August 2003 and July 2012. The primary outcome was the comparison of postoperative overall survival (OS) and recurrence-free survival (RFS) between the statin group of patients, who were administered statins at least 1 month before the surgery and continued it after the surgery, and the nonstatin group of patients, who were not administered statins. Propensity score (PS) matching was used to balance the 2 groups, and the analysis was performed using a Cox proportional hazards model. In total, 994 patients with NSCLC were included in the final analysis: 135 patients in the statin group and 859 patients in the nonstatin group. After PS matching, there was no significant difference in postoperative recurrence ( P = .862) or death ( P = .074) between the statin group and the nonstatin group. Similarly, there was no significant difference in postoperative RFS ( P = .862) and OS ( P = .072) between the 2 groups after PS matching. This study demonstrated that statin administration had no significant association with recurrence or survival after NSCLC treatment.

Propofol-based total intravenous anesthesia (TIVA) has been reported to improve long-term outcome following cancer surgery, when compared with inhalation agents. However, such investigational reports are still controversial, and no studies have been conducted in relation to non-small cell lung cancer (NSCLC) surgery. The present study aimed to compare the favorable effects of TIVA versus inhalation agents on recurrence-free survival and overall survival after curative resection of NSCLC. This retrospective cohort study examined medical records of the patients who were diagnosed with NSCLC and underwent curative resection at Seoul National University Bundang Hospital from August 2003 to July 2012. The primary outcome included the comparison of postoperative overall survival and recurrence-free survival in both groups. To balance the 2 groups for analysis, a propensity matching method was used, and stratified Cox proportional hazard models were used for statistical analysis. This study included 943 cases of NSCLC for final analysis, and the cases were divided into the TIVA group (n = 749) and inhalation group (n = 194). Propensity matching produced 196 patients in each group. The final analysis revealed no significant difference in the hazard ratio (HR) for recurrence between the TIVA and inhalation groups ( P = .233). The HR for death between the 2 groups was not significantly different either ( P = .551). In this study, we found no benefit of propofol-based TIVA for long-term oncologic outcome after NSCLC surgery, relative to inhalation agents.

BACKGROUND: The extracellular glutamate concentration is tightly controlled by excitatory amino acid transporters (EAATs). EAAT4 is the predominant EAAT in the cerebellar Purkinje cells. Purkinje cells play a critical role in motor coordination and may be an important target for ethanol to cause motor impairments. We designed this study to determine the effects of chronic ethanol exposure on the activity of EAAT4 and evaluate the involvement of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in these effects. METHODS: EAAT4 was expressed in Xenopus oocytes following injection of EAAT4 mRNA. Oocytes were incubated with ethanol-containing solution for 24 to 96 hours. Membrane currents induced by l-aspartate were recorded using 2-electrode voltage clamps. Responses were quantified by integration of the current trace and reported in microCoulombs (microC). RESULTS: Ethanol dose- and time-dependently reduced EAAT4 activity. EAAT4 activity after a 96-hour exposure was significantly decreased compared to the control values at all concentrations tested (10 to 100 mM). Ethanol (50 mM) significantly decreased the Vmax (2.2 +/- 0.2 microC for control vs. 1.6 +/- 0.2 microC for ethanol, n = 18, p < 0.05) of EAAT4 for L-aspartate. Preincubation of ethanol-treated (50 mM for 96 hours) oocytes with phorbol-12-myrisate-13-acetate (100 nM for 10 minutes) abolished the ethanol-induced decrease in EAAT4 activity. While staurosporine (2 microM for 1 hour) or chelerythrine (100 microM for 1 hour) significantly decreased EAAT4 activity, no difference was observed in EAAT4 activity among the staurosporine, ethanol, or ethanol plus staurosporine groups. Similarly, EAAT4 activity did not differ among the chelerythrine, ethanol, or ethanol plus chelerythrine groups. Pretreatment of the oocytes with wortmannin (1 microM for 1 hour) also significantly decreased EAAT4 activity. However, no difference was observed in the wortmannin, ethanol, or ethanol plus wortmannin groups. CONCLUSIONS: The results of this study suggest that chronic ethanol exposure decreases EAAT4 activity and that PKC and PI3K may be involved in these effects. These effects of ethanol on EAAT4 may cause an increase in peri-Purkinje cellular glutamate concentration, and may be involved in cerebellar dysfunction and motor impairment after chronic ethanol ingestion.

We evaluated changes in rotational thromboelastometry (ROTEM(®) ) parameters and clinical outcomes in patients undergoing total hip replacement arthroplasty, with concomitant infusions of tranexamic acid and of 6% hydroxyethyl starch 130/0.4. Fifty-five patients were randomly assigned to either the tranexamic acid (n = 29) or the control (n = 26) group. Hydroxyethyl starch was administered in the range of 10-15 ml.kg(-1) during the operation in both groups. In the control group, the clot formation time and maximum clot firmness of APTEM showed significant differences when compared with those of EXTEM at one hour postoperatively, suggestive of fibrinolysis. In the tranexamic acid group, there was no significant difference between each postoperative EXTEM and APTEM parameter. In the tranexamic acid and control group, postoperative blood loss was 308 ml (210-420 [106-745]) and 488 ml (375-620 [170-910], p = 0.002), respectively, and total blood loss was 1168 ml (922-1470 [663-2107]) and 1563 ml (1276-1708 [887-1494], p = 0.003). Haemoglobin concentration was higher in the tranexamic acid group on the second postoperative day (10.5 (9.4-12.1 [7.9-14.0]) vs. 9.6 (8.9-10.5[7.3-16.0]) g.dl(-1) , p = 0.027). In patients undergoing total hip replacement arthroplasty, postoperative fibrinolysis aggravated by hydroxyethyl starch was attenuated by co-administration of 10 mg.kg(-1) tranexamic acid, which may have led to less postoperative blood loss.

analgesia, and catheter migration were compared between groups. The incidence of audible air leak was 35.9 %. Rates of overall failure including unintentional dural puncture and intravenous catheter placement were significantly lower in group A than in group N (Supplementary Table 1). The presence of audible air leak was estimated to have a positive predictive value of 98.6 %, a negative predictive value of 2.7 %, a specificity of 76.2 % and a sensitivity of 38.4 % for successful labor analgesia after catheter placement (Supplementary Table 2). Our study has some limitations. The audibility of air leakage is subjective and depends on the hearing acuity of individual observers as well as the level of ambient noise. In addition, audible air leak may not be a confirmative method for identifying the epidural space. In summary, the occurrence of audible air leak during Tuohy needle placement seems to be associated with a lower incidence of both overall failure and intravenous catheter placement in labor epidural analgesia.

This study was designed to investigate whether stepwise tapering of remifentanil at the end of surgery could decrease postoperative pain scores and requirements of rescue analgesics after remifentanil-desflurane anesthesia in patients with thyroidectomy. Sixty two patients undergoing thyroidectomy under general anesthesia were randomly allocated into two groups. All patients were anesthetised with desflurane and high-dose remifentanil. Remifentnail was infused at the rate of 0.3 μg/kg/min until the end of surgery in patients of the control group (group A) whereas remifentanil was tapered gradually from 0.3 to 0.1 μg/kg/min until the end of surgery for at least 30 minutes in patients with group B. Pain scores (0–100 numerical rating scale, NRS), rescue analgesic requirements and adverse events were assessed at 30 min, 2 h, 6 h, 12 h, and 24 h after operation. There was a significant decrease in pain scores at 30 min (20 [0–80] vs. 50 [0–100], P = 0.002) and 2 h (30 [10–60] vs. 40 [20–80], P = 0.018) after surgery in group B compared with group A. In addition, rescue analgesics are less required in group B than in group A postoperatively (2 [1-3] vs. 3 [2,3], P = 0.039). There were no significant differences in adverse events between the two groups. Tapering of remifentanil at the end of surgery decreased postoperative pain scores immediately after thyroidectomy with desflurane and high-dose remifentanil anesthesia. Clinical Research information Service (CRiS, registration number KCT0000589 ).

Summary Total hip arthroplasty results in substantial blood loss in the peri-operative period. We evaluated the effects of acute normovolaemic haemodilution on blood coagulation and platelet function in 11 patients undergoing total hip arthroplasty. We performed acute normovolaemic haemodilution and haematological tests, rotational thromboelastometry (ROTEM®) and whole-blood impedance aggregometry. Blood samples were obtained at three time points: (i) before the initiation of acute normovolaemic haemodilution; (ii) 20 min after completion of acute normovolaemic haemodilution; and (iii) 20 min after retransfusion. After acute normovolaemic haemodilution, ROTEM parameters demonstrated hypocoagulability. Clot formation time of INTEM was increased by 31.6% (p = 0.016), whereas the α-angle and maximum clot formation of INTEM decreased by 8.1% (p = 0.032) and 3.0% (p = 0.013) respectively, compared with baseline values. Clotting time and clot formation time of EXTEM were increased by 40.8% (p = 0.042) and 31.3% (p = 0.016), respectively, whereas the α-angle and maximum clot formation of EXTEM were decreased by 11.9% (p = 0.020) and 9.5% (p = 0.013), respectively. The maximum clot formation of FIBTEM decreased by 35.1% compared with the baseline value (p = 0.007). Following retransfusion, ROTEM values returned to baseline; clot formation time decreased and the α-angle and maximum clot formation increased. There were no significant changes in platelet aggregation during the study. At 20 min after the end of acute normovolaemic haemodilution, the international normalised ratio of prothrombin time was increased compared with the baseline value (p = 0.003). We conclude that acute normovolaemic haemodilution resulted in a hypocoagulable state compared with baseline values and that coagulation parameters returned to normal after retransfusion.

The purpose of this study was to evaluate the effect of ondansetron on excitatory amino acid transporter type 3 (EAAT3) and to elucidate the roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in the effect. EAAT3 was expressed in Xenopus oocytes following the injection of rat EAAT3 mRNAs. Using the two-electrode voltage clamping method, the inward currents induced by l -glutamate were measured for 1 min in the presence and absence of ondansetron (1–1000 μM). Different concentrations of l -glutamate (3–300 μM) were used to determine the kinetic characteristics of EAAT3. To identify the involvement of PKC and PI3K in the effect, oocytes were exposed to a PKC activator and to PKC inhibitors and PI3K inhibitors, and l -glutamate-induced currents were recorded. Ondansetron decreased EAAT3 activity in a dose-dependent manner. In a kinetic study, ondansetron (10 μM for 3 min) reduced V max , but not K m compared with the control group. The PKC activator abolished the ondansetron-induced decrease in EAAT3 activity. The PKC inhibitors (staurosporine and chelerythrine) and ondansetron had not additive or synergistic effects on EAAT3 activity. The PI3K inhibitors (wortmannin and LY294002) decreased the EAAT3 response, although there were no differences among the groups comprising ondansetron, PI3K inhibitors, and PI3K inhibitors plus ondansetron. Our results demonstrate that ondansetron attenuates EAAT3 activity and this effect seems to be mediated by PKC and PI3K.

Background It has been reported that the direction of the guidewire J-tip is associated with misplacement of a central venous catheter. We hypothesized that real-time ultrasound-guided infraclavicular subclavian venous cannulation would be less influenced by the direction of guidewire J-tip compared to landmark method. Methods Sixty adult patients who required subclavian venous catheterization for neurosurgery were enrolled in this prospective randomized controlled study. Patients were randomly divided into a landmark group (n = 30) or an ultrasound group (n = 30). After the subclavian vein was punctured, the guidewire was advanced with the guidewire J-tip directed cephalad. Misplacement or advancement failure of the guidewire was regarded as an unsuccessful placement. Postoperative chest radiography was performed to confirm pneumothorax and the location of the catheter tip. Results The two groups were comparable with respect to age, gender, height, and weight distribution. The incidence of unsuccessful guidewire placement was lower in the ultrasound group than in the landmark group (13% vs. 47%, P = 0.01). Among the unsuccessful guidewire placements, the incidence of misplacement were comparable between the groups and were all located in the ipsilateral internal jugular vein (7% vs. 7%). However, the incidence of advancement failure was significantly higher in landmark group (40% vs. 7%, P = 0.005). There were no complications such as pneumothorax or hemothorax. Conclusions The proper placement of guidewire was less influenced by the direction of the guidewire J-tip with ultrasound-guided subclavian venous cannulation than with the landmark approach.

Nicotine, the main ingredient of tobacco, elicits seizures in animal models and cigarette smoking is regarded as a behavioral risk factor associated with epilepsy or seizures. In the hippocampus, the origin of nicotine-induced seizures, most glutamate uptake could be performed primarily by excitatory amino acid transporter type 3 (EAAT3). An association between temporal lobe epilepsy and EAAT3 downregulation has been reported. Therefore, we hypothesized that nicotine may elicit seizures through the attenuation of EAAT3 activity. We investigated chronic nicotine exposure (72 h) cause reduction of the activity of EAAT3 in a Xenopus oocyte expression system using a two-electrode voltage clamp. The roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) were also determined. Nicotine (0.001-1 μM) resulted in a time- and dose-dependent decrease in EAAT3 activity with maximal inhibition at nicotine concentrations of 0.03 μM or higher and at an exposure time of 72 h. Vmax on the glutamate response was significantly reduced in the nicotine group (0.03 μM for 72 h), but the Km value of EAAT3 for glutamate was not altered. When nicotine-exposed oocytes (0.03 μM for 72 h) were pretreated with phorbol-12-myristate-13-acetate (PMA, a PKC activator), the nicotine-induced reduction in EAAT3 activity was abolished. PKC inhibitors (staurosporine, chelerythrine, and calphostin C) significantly reduced basal EAAT3 activity, but there were no significant differences among the PKC inhibitors, nicotine, and PKC inhibitors+nicotine groups. Similar response patterns were observed among PI3K inhibitors (wortmannin and LY294002), nicotine, and PI3K inhibitors+nicotine. In conclusion, this study suggests that nicotine decreases EAAT3 activity, and that this inhibition seems to be dependent on PKC and PI3K. Our results may provide an additional mechanism for nicotine-induced seizure.

The adverse effects of spinal anesthesia (SA) include arterial hypotension and bradycardia. The aim of this study was to compare the effects of 2 type 3 serotonin receptor antagonists in SA-induced adverse effects. Specifically, we assessed whether ramosetron was more effective than ondansetron in reducing SA-induced decreases in blood pressure (BP) and heart rate (HR).A total of 117 patients undergoing orthopedic surgery and receiving SA were intravenously administered 0.3 mg of ramosetron (n = 39, group R), 4 mg of ondansetron (n = 39, group O4), or 8 mg of ondansetron (n = 39, group O8). Systolic BP (SBP), diastolic BP (DBP), mean BP (MBP), HR, and the lowest SBP, DBP, MBP, and HR values were measured preoperatively (baseline) and intraoperatively. The incidence of postoperative nausea and vomiting, the need for rescue antiemetics, the amount of patient-controlled analgesia consumption, and pain score in the first 48 hours after surgery were determined.Baseline values did not significantly differ among the 3 groups. After SA, SBP, DBP, MBP, and HR were lower than their baseline values in all 3 groups. The differences between the baseline and the lowest values were significantly less in group R than in groups O4 and O8 with respect to SBP (P0.001), DBP (P = 0.001), and MBP (P0.001) less in group R than in group O4 with respect to HR (P = 0.032). Intergroup differences were not significant for postoperative nausea and vomiting, the need for rescue antiemetics, patient-controlled analgesia consumption, or pain score.The administration of ramosetron (0.3 mg) significantly attenuated the SA-induced decrease in BP compared with 4 or 8 mg of ondansetron and HR compared with 4 mg of ondansetron.

Many anti-epileptics cause resistance to non-depolarizing neuromuscular blocking agents, but this has not been reported for valproic acid (VPA). We hypothesized that VPA would increase the rocuronium requirement and that magnesium sulphate (MgSO(4)) may reduce this increase.Fifty-five patients undergoing cerebrovascular surgeries were studied. Subjects were allocated into three groups at a 1:1:1 ratio: Groups VM, VC, and C. Groups VM and VC were given VPA premedication; Group C was not. A rocuronium injection (0.6 mg kg(-1) i.v.) was administered to Group VM, followed by MgSO(4) as a 50 mg kg(-1) i.v. bolus and 15 mg kg(-1) h(-1) infusion. The same volume of 0.9% saline was administered to the other groups. Supplementary rocuronium (0.15 mg kg(-1)) was given whenever the train-of-four count reached 2. Rocuronium requirements (primary outcome), mean arterial pressure (MAP), heart rate (HR), nausea, vomiting, shivering, and use of anti-emetics and nicardipine were compared.Group VC showed the highest rocuronium requirement [mg kg(-1) h(-1): 0.47 (0.08) vs 0.33 (0.12) (Group C), 0.31 (0.07) (Group VM); P0.001]. MAP, intraoperative HR, nausea, vomiting, shivering, and use of anti-emetics and nicardipine were not significantly different among the groups. Postoperative HR was lower in Group VM than in Group VC.VPA increased the rocuronium requirement, and MgSO(4) infusion attenuated this increase.

In a randomized, double-blind, prospective study, we have evaluated the effect of i.v. infusion of magnesium sulphate during spinal anaesthesia on postoperative analgesia and postoperative analgesic requirements.Forty patients undergoing total hip replacement arthroplasty under spinal anaesthesia were included. After the induction of spinal anaesthesia, the magnesium group (Group M) received magnesium sulphate 50 mg kg(-1) for 15 min and then 15 mg kg(-1) h(-1) by continuous i.v. infusion until the end of surgery. The saline group (Group S) received the same volume of isotonic saline over the same period. After surgery, a patient-controlled analgesia (PCA) device containing morphine and ketorolac was provided for the patients. Postoperative pain scores, PCA consumption, and the incidences of shivering, postoperative nausea, and vomiting were evaluated immediately after surgery, and at 30 min, 4, 24, and 48 h after surgery. Serum magnesium concentrations were checked before the induction of anaesthesia, immediately after surgery, and at 1 and 24 h after surgery.Postoperative pain scores were significantly lower in Group M at 4, 24, and 48 h after surgery (P0.05). Cumulative postoperative PCA consumptions were also significantly lower in Group M at 4, 24, and 48 h after surgery (P0.05). Postoperative magnesium concentrations were higher in Group M (P0.05 at 4, 24, and 48 h after surgery), but no side-effects associated with hypermagnesemia were observed. Haemodynamic variables and the incidences of shivering, nausea, and vomiting were similar in the two groups.I.V. magnesium sulphate administration during spinal anaesthesia improves postoperative analgesia.

BACKGROUND With supraglottic airway devices, such as the laryngeal tube suction (LTS), ProSeal laryngeal mask airway (PLMA) and Cobra perilaryngeal airway (CobraPLA), oropharyngeal leak pressure or cuff position may vary according to changes in the position of the head and neck. We evaluated oropharyngeal leak pressure and cuff pressure of the PLMA, LTS, and CobraPLA in different head and neck positions. METHODS One-hundred-thirty-nine patients (aged 18-70 yr) scheduled for minor surgical procedures were randomly allocated to one of the supraglottic airway devices. Oropharyngeal leak pressure and cuff pressure were evaluated in four head and neck positions: neutral, 45 degrees of flexion, 45 degrees of extension, and 45 degrees of right rotation. Adverse events (i.e., difficulty in ventilation or gastric insufflation) were assessed during the study. RESULTS Leak pressures of the PLMA were lowest in the extension (18.5 vs 23.9 and 26.8 cm H(2)O of LTS and CobraPLA, respectively; P < 0.001) and in the rotation position (25.0 vs 29.4 and 28.5 cm H(2)O of LTS and CobraPLA, respectively; P < 0.005). With the CobraPLA, gastric insufflations occurred before the oropharyngeal leak in 37 of 45 patients. There were ventilatory difficulties in seven patients with LTS after neck flexion, which required tracheal intubation. CONCLUSIONS The PLMA showed significantly lower oropharyngeal leak pressures than did the LTS or CobraPLA in the neck extension and rotation positions. Caution is warranted when changing the position of the head and neck when using the Cobra-PLA or LTS as gastric insufflation or ventilatory difficulty may occur.

Because complications are more common in patients with cerebral palsy (CP), surgeons and anesthesiologists must be aware of perioperative morbidity and be prepared to recognize and treat perioperative complications. This study aimed to determine the incidence of and risk factors for perioperative complications of orthopedic surgery on the lower extremities in patients with CP. We reviewed the medical records of consecutive CP patients undergoing orthopedic surgery. Medical history, anesthesia emergence time, intraoperative body temperature, heart rate, blood pressure, immediate postoperative complications, Gross Motor Function Classification System (GMFCS) level, Cormack-Lehane classification, and American Society of Anesthesiologists physical status classification were analyzed. A total of 868 patients was included. Mean age at first surgery was 11.8 (7.6) yr. The incidences of intraoperative hypothermia, absolute hypotension, and absolute bradycardia were 26.2%, 4.4%, and 20.0%, respectively. Twenty (2.3%) patients had major complications, and 35 (4.0%) patients had minor complications postoperatively. The incidences of intraoperative hypothermia, absolute hypotension, and major postoperative complications were significantly higher in patients at GMFCS levels IV and V compared with patients at GMFCS levels I to III (P

Glutamate is a major excitatory neurotransmitter in the central nervous system. Glutamate transporters play a critical role in maintaining extracellular glutamate concentrations. We investigated the effects of ethanol on a neuronal glutamate transporter, excitatory amino acid transporter type 3 (EAAT3), and the role of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3 K) in mediating these effects.EAAT3 was expressed in Xenopus oocytes by injection of EAAT3 messenger RNA. By using a two-electrode voltage clamp, membrane currents were recorded after the application of l-glutamate. Responses were quantified by integration of the current trace and reported as microcoulombs. Data are mean +/- SEM.Ethanol enhanced EAAT3 activity in a concentration-dependent manner. At 25, 50, 100, and 200 mM of ethanol, the responses were significantly increased compared with control values. Kinetic study demonstrated that ethanol (50 mM) significantly increased Vmax (3.48 +/- 0.2 microC for control versus 4.16 +/- 0.24 microC for ethanol; n = 19; p0.05) without a significant change in the Km (65.6 +/- 11.1 microM for control versus 55.8 +/- 9.6 microM for ethanol; n = 19; p0.05) of EAAT3 for glutamate. Preincubation of the oocytes with phorbol-12-myristate-13-acetate (PMA) significantly increased EAAT3 activity (0.98 +/- 0.08 muC for control versus 1.28 +/- 0.09 microC for ethanol; n = 19; p0.05). However, there was no statistical difference among the responses of EAAT3 to PMA, ethanol, or PMA plus ethanol. Although the PKC inhibitors chelerythrine and staurosporine did not decrease the basal EAAT3 activity, they abolished the enhancement of EAAT3 activity by ethanol. Pretreatment with wortmannin, a PI3 K inhibitor, also abolished the ethanol-enhanced EAAT3 activity.These results suggest that acute ethanol exposure increases EAAT3 activity at clinically relevant concentrations and that PKC and PI3 K may be involved in mediating these ethanol effects.

Background Prophylactic fluid preloading before spinal anesthesia has been a routine procedure to prevent maternal hypotension during cesarean delivery. Unlike colloid, timing of infusion of crystalloid may be important because of its short stay in intravascular space. We hypothesized that crystalloid loading just after intrathecal injection compared to preload would be more effective in preventing maternal hypotension. Methods In this prospective controlled study, sixty parturients were randomized to receive 15 ml/kg of crystalloid before (preload group) or after (coload group) intrathecal drug injection for spinal anesthesia. Hypotension was defined if systolic arterial pressure decreased below 80% of baseline and ephedrine was administered to treat hypotension. The incidence of hypotension and the total dose of ephedrine were checked. Blood pressure, heart rate and nausea before childbirth were assessed. Neonatal outcomes were evaluated with Apgar scores and umbilical blood gas analysis. Results The incidence of hypotension was lower in the coload group compared to the preload group (53% vs. 83%, P = 0.026). The blood pressure showed the bigger drop during spinal anesthesia in the preload group (34 ± 13 vs. 25 ± 10 mmHg, P = 0.002) and smaller dose of ephedrine was required in the coload group (7.5 [0–30] vs. 15 [0–40] mg, P = 0.015). The incidence of nausea was also lower in the coload group (27% vs. 60%, P = 0.019). Neonatal outcome measures were comparable between two groups. Conclusions In case of using crystalloids for cesarean delivery, coload is more effective than preload for the prevention of maternal hypotension after spinal anesthesia. Trial registration Clinical Research Information Service KCT0000324 (Jan 12th, 2012)