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ObjectiveTo investigate the effect-site concentration of remifentanil required to blunt haemodynamic responses during tracheal intubation with a single-lumen tube (SLT) or a double-lumen tube (DLT).MethodsPatients scheduled for thoracic surgery requiring one-lung ventilation were randomly allocated to either the SLT or DLT group. All patients received a target-controlled infusion of propofol and a predetermined concentration of remifentanil. Haemodynamic parameters during intubation were recorded. The effect-site concentration of remifentanil was determined using a delayed up-and-down sequential allocation method.ResultsA total of 92 patients were enrolled in the study. The effective effect-site concentrations of remifentanil required to blunt haemodynamic responses in 50% of patients (EC50) estimated by isotonic regression with bootstrapping was higher in the DLT than the SLT group (8.5 ng/ml [95% confidence interval (CI) 8.0–9.5 ng/ml] versus 6.5 ng/ml [95% CI 5.6–6.7 ng/ml], respectively). Similarly, the effective effect-site concentrations of remifentanil in 95% of patients in the DLT group was higher than the SLT group (9.9 ng/ml [95% CI 9.8–10.0 ng/ml] versus 7.0 ng/ml [95% CI 6.9–7.0 ng/ml], respectively).ConclusionsThis study demonstrated that a DLT requires a 30% higher EC50of remifentanil than does an SLT to blunt haemodynamic responses during tracheal intubation when combined with a target-controlled infusion of propofol.Trial registrationClinicaltrials.gov identifier: NCT01542099.

The purpose of the study is to investigate the relationship between microvascular reactivity and postoperative bleeding in cardiac surgery. The authors retrospectively analyzed a prospectively collected registry of cardiac surgery patients. Data from 154 patients enrolled in the registry were analyzed. A linear mixed model was performed to evaluate the association between the amount of postoperative chest tube output (CTO, milliliter, repeatedly measured at 0–8, 8–24, and 24–48 h) and tissue oxygen saturation (StO2) recovery slope (%/s) measured by vascular occlusion test (VOT) at skin closure. A logistic regression was carried out to see the relationship between StO2 recovery slope and packed red blood cell (PRBC) transfusion during the 48-h postoperative period. In the multivariable adjusted model, the effect of StO2 recovery slope on postoperative CTO (log-transformed) was statistically significant, and the degree of StO2 recovery slope was inversely related to the amount of CTO (exp(estimate) = 0.935; exp(95% CI) 0.881–0.992; p = 0.027). StO2 recovery slope was also inversely associated with postoperative PRBC transfusion possibility (OR = 0.795; 95% CI 0.633–0.998; p = 0.048). Microvascular reactivity measured by VOT is independently and inversely associated with postoperative bleeding in patients undergoing cardiac surgery.

Background Remote ischemic conditioning has been shown to confer myocardial protection. However, there is still no sufficient data on its long-term clinical outcomes. We analyzed the long-term results of the Remote Ischemic Preconditioning and Postconditioning Outcome (RISPO) trial in cardiac surgery patients. Methods In the RISPO trial, 1280 patients were randomized to receive remote ischemic preconditioning (RIPC) with postconditioning (RIPostC, upper arm ischemia by four cycles of 5-min inflation followed by 5-min deflation of a pneumatic cuff, N =644) or sham ( N =636) during cardiac surgery. Patient follow-up data were collected by review of medical records, telephone interviews, and from the National Statistical Office. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE; a composite of all-cause mortality, myocardial infarction (MI), stroke, and revascularization), and the secondary endpoints were the individual components of the primary endpoint. Results At completion of follow-up (mean 44months), there was no difference in MACCE between the groups (90 [14.0%] versus 101 [15.9%] in the RIPC with RIPostC versus control groups; hazard ratio [HR], 0.893; 95% confidence interval [CI], 0.672–1.187; P =0.435). However, MI was reduced to half in the RIPC with RIPostC group (10 [1.6%] versus 23 [3.6%]; HR, 0.468; 95% CI, 0.222–0.984; P =0.045). Conclusions Remote ischemic preconditioning with RIPostC did not improve long-term MACCE after cardiac surgery. However, MI was reduced in the RIPC with RIPostC group compared with the control group during the follow-up period. Clinical trial registration ClinicalTrials.gov identifier, NCT00997217

Background Serum alkaline phosphatase (ALP) is related to vascular calcification. In a recent study on percutaneous coronary intervention (PCI) with a drug-eluting stent, higher ALP was associated with poor clinical outcomes in terms of mortality, myocardial infarction, and stent thrombosis. The aim of this study was to evaluate the relationship between preoperative ALP and clinical outcome of off-pump coronary artery bypass surgery (OPCAB).Methods and Results:We retrospectively enrolled and reviewed a total of 1,335 patients who underwent OPCAB. Patients were divided into tertiles based on preoperative serum ALP ( 76 IU/L). As preoperative ALP increased, the HR of mortality remained constant after adjusting for confounders. On Cox proportional hazards regression analysis, there was no association between ALP and all-cause mortality. The adjusted HR for all-cause mortality for the middle tertile was 0.882 (95% CI: 0.592-1.314, P=0.537), and 0.915 (95% CI: 0.605-1.383, P=0.672) for the highest tertile. In addition, no associations between ALP and cardiovascular mortality, myocardial infarction, revascularization, or major adverse cardiac events were found. Conclusions Unlike after PCI, high ALP is not related to adverse clinical events, such as mortality, myocardial infarction, or revascularization after OPCAB. ALP might be considered when determining the optimal revascularization technique.

Background Remote ischemic preconditioning (RIPC) has two time windows for organ protection: acute and delayed. Previous studies have mainly focused on the acute time window to evaluate organ protection by RIPC. We evaluated myocardial protection by delayed RIPC in adult patients undergoing cardiac surgery. Methods A total of 160 adult patients undergoing cardiac surgery with cardiopulmonary bypass were randomized to receive either delayed RIPC (four cycles of 5min of ischemia followed by 5min of reperfusion by inflation to 200mmHg and deflation of a blood pressure cuff on the upper arm) or the control treatment 24–48h before surgery. The primary endpoint was post-operative troponin I levels serially measured for 72h. Secondary endpoints included post-operative serum creatinine levels, acute kidney injury, and composite complications. Results There were no significant differences in post-operative troponin I values. The incidence of acute kidney injury, defined by the Acute Kidney Injury Network staging system, was lower in the delayed RIPC group compared to the control group (30.0% vs. 47.5%; relative risk, 0.768; 95% confidence interval, 0.599–0.985; p=0.023). Moreover, the occurrence of composite complications was lower in the delayed RIPC group compared with the control group (65.0% vs. 81.3%; relative risk, 0.536; 95% confidence interval, 0.311–0.924; p=0.020). Conclusions While RIPC did not provide cardioprotective effects in patients undergoing cardiac surgery, it appeared to reduce acute kidney injury, as well as the rate of composite complications.

General anesthesia can affect microcirculatory properties. However, differential effects on the microcirculation according to the anesthetic technique used during thoracoscopic surgery have not been well documented. We conducted a randomized clinical trial in which the effects of desflurane and propofol, both with remifentanil, on systemic arterial oxygenation during one-lung ventilation were compared in patients undergoing thoracoscopic surgery. As a subgroup analysis, we compared the effects of two commonly used anesthetic techniques, desflurane–remifentanil (n = 52) and propofol–remifentanil (n = 48), on tissue oxygen saturation using a vascular occlusion test in patients undergoing thoracoscopic surgery. Tissue oxygen saturation was higher in the desflurane than the propofol group (mean ± standard deviation, 83 ± 6 vs. 80 ± 9, 84 ± 6 vs. 76 ± 10, and 87 ± 7 vs. 77 ± 10 % at 30 and 60 min of one-lung ventilation and at two-lung ventilation; adjusted p = 0.026

The infusion of fluids to patients may affect tissue microcirculation and the endothelial glycocalyx. However, the effects of hydroxyethyl starch and crystalloid on endothelial glycocalyx degradation and microvascular reactivity have not been evaluated in detail. We hypothesised that hydroxyethyl starch may cause less endothelial glycocalyx degradation and better microvascular reactivity than that caused by crystalloid. We randomly allocated 120 patients undergoing off-pump coronary artery bypass graft surgery to receive up to 20 ml.kg-1 of either hydroxyethyl starch 670/0.75 or crystalloid for intra-operative fluid resuscitation. Crystalloid was then infused to meet ongoing fluid requirements. During the peri-operative period, vascular occlusion tests were performed to assess microvascular reactivity, and serum syndecan-1 was measured as an index of endothelial glycocalyx degradation. The median (IQR [range]) fluid infused during surgery was significantly less in the hydroxyethyl starch group than the crystalloid group; 2800 (2150-3550 [1400-7300]) vs. 3925 (3100-4725 [1900-6700]) ml, respectively, p < 0.001. Vascular occlusion test parameters, including tissue oxygen saturation, occlusion and recovery slope did not differ significantly between the groups. Peri-operative changes in syndecan-1 were not significantly different between the groups. We conclude that, in patients undergoing off-pump coronary artery bypass graft surgery, compared with crystalloid, the use of hydroxyethyl starch 670/0.75 did not result in significant differences in microvascular reactivity or endothelial glycocalyx degradation.

It remains unclear whether we have to interrupt mechanical ventilation during infraclavicular subclavian venous catheterization. In practice, the clinicians' choice about lung deflation depends on their own discretion. The purpose of this study was to assess the influence of mechanical ventilation on the incidence of pneumothorax during infraclavicular subclavian venous catheterization.A total of 332 patients, who needed subclavian venous catheterization, were randomly assigned to 1 of the 2 groups: catheterizations were performed with the patients' lungs under mechanical ventilation (ventilation group, n = 165) or without mechanical ventilation (deflation group, n = 167). The incidences of pneumothorax and other complications such as arterial puncture, hemothorax, or catheter misplacements and the success rate of catheterization were compared.The incidences of pneumothorax were 0% (0/165) in the ventilation group and 0.6% (1/167) in the deflation group. The incidence of pneumothorax in the deflation group was 0.6% higher than that in the ventilation group and the 2-sided 90% confidence interval for the difference was (-1.29% to 3.44%). Because the lower bound for the 2-sided 90% confidence interval, -1.29%, was higher than the predefined noninferiority margin of -3%, the inferiority of the ventilation group over the deflation group was rejected at the .05 level of significance. Other complication rates and success rates of catheterization were comparable between 2 groups. The oxygen saturation dropped below 95% in 9 patients in the deflation group, while none in the ventilation group (P = .007).The success and complication rates were similar regardless of mechanical ventilation. During infraclavicular subclavian venous catheterization, interruption of mechanical ventilation does not seem to be necessary for the prevention of pneumothorax.

The RISPO (Remote Ischemic Preconditioning with Postconditioning Outcome) trial evaluated whether remote ischaemic preconditioning (RIPC) combined with remote ischaemic postconditioning (RIPostC) improves the clinical outcomes of patients undergoing cardiac surgery. This substudy of the RISPO trial aimed to evaluate the effect of RIPC with RIPostC on pulmonary function in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).Sixty-five patients were enrolled (32: control and 33: RIPC-RIPostC). In the RIPC-RIPostC group, four cycles of 5min ischaemia and 5min reperfusion were administered before and after CPB to the upper limb. Peri-operative PaO2/FIO2 ratio, intra-operative pulmonary shunt, and dynamic and static lung compliance were determined.The mean PaO2/ FIO2 was significantly higher in the RIPC-RIPostC group at 24h after surgery [290 (96) vs. 387 (137), p=0.001]. The incidence of mechanical ventilation for longer than 48h was significantly higher in the control group (23% vs. 3%, p0.05). However, there were no significant differences in other pulmonary profiles, post-operative mechanical ventilation time, and duration of intensive care unit stay.In our study, RIPC-RIPostC improved the post-operative 24h PaO2/FIO2 ratio. Remote ischaemic preconditioning-Remote ischaemic postconditioning has limited and delayed pulmonary protective effects in cardiac surgery patients with CPB.

Background Intraoperative anaphylaxis to neuromuscular blocking agents (NMBAs) is a rare event that is unpredictable and potentially life threatening. Most of the previous reports on such intraoperative anaphylaxis used market share surveys or self-reported data to estimate the incidence. Objective To determine the incidences of intraoperative anaphylaxis to NMBAs using electronic medical records. Design A retrospective observational study. Setting Two tertiary hospitals in South Korea. Patients This study involved patients exposed to NMBAs during anaesthesia between 1 January 2005 and 31 May 2014. Nineteen episodes were deemed to be intraoperative anaphylaxis to NMBAs. Main outcome measures We calculated the incidences of intraoperative anaphylaxis to NMBAs. Exposure to the agents was determined from intraoperative records maintained in an electronic medical recording system. An anaphylactic reaction was determined from both clinical signs and the results of skin tests. Results Over 9 years, 729 429 patients were exposed to NMBA, the most frequently used being rocuronium [425 047 (58.3%)] and vecuronium [274 801 (37.7%)]. The overall incidence of intraoperative anaphylaxis was 2.6 per 100 000 (19 cases), and was higher with rocuronium (16 cases, 3.8 per 100 000) than with vecuronium (two cases, 0.7 cases per 100 000), P = 0.014. Comparing the first 3 years with the last 6 years, the incidence of intraoperative rocuronium anaphylaxis appeared to increase 1.4-fold (P = 0.006). Conclusion Among commonly used NMBAs, rocuronium appears to have the highest incidence of anaphylaxis. Our findings suggest that future prospective investigation for NMBA-induced anaphylaxis should use internationally agreed skin test protocols.

ObjectiveTo evaluate the efficacy and safety of intrathecal morphine (ITM) for postoperative pain control in patients with renal cell carcinoma undergoing open nephrectomy.MethodsForty-five patients scheduled for open nephrectomy were randomised to receive 300 µg ITM and intravenous patient-controlled analgesia (IV-PCA) ( n = 22) or IV-PCA alone ( n = 23) for postoperative analgesia. The numeric pain score (NPS), postoperative IV-PCA requirements and opioid-related complications including nausea, vomiting, dizziness, headache, and pruritus were compared between groups.ResultsNPS was significantly lower in the ITM group up to 24 h postoperatively. Upon coughing, NPS at 24 h postoperatively was 50 (interquartile range (IQR) 30–60) in the ITM group and 60 (45–70) in the IV-PCA group. Cumulative morphine consumption at 72 h postoperatively was significantly lower in the ITM group compared with the IV-PCA group (20 (9–33) mg vs. 31 (21–49) mg, respectively). Opioid-related complications were similar in both groups with the exception of pruritus (ITM, 77% vs. IV-PCA, 26%).ConclusionsITM was associated with greater analgesia without serious complications in patients undergoing open nephrectomy.

For needle insertion and guidewire placement during central venous catheterization, a thin-wall introducer needle technique and a cannula-over-needle technique have been used. This study compared these two techniques regarding the success rates and complications during internal jugular vein catheterization.Prospective, randomized, controlled study.A university-affiliated hospital.Two hundred sixty-six patients scheduled for thoracic surgery, gynecologic surgery, or major abdominal surgery, who required central venous catheterization.Patients were randomly assigned to either the thin-wall introducer needle group (n = 134) or the cannula-over-needle group (n = 132). Central venous catheterization was performed on the right internal jugular vein under assistance with real-time ultrasonography. Needle insertion and guidewire placement were performed using a thin-wall introducer needle technique in the thin-wall introducer needle group and a cannula-over-needle technique in the cannula-over-needle group.The guidewire placement on the first skin puncture was regarded as a successful guidewire insertion on the first attempt. The number of puncture attempts for internal jugular vein catheterization was recorded. Internal jugular vein was assessed by ultrasonography to identify complications. The rate of successful guidewire insertion on the first attempt was higher in the thin-wall introducer needle group compared with the cannula-over-needle group (87.3% vs 77.3%; p = 0.037). There were fewer puncture attempts in the thin-wall introducer needle group than in the cannula-over-needle group (1.1 ± 0.4 vs 1.3 ± 0.6; p = 0.026). There was no significant difference in complications of internal jugular vein catheterization between the two groups.The thin-wall introducer needle technique showed a superior success rate for first attempt of needle and guidewire insertion and required fewer puncture attempts during internal jugular vein catheterization.

Cardiac output measurement has a long history in haemodynamic management and many devices are now available with varying levels of accuracy. The purpose of the study was to compare the agreement and trending abilities of cardiac output, as measured by transpulmonary thermodilution and calibrated pulse contour analysis, using the VolumeView™ system, continuous thermodilution via a pulmonary artery catheter, and uncalibrated pulse contour analysis, using FloTrac™ with pulmonary artery bolus thermodilution. Twenty patients undergoing off-pump coronary artery bypass surgery using a pulmonary artery catheter and the VolumeView™ and FloTrac™ systems were included in this subgroup analysis of the cardiovascular anaesthesia registry at a single tertiary centre. During surgery, cardiac output was assessed after the induction of anaesthesia, after sternotomy, during the harvesting of grafts, during revascularization of the anterior and posterior/lateral wall, after protamine infusion, and after sternal fixation. In total, 145 sets of measurements were evaluated using Bland-Altman with % error calculation, correlation, concordance, and polar plot analyses. The percentage error (bias, limits of agreement) was 12.6 % (-0.12, -0.64 to 0.41 L/min), 26.7 % (-0.38, -1.50 to 0.74 L/min), 29.3 % (-0.08, -1.32 to 1.15 L/min), and 33.8 % (-0.05, -1.47 to 1.37 L/min) for transpulmonary thermodilution, pulmonary artery continuous thermodilution, calibrated, and uncalibrated pulse contour analysis, respectively, compared with pulmonary artery bolus thermodilution. All pairs of measurements showed significant correlations (p

Tissue microcirculation measured by vascular occlusion test is impaired during septic shock. However, it has not been investigated extensively during anesthesia induction. The aim of the study is to evaluate tissue microcirculation during anesthesia induction. We hypothesized that during anesthesia induction, tissue microcirculation measured by vascular occlusion test might be enhanced with peripheral vasodilation during anesthesia induction. We conducted a prospective observational study of 50 adult patients undergoing cardiac surgery. During anesthesia induction, we measured and analyzed tissue oxygen saturation, vascular occlusion test, cerebral oximetry, forearm-minus-fingertip skin temperature gradients and hemodynamic data in order to evaluate microcirculation as related to alterations in peripheral vasodilation as reflected by increased Tforearm-finger thermal gradients. During anesthesia induction, recovery slope during vascular occlusion test and cerebral oxygen saturation increased from 4.0 (1.5) to 4.7 (1.3) % s(-1) (p = 0.02) and 64.0 (10.2) to 74.2 (9.2) % (p 0.001), respectively. Forearm-minus-fingertip skin temperature gradients decreased from 1.9 (2.9) to -1.4 (2.2) °C (p 0.001). There was an inverse correlation between changes in the skin temperature gradients and changes in cerebral oximetry (r = 0.33; p = 0.02). During anesthesia induction, blood pressure and forearm-minus-fingertip skin temperature gradients decrease while cerebral oximetry and vascular occlusion test recovery slope increase. These findings suggest that anesthesia induction increases tissue microcirculation with peripheral vasodilation.

Background Ionised calcium plays an important role in neuromuscular transmission, but its effects on the reversal of nondepolarising neuromuscular blockade have not been fully evaluated. Objective We examined whether calcium chloride coadministered with neostigmine could enhance the rate of neuromuscular recovery. Design Randomised double-blind trial. Setting A tertiary teaching hospital. Patients In total, 53 patients undergoing elective surgery under general anaesthesia with neuromuscular monitoring by acceleromyography using a TOF-Watch SX monitor. Interventions Patients were randomly allocated to receive either 5 mg kg of calcium chloride (calcium group, n = 26) or the same volume of normal saline (control group, n = 27) coadministered with 25 μg kg of neostigmine and 15 μg kg of atropine at the end of surgery. Main outcome measures The primary end point was the neuromuscular recovery time [time from neostigmine administration to recovery of the TOF ratio (TOFr) to 0.9]. Secondary end points included the TOFr at 5, 10 and 20 min after neostigmine administration and the incidence of postoperative residual curarisation (PORC), defined as a TOFr less than 0.9 at each time point. Results The neuromuscular recovery time was significantly faster in the calcium group than in the control group (median [Q1 to Q3]; 5.0 [3.0 to 7.0] vs. 6.7 [5.7 to 10.0] min, respectively; P = 0.007). At 5 min after neostigmine administration, the TOFr was higher [87 (74 to 100) vs. 68 (51 to 81)%, respectively; P = 0.002] and the incidence of PORC was lower (50.0 vs. 81.5%, respectively; P = 0.016) in the calcium group than in the control group. There were no differences between the two groups with respect to the TOFr or incidence of PORC at 10 and 20 min after neostigmine administration. Conclusion Calcium chloride coadministered with neostigmine enhanced neuromuscular recovery in the early period of nondepolarising neuromuscular blockade reversal.

Background Palonosetron is a recently introduced 5-HT3 receptor antagonist for postoperative nausea and vomiting. Detailed standardized evaluation of corrected QT (QTc) interval change by palonosetron under sevoflurane anaesthesia is lacking. We evaluated QTc intervals in patients who are undergoing surgery with sevoflurane anaesthesia and receive palonosetron. Methods Our study included 100 patients who were undergoing elective surgery under sevoflurane anaesthesia. The patients were randomly assigned to two groups: those who received an i.v. injection of palonosetron 0.075 mg immediately before induction of anaesthesia (pre-surgery group, n=50) and those who received it after surgery in the recovery room (post-surgery group, n=50). QTc intervals were measured before operation, intraoperatively (baseline, immediately after tracheal intubation, and at 2, 10, 15, 30, 60, and 90 min after administration of palonosetron or placebo), and after operation (before and at 3, and 10 min after administration of palonosetron or placebo). QTc intervals were calculated using Fridericia's, Bazett's, or Hodges formulas. Results The perioperative QTc intervals were significantly increased from the baseline values, but were not affected by the pre- or post-surgical timing of palonosetron administration. Conclusions There was no significant difference in the QTc intervals during the perioperative period, whether 0.075 mg of palonosetron is administered before or after sevoflurane anaesthesia. Palonosetron may be safe in terms of QTc intervals during sevoflurane anaesthesia. Clinical trial registration ClinicalTrials.gov: NCT01650961.

Robot-assisted laparoscopic prostatectomy (RALP) is minimally invasive surgery, but also causes moderate to severe pain during the immediate postoperative period. We evaluated the efficacy and safety of intrathecal morphine (ITM) for postoperative pain control in patients undergoing RALP. Thirty patients scheduled for RALP were randomly assigned into one of two groups. In the ITM group (n = 15), postoperative pain was managed using 300 µg intrathecal morphine with intravenous patient-controlled analgesia (IV-PCA). In the IV-PCA group (n = 15), only intravenous patient-controlled analgesia was used. The numerical pain score (NPS; 0 = no pain, 100 = worst pain imaginable), postoperative IV-PCA requirements and opioid-related complications including nausea, vomiting, dizziness, headache and pruritus were compared between the two groups. The NPSs on coughing were 20 (IQR 10–50) in the ITM group and 60 (IQR 40–80) in the IV-PCA group at postoperative 24 h (p = 0.001). The NPSs were significantly lower in the ITM group up to postoperative 24 h. The ITM group showed less morphine consumption at postoperative 24 h in the ITM group than in the IV-PCA group [5 (IQR 3–15) mg vs 17 (IQR 11–24) mg, p = 0.001]. Complications associated with morphine were comparable between the two groups and respiratory depression was not reported in either group. Intrathecal morphine provided more satisfactory analgesia without serious complications during the early postoperative period in patients undergoing RALP.

Aims The aim of this study was to evaluate whether remote ischaemic preconditioning (RIPC) combined with remote ischaemic postconditioning (RIPostC) improves the clinical outcomes of patients undergoing cardiac surgery. Methods and results From June 2009 to November 2010, 1280 patients who underwent elective cardiac surgery were randomized into the RIPC with RIPostC group or the control group in the morning of the surgery. In the RIPC with RIPostC group, four cycles of 5-min ischaemia and 5-min reperfusion were administered twice to the upper limb—before cardiopulmonary bypass (CPB) or coronary anastomoses for RIPC and after CPB or coronary anastomoses for RIPostC. The primary endpoint was the composite of major adverse outcomes, including death, myocardial infarction, arrhythmia, stroke, coma, renal failure or dysfunction, respiratory failure, cardiogenic shock, gastrointestinal complication, and multiorgan failure. Remote ischaemic preconditioning with RIPostC did not reduce the composite outcome compared with the control group (38.0 vs . 38.1%, respectively; P = 0.998) and there was no difference in each major adverse outcome. The intensive care unit and hospital stays were not different between the two groups. However, in the off-pump coronary artery bypass surgery subgroup, multivariate logistic regression analysis revealed that RIPC with RIPostC was related to increased composite outcome (odds ratio: 1.54; 95% confidence interval: 1.02–2.30; P = 0.038). Conclusion Remote ischaemic preconditioning with RIPostC by transient upper limb ischaemia did not improve clinical outcome in patients who underwent cardiac surgery. Clinical Trial Registration clinicaltrials.gov, [NCT00997217][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00997217&atom=%2Fehj%2Fearly%2F2013%2F09%2F07%2Feurheartj.eht346.atom

Background There are controversies regarding the most efficient shoulder position during infraclavicular subclavian venous catheterization. We hypothesized that, regarding the success rate of subclavian venous catheterization, the neutral shoulder position would not be inferior to the retracted shoulder position. Methods A total of 362 patients who underwent elective surgery were randomly assigned to two groups: those who underwent subclavian venous catheterizations in the neutral shoulder position (neutral group, n=181) or in the retracted shoulder position (retracted group, n=181). In the retracted group, a 1 litre saline bag was placed longitudinally beneath the spinal column between the scapulae to allow the shoulders to fall into a ‘retracted’ position. The incidence of failures to place the central venous catheters and complications such as arterial puncture, pneumothorax, or haemothorax were recorded. Results The success rates were 95.6% (173/181) in the neutral group and 96.1% (174/181) in the retracted group. The difference of 0.5% was within the prespecified non-inferiority margin of 5% with a P-value of 0.017 [two-sided 95% confidence interval (CI), −0.036 to 0.047; upper limit of the 95% CI, 0.040]. There were four catheterization failures (2.2%) in the neutral group and two failures (1.1%) in the retracted group. Complication rates were not significantly different between the neutral and retracted groups [3/181 (1.7%) vs 4/181 (2.2%) for arterial punctures and 1/181 (0.6%) vs 1/181 (0.6%) for pneumothorax]. Conclusions The neutral shoulder position was as effective as the retracted shoulder position for infraclavicular subclavian venous catheterization. Shoulder retraction does not appear to be necessary for the infraclavicular subclavian venous catheterization. Clinical trial registration ClinicalTrials.gov , NCT01368692.

Left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of mitral valve is not only limited to patients with hypertrophic cardiomyopathy. A diagnosis of LVOT obstruction with SAM is important because conventional inotropic support may potentially aggravate hemodynamic deterioration. We present a case of LVOT obstruction with SAM in a patient who underwent an emergent surgery for ascending aortic dissection with pericardial effusion. The patient showed refractory hypotension after standard pharmacologic interventions during induction of anesthesia. Transesophageal echocardiography (TEE) revealed LVOT obstruction with SAM and it was managed appropriately under the guidance of TEE. Intraoperative TEE can play an important role in diagnosis and management of LVOT obstruction with SAM caused by pericardial effusion.

High-dose remifentanil during surgery paradoxically increases postoperative pain intensity and morphine consumption. Cyclooxygenase inhibitors decrease prostaglandin synthesis, thereby antagonizing N-methyl-d-aspartate receptor activation, and may reduce hyperalgesia. This study was performed to evaluate whether postoperative morphine consumption increased following intraoperative continuous remifentanil infusion and whether this could be prevented by intravenous ibuprofen pretreatment.A randomized controlled study.Single university hospital, study period from September 2014 to March 2015.One hundred and twenty patients undergoing pancreaticoduodenectomy.After induction of anesthesia, patients received remifentanil target-controlled infusion (effect site concentration of 4 ng/mL or 1 ng/mL) with or without intravenous ibuprofen (800 mg).Postoperative cumulative total morphine consumption and pain intensity were assessed.Intraoperative remifentanil use in patients receiving high-dose remifentanil was more than 3-fold higher than that in patients receiving low-dose remifentanil (2666.8 ± 858.4 vs 872.0 ± 233.3 μg, respectively; P.001). However, cumulative total morphine consumption at postoperative 1, 3, 6, 12, 24, and 48 hours did not differ among the groups. There were no differences among the groups in the self-administered analgesic dose by the patients using a controlled analgesia device, number of self-administration attempts, numerical rating scale for pain, or analgesic side effects.We found no influence on postoperative pain after high-dose remifentanil in patients undergoing pancreaticoduodenectomy. Addition of intravenous ibuprofen did not reduce postoperative morphine consumption or pain intensity.

Background General anesthesia may induce inadvertent hypothermia and this may be related to perioperative cardiovascular complications. Microvascular reactivity, measured by the recovery slope during a vascular occlusion test, is decreased during surgery and is also related to postoperative clinical outcomes. We hypothesized that microvascular changes during surgery may be related to intraoperative hypothermia. To evaluate this, we conducted a randomized study in patients undergoing off-pump coronary artery bypass surgery, in which the effect of prewarming on microvascular reactivity was evaluated. Methods Patients scheduled for off-pump coronary artery bypass surgery were screened. Enrolled patients were randomized to the prewarming group to receive forced-air warming during induction of anesthesia or to the control group. Measurement of core and skin temperatures and vascular occlusion test were conducted before anesthesia induction, 1, 2, and 3 h after induction, and at the end of surgery. Results In total, 40 patients were enrolled and finished the study (n = 20 in the prewarming group and n = 20 in the control group). During the first 3 h of anesthesia, core temperature was higher in the prewarming group than the control group (p < 0.001). The number of patients developing hypothermia was lower in the prewarming group than the control group (4/20 vs. 13/20, p = 0.004). However, tissue oxygen saturation and changes in recovery slope following a vascular occlusion test at 3 h after anesthesia induction did not differ between the groups. There was no difference in clinical outcome, including perioperative transfusion, wound infection, or hospital stay, between the groups. Conclusions Prewarming during induction of anesthesia decreased intraoperative hypothermia, but did not reduce the deterioration in microvascular reactivity in patients undergoing off-pump coronary artery bypass surgery. Trial Registration ClinicalTrials.gov NCT02186210

The correct position of double-lumen tubes (DLTs) is customarily confirmed after tracheal intubation by bronchoscopy with the patient supine on a headrest. However, displacement of DLTs usually occurs during lateral positioning because of neck extension. This study was undertaken to determine whether displacement of DLTs could be minimized during lateral positioning if DLTs were positioned without a headrest.One hundred patients scheduled for thoracic surgery were randomized into two groups (n = 50 each). After tracheal intubation using a headrest, adjustment of DLT position was performed according to group assignment, i.e., either with the headrest in place or without the headrest. Using a bronchoscope, distances from the tracheal opening to the main carina and from the bronchial opening to the left bronchial carina were measured in both the supine and lateral positions.Displacement of DLTs [mean (standard deviation)] during lateral positioning was greater in the headrest group than in the no-headrest group [12.3 (6.5) mm vs 6.8 (5.5) mm, respectively, in the trachea; 11.6 (6.7) mm vs 6.0 (4.6) mm, respectively, in the bronchus; P0.001]. The incidence of significant displacement, defined as10 mm from initial correct position, was greater in the headrest group than in the no-headrest group (64% vs 28%, respectively, in the trachea; 58% vs 20%, respectively, in the bronchus; P0.001).Displacement of DLTs during lateral positioning appears to be caused primarily by extension of the neck. Correct adjustment of DLT position without a headrest in the supine position is an easy and effective method to minimize DLT displacement during lateral positioning.

Background Ramosetron is a relatively new 5-hydroxytryptamine three receptor antagonist with higher binding affinity and more prolonged duration of action compared to ondansetron. The present study was performed to evaluate the effects of ramosetron on QTc interval and possible cardiovascular adverse effects in patients undergoing cardiac surgery. Method A total of 114 patients who underwent off-pump coronary artery bypass surgery were enrolled in this randomised placebo-controlled trial. Patients were allocated into two groups that received intravenous injection of 0.3 mg ramosetron or normal saline during induction of anaesthesia. QTc intervals were measured before the operation, intraoperatively (0, 1, 2, 3, 5, 10, 15, 30, 45, 60, 90, 120, and 240 min after injection of ramosetron or normal saline), at the end of the operation, and on postoperative day 1. Results There were no differences in mean QTc interval between groups at every time point. However, maximal change in QTc interval during surgery was higher in the ramosetron group than the placebo group (25.1 ± 22.0 vs. 17.5 ± 14.5 ms, 95 % CI 0.34–14.78, P = 0.040). Also, there were more patients with a QTc interval increase of > 60 ms in the ramosetron group (5 vs. 0, 95 % CI 1.6–18.0, P = 0.021). There were no significant differences in cardiovascular complications. Conclusions Ramosetron administered during induction of anaesthesia may affect maximal change in QTc interval during off-pump coronary artery bypass surgery. Ramosetron should be used with caution in high risk patients for developing Torsades de Pointes. Trial registration ClinicalTrials.gov NCT02139241. Registered November 12, 2013 Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0222-1) contains supplementary material, which is available to authorized users.

Introduction Microvascular reactivity is decreased in patients with septic shock; this is associated with worse clinical outcomes. The objectives of the present study were to investigate microvascular reactivity in cardiac surgery patients and to assess any association with clinical outcomes. Methods We retrospectively analyzed a prospectively collected registry. In total, 254 consecutive adult patients undergoing cardiac and thoracic aortic surgeries from January 2013 through May 2014 were analyzed. We performed a vascular occlusion test (VOT) by using near-infrared spectroscopy to measure microvascular reactivity. VOT was performed three times per patient: prior to the induction of anesthesia, at the end of surgery, and on postoperative day 1. The primary endpoint was a composite of major adverse complications, including death, myocardial infarction, acute kidney injury, acute respiratory distress syndrome, and persistent cardiogenic shock. Results VOT recovery slope decreased during the surgery. VOT recovery slope on postoperative day 1 was significantly lower in patients with composite complications than those without (3.1 ± 1.6 versus 4.0 ± 1.5 %/s, P = 0.001), although conventional hemodynamic values, such as cardiac output and blood pressure, did not differ between the groups. On multivariable regression and linear analyses, low VOT recovery slope on postoperative day 1 was associated with increases of composite complications (odds ratio 0.742; 95 % confidence interval (CI) 0.584 to 0.943; P = 0.015) and hospital length of stay (regression coefficient (B) −1.276; 95 % CI −2.440 to −0.112; P = 0.032). Conclusion Microvascular reactivity largely recovered on postoperative day 1 in the patients without composite complications, but this restoration was attenuated in patients with composite complications. Trial registration ClinicalTrials.gov NCT01713192. Registered 22 October 2012.

Pulse pressure variation (PPV) is increasingly advocated as a predictor of fluid responsiveness in patients receiving mechanical ventilation. However, the ability of PPV has never been studied during one-lung ventilation (OLV). Therefore, we evaluated the value of PPV to predict fluid responsiveness in patients receiving conventional and protective OLV using receiver operating characteristic (ROC) analysis, respectively.Forty-nine patients undergoing lung surgery requiring OLV were enrolled in this study. Patients were randomised either to group P [patients receiving protective OLV with tidal volume 6 ml kg, inspired oxygen fraction (FIO2) of 0.5 and positive end-expiratory pressure (PEEP) of 5 cmH2O) or group C (patients receiving conventional OLV with tidal volume of 10 ml kg, FIO2 of 1.0 and no PEEP). Following OLV, PPV and cardiac output were measured before and 12 min after fluid loading (7 ml kg hydroxyethyl starch 6%). Patients whose cardiac indices increased by at least 15% to fluid loading were defined as the responders.The areas under ROC curve for PPV were 0.857 (P = 0.006) in group P and 0.524 (P = 0.839) in group C, respectively. The optimal threshold value given by ROC analysis for PPV was 5.8% in group P.PPV could predict fluid responsiveness only during protective OLV, but not conventional OLV. PPV would be helpful for fluid management in patients receiving protective OLV for lung surgery using thoracotomy.

Background It is well known that thermal softening of polyvinyl chloride tracheal tubes reduces nasal damage during nasotracheal intubation. We hypothesized that thermal softening of double-lumen endobronchial tubes (DLTs) may be effective for reducing airway injury. This randomized double-blind study was performed to investigate whether thermal softening of DLTs decreased postoperative sore throat, hoarseness or vocal cord injuries. Methods Patients (n+140) undergoing one lung anaesthesia were randomized into two groups (n+70 each) depending on whether the DLT was softened by warming or not before tracheal intubation. The DLTs were placed in warm saline [40(1)°C] in the thermal softening group or in room temperature saline in the control group for 10 min. The vocal cords were examined by using flexible laryngoscopy immediately after extubation. Sore throat and hoarseness were evaluated for three postoperative days. The primary outcomes were the incidence of sore throat, hoarseness, and vocal cord injuries. Results Sore throat and vocal cord injuries occurred less frequently in the thermal softening group than in the control group [14/70 vs 27/70, risk ratio (95% CI): 0.52 (0.30–0.90), P+0.025 for sore throat; 15/70 vs 27/70, risk ratio (95% CI): 0.56 (0.32–0.95), P+0.042 for vocal cord injuries]. However, the incidence of hoarseness was comparable between the two groups. Conclusion Tracheal intubation with DLTs softened by warming decreased the postoperative incidence of sore throat and vocal cord injuries. Therefore, thermal softening of DLTs before intubation seems to be helpful in reducing airway injuries associated with DLT intubation. Clinical trial registration NCT 01626365.

Background Excessive tracheal cuff pressure reduces tracheal mucosal blood flow and increases tracheal morbidity. Inserting a transoesophageal echocardiography (TOE) probe has been shown to increase tracheal cuff pressure. Objective To evaluate the effect of inserting a TOE probe on tracheal cuff pressure and compare the effect in patients who received a single-lumen endotracheal tube (SLT) with those who received a double-lumen endotracheal tube (DLT). Design A prospective, observational study. Setting Single-centre trial, study period from October 2013 to January 2014. Patients Forty-four adult patients scheduled for elective cardiothoracic surgery requiring intraoperative TOE monitoring. Interventions After tracheal intubation with a SLT (n = 22) or DLT (n = 22), the tracheal cuff was inflated to 18 mmHg (25 cmH2O) with air. Tracheal cuff pressure was monitored continuously for 5 min after inserting the TOE probe. Main outcome measures The primary endpoint was steady-state tracheal cuff pressure after insertion of the TOE probe. Results Median (interquartile range, IQR) tracheal cuff pressure stabilised at 3 (2 to 3) min in the SLT group and at 2 (1 to 3) min in the DLT group. Steady-state cuff pressure was significantly higher in the DLT group than that in the SLT group [36.7 (31.3 to 44.1) vs. 31.3 (29.6 to 35.7) cmH2O; (P = 0.03)]. Steady-state cuff pressure more than 40 cmH2O was observed in two patients (18.2%) in the SLT group and nine patients (40.9%) in the DLT group (P = 0.02). Conclusion Insertion of a TOE probe increased tracheal cuff pressure in both the SLT and DLT groups. The increase in cuff pressure was greater in patients who received a DLT. Frequent measurement and adjustment of cuff pressure should be emphasised particularly when TOE is used in patients receiving a DLT. Trial registration Clinicaltrials.gov identifier: NCT02034643.

Background Prolonged storage of red blood cells (RBCs) leads to fundamental changes in both the RBCs and the storage media. We retrospectively evaluated the relationship between the RBC age and in-hospital and long-term postoperative outcomes in patients undergoing off-pump coronary artery bypass. Methods The electronic medical records of 1,072 OPCAB patients were reviewed and information on the transfused RBCs and clinical data were collected. The effects of RBCs age (mean age, oldest age of transfused RBCs, any RBCs older than 14 days) on various in-hospital postoperative complications and long-term major adverse cardiovascular and cerebral events over a mean follow-up of 31 months were investigated. Correlations between RBCs age and duration of intubation, intensive care unit, or hospital stay, and base excess at the first postoperative morning were also analyzed. Results After adjusting for confounders, there was no relationship between the RBCs age and in-hospital and long-term clinical outcomes except for postoperative wound complications. A significant linear trend was observed between the oldest age quartiles of transfused RBCs and the postoperative wound complications (quartile 1 vs. 2, 3 and 4: OR, 8.92, 12.01 and 13.79, respectively; P for trend = 0.009). The oldest transfused RBCs showed significant relationships with a first postoperative day negative base excess (P = 0.021), postoperative wound complications (P = 0.001), and length of hospital stay (P = 0.008). Conclusions In patients undergoing off-pump coronary artery bypass, the oldest age of transfused RBCs were associated with a postoperative negative base excess, increased wound complications, and a longer hospital stay, but not with the other in-hospital or long-term outcomes. Electronic supplementary material The online version of this article (doi:10.1186/1471-2253-14-95) contains supplementary material, which is available to authorized users.

Background Craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). This prospective, randomized, double-blind, multi-center study was performed to evaluate the efficacy of prophylactic ramosetron in preventing PONV compared with ondansetron after elective craniotomy in adult patients. Methods A total of 160 American Society of Anesthesiologists physical status I–II patients aged 19–65 years who were scheduled to undergo elective craniotomy for various intracranial lesions were enrolled in this study. All patients received total intravenous anesthesia (TIVA) with propofol and remifentanil. Patients were randomly allocated into three groups to receive ondansetron (4 mg; group A, n = 55), ondansetron (8 mg; group B, n = 54), or ramosetron (0.3 mg; group C, n = 51) intravenously at the time of dural closure. The incidence of PONV, the need for rescue antiemetics, pain score, patient-controlled analgesia (PCA) consumption, and adverse events were recorded 48 h postoperatively. Results Among the initial 160 patients, 127 completed the study and were included in the final analysis. The incidences of PONV were lower (nausea, 14% vs. 59% and 41%, respectively; P

Lung resection surgery has been associated with numerous postoperative complications. Seventy-eight patients scheduled for elective video-assisted thoracoscopic lung resection were randomly assigned to receive standard postoperative care with incentive spirometry or standard care plus positive vibratory expiratory pressure treatment using the Acapella(®) device. There was no significant difference between incentive spirometry and the Acapella device in the primary outcome, forced expiratory volume in 1 s, on the third postoperative day, mean (SD) 53% (16%) vs 59% (18%) respectively, p = 0.113. Patients treated with both devices simultaneously found incentive spirometry to be less comfortable compared with the Acapella device, using a numeric rating scale from 1 to 5 with lower scores indicating higher comfort, median (IQR [range]) 3 (2-3 [2-4]) vs 1 (1-2 [1-3]) respectively, p < 0.001. In addition, 37/39 patients (95%) stated a clear preference for the Acapella device. Postoperative treatment with the Acapella device did not improve pulmonary function after thoracoscopic lung resection surgery compared with incentive spirometry, but it may be more comfortable to use.

Background A number of ‘proof-of-concept' trials suggest that remote ischaemic preconditioning (RIPC) reduces surrogate markers of end-organ injury in patients undergoing major cardiovascular surgery. To date, few studies have involved hard clinical outcomes as primary end-points. Methods Randomised clinical trials of RIPC in major adult cardiovascular surgery were identified by a systematic review of electronic abstract databases, conference proceedings and article reference lists. Clinical end-points were extracted from trial reports. In addition, trial principal investigators provided unpublished clinical outcome data. Results In total, 23 trials of RIPC in 2200 patients undergoing major adult cardiovascular surgery were identified. RIPC did not have a significant effect on clinical end-points (death, peri-operative myocardial infarction (MI), renal failure, stroke, mesenteric ischaemia, hospital or critical care length of stay). Conclusion Pooled data from pilot trials cannot confirm that RIPC has any significant effect on clinically relevant end-points. Heterogeneity in study inclusion and exclusion criteria and in the type of preconditioning stimulus limits the potential for extrapolation at present. An effort must be made to clarify the optimal preconditioning stimulus. Following this, large-scale trials in a range of patient populations are required to ascertain the role of this simple, cost-effective intervention in routine practice.

Minimizing hemodynamic changes during the peri-intubation period is a concern for anesthesiologists. We investigated the effect of lidocaine sprayed on the laryngoscope blade and trachea on hemodynamics during direct laryngoscopic intubation. Seventy-two patients were randomly allocated to one of four groups: 10 % lidocaine was sprayed either on the laryngoscope blade (group L), on the trachea (group V), or on the laryngoscope blade and the trachea (group LV). No lidocaine was used in group C. Anesthesia was induced in all patients with remifentanil (effect site concentration: 4.0 ng/ml) and propofol (effect site concentration 4.0 μg/ml) continuous infusion using a target control infusion (TCI) device. Mean arterial pressure (MAP) and heart rate (HR) were recorded during the peri-intubation period. Changes in MAP and HR over time were markedly different among the four groups (P

Recently, the number of diagnostic and interventional angiographic procedures performed is increasing. Many patients who undergo surgery receive various angiographic procedures. Some of them may have complications related to the procedures. One of the complications, femoral pseudoaneurysm (PSA), is a complication that follows femoral arterial cannulation for angiographic procedures [1]. We would like to report a case of an undiagnosed right femoral artery PSA found during a right femoral arterial line insertion. A 60-year old female patient, 161 cm in height and 51.7 kg in weight, was admitted for heart valve surgery. She had hypertension, severe mitral regurgitation, moderate aortic regurgitation and atrial fibrillation. She was taking antihypertensives and warfarin. During the preoperative evaluation, Takayasu arteritis was diagnosed. A preoperative CT angiogram showed bilateral total occlusion of the subclavian arteries and severe stenosis of the right and left common carotid arteries. Thus, the surgical plan was changed from heart valve surgery to innominate to left common carotid artery bypass surgery. Preoperative coronary angiography was performed via the right femoral artery three days before the operation. In the operating room, arterial cannulation of the right femoral artery was attempted. We tried to insert a femoral arterial line because the patient's bilateral brachial arterial stenosis made her radial artery unsuitable for an arterial line. Also, since an arterial line in the dorsalis pedis artery is easily underdamped, our first choice was the femoral artery. On visual inspection, there were no abnormalities of the right inguinal area except a small skin scar. An 18 gauge needle was inserted after palpation for the most pulsatile area. Blood was aspirated in the first attempt. However, the guide wire could not be advanced through the inserted needle. After several attempts, we used an ultrasound-guided technique to insert the wire and a PSA was found (Fig. 1). The PSA communicated with the right femoral artery through a small channel, and the guide wire was in the PSA. Therefore, we inserted an arterial line into the left dorsalis pedis artery. The resection of the PSA and the innominate to carotid bypass were done under general anesthesia and were uneventful. Fig. 1 Doppler image of the right femoral artery, showing a pseudoaneurysm communicating with the common femoral artery; CFA: common femoral artery. A PSA is a hematoma which communicates with the arterial circulation but is not surrounded by an arterial wall. It is distinguished from a true aneurysm which is a localized dilatation of an artery [2]. The femoral PSA is a complication that follows femoral arterial cannulation for angiographic procedures. The risk factors for femoral PSA formation include procedural and patient factors [3]. Procedural factors are low femoral puncture into the superficial femoral or profunda femoris artery, arterial cannulation for interventional purposes rather than diagnostic purposes, and inadequate compression after the procedure. Patient factors are obesity, anticoagulation, hemodialysis and calcified arteries. In this case, the patient was not obese and the puncture site was at the common femoral artery but she was taking warfarin due to atrial fibrillation. Doppler ultrasound has been the main method of diagnosis of PSA [1]. Typical findings include swirling color flow seen in a mass separate from the affected artery, and color flow within a tract communicating with the mass and the affected artery as a PSA neck [4]. The treatment options of PSA include conservative management, ultrasound-guided compression, minimally invasive percutaneous therapies (thrombin or collagen injection and coil embolization), and surgical repair [2]. Percutaneous ultrasound-guided thrombin injection is currently the treatment of choice in many centers due to advantages such as a shorter procedural time, better patient tolerance and higher effectiveness in patients on anticoagulants, compared with ultrasound-guided compression [2]. Indications for surgical treatment are rapid expansion of the PSA, failure of percutaneous intervention, concomitant distal ischemia, and neurological deficits [1]. The PSA of this patient did not meet the indications for surgery. However, considering that the patient was already anesthetized, surgical repair as a definitive treatment was performed. Complications of PSA include rupture, distal embolization, local pain, neuropathy and local skin ischemia from its mass effect [4]. According to the medical record, a vascular closure device (Perclose ProGlide™, Abbott Vascular Inc., Redwood City, CA, USA) was used after the coronary angiography but the impact of arterial puncture closure devices on PSA formation is unclear [5]. The number of angiographic procedures being performed and the number of patients who need invasive blood pressure monitoring during surgery are constantly increasing. Many patients who need angiographic procedures before surgery also need invasive blood pressure monitoring. As in this case, options for sites for insertion of an arterial line may be limited because of underlying disease, vascular status, and the type of surgery involved. If the artery selected for cannulation was previously an access site for a percutaneous angiographic procedure, ultrasonographic examination of the artery before cannulation may be useful for avoiding further complications. Also, if an arterial line cannot be inserted even after repeated attempts, an anesthesiologist may consider examination of the puncture site with an ultrasound device.

Antiphospholipid syndrome (APS) is a rare disease in which patients display prolonged coagulation test results in vitro, but usually develop thrombotic symptoms in vivo. Patients with APS are at increased risk of valvular heart disease or coronary vascular disease, conditions that often necessitate cardiac surgery via bypass. The management of anticoagula tion during cardiopulmonary bypass (CPB) is particularly challenging in these patients because of the unique features of APS. Patients with APS are constantly at risk of arterial and venous thrombotic events. Therefore it is very important to maintain proper anticoagulation perioperatively, especially during CPB. In this paper, we present three successful cases of APS patients who underwent cardiac surgery with CPB. (Korean J Anesthesiol 2014; 66: 164-168)

Background: Myocardial injury is associated with an adverse outcome after off-pump coronary artery bypass graft surgery (OPCAB). The authors conducted a randomized controlled trial to evaluate whether remote ischemic preconditioning (RIPC) with remote ischemic postconditioning (RIPostC) reduces myocardial injury in patients undergoing OPCAB. Methods and Results: Seventy patients scheduled for OPCAB were randomly assigned to an RIPC+RIPostC group (n=35) or a control group (n=35). In the RIPC+RIPostC group, 4 cycles of 5-min ischemia and 5-min reperfusion were done on a lower limb before anastomoses (RIPC) and after anastomoses (RIPostC). RIPC+RIPostC significantly reduced postoperative serum troponin I levels (P=0.001). The area under the curve for postoperative troponin I was 48.7% lower in the RIPC+RIPostC group (median [interquartile range], 21.3h·ng-1·ml-1, 16.5-53.1h·ng-1·ml-1 vs. 41.5h·ng-1·ml-1, 24.6-90.2h·ng-1·ml-1, P=0.020). There was no significant difference in creatinine levels and PaO2/FiO2 ratios between the 2 groups. Conclusions: RIPC+RIPostC by lower limb ischemia decreased postoperative myocardial enzyme elevation by almost half postoperatively in patients undergoing OPCAB. (Circ J 2012; 76: 884-890)

The aim of this study was to evaluate the ability of pulse-pressure variation to predict fluid responsiveness during heart displacement for off-pump coronary artery bypass surgery using receiver operating characteristic analysis.A prospective study.A clinical study in a single cardiac anesthesia institution.Thirty-five patients undergoing elective off-pump coronary artery bypass surgery.Central venous pressure, pulmonary arterial occlusion pressure, pulse-pressure variation, and cardiac index were measured 5 minutes after revascularization of the left anterior descending coronary artery and before heart displacement. Immediately after heart displacement for revascularization of the left circumflex artery, and 10 minutes after fluid loading with hydroxyethyl starch 6% (10 mL/kg) during heart displacement, the measurements were repeated. Patients whose cardiac indices increased by ≥15% from fluid loading were defined as responders. After heart displacement, only pulse-pressure variation showed significant difference between the responders and nonresponders (13.48 ± 6.42 v 7.33 ± 3.81, respectively; p0.01). Moreover, receiver operating characteristic analysis showed that pulse-pressure variation successfully predicted fluid responsiveness (area under the curve = 0.839, p = 0.0001). Pulse-pressure variation7.69% identified the responders, with a sensitivity of 86% and a specificity of 83%.Pulse-pressure variation successfully predicted fluid responsiveness and would be useful in guiding fluid management during heart displacement for off-pump coronary artery bypass surgery.

Previous studies have failed to demonstrate that the head-down tilt position confers benefits in hypovolaemic hypotensive patients. The aim of this study was to evaluate the haemodynamic effect and vasopressor use by this position in hypotensive patients after the induction of general anaesthesia.This prospective randomised study involved 98 patients scheduled for elective cardiac surgery and 40 patients (40.1%) developed hypotension after anaesthesia induction. Upon occurrence of hypotension, patients were randomly allocated to the supine (n = 19) or head-down tilt (n = 21) groups (15° head-down tilt position). Blood pressure, heart rate, cardiac index and stroke volume index were recorded at 1-min interval for 10 min from the occurrence of hypotension. Vasopressors were administered to treat hypotension in both groups.No haemodynamic difference was observed between the supine and head-down tilt groups except for SBP changes from baseline at 1 min (-3.98 ± 6.31 vs. 1.84 ± 8.25%, P = 0.004) and 2 min (1.51 ± 14.34 vs. 9.37 ± 10.57%, P = 0.032). The number of vasopressor administrations and percentage of the patients requiring vasopressors in the supine group were greater than that in the head-down tilt group [median 1 (range 1-5) vs. median 0 (range 0-2), P = 0.002, 19/19 (100%) vs. 10/21 (47.6%), P0.001].The head-down tilt position in hypotensive patients following anaesthesia induction reduced vasopressor requirement by almost one third. Minimal haemodynamic effect may be caused by different vasopressor administrations. This result suggests that the head-down tilt position may enable more stable anaesthesia induction in patients undergoing elective coronary artery bypass graft or valvular heart surgeries.

Background: We hypothesized that, even in patients taking aspirin, the variance of preoperative platelet response to collagen might be associated with myocardial injury during coronary artery bypass graft (CABG) surgery. Therefore, we evaluated the relationship between preoperative whole-blood aggregometry (WBA) by collagen and the post operative myocardial injuries. Methods: For 44 patients who were scheduled for elective off -pump CABG and taking aspirin, WBA was measured by the impedance method in the presence of collagen (2 mg/ml or 5 mg/ml) as stimulatory agents. After CABG, myocardial injury was evaluated by analysis of the creatine kinase (CK), creatine kinase-MB (CK-MB), and lactate dehydrogenase (LD), and by electrocardiography. Results: High response group (n = 13) on preoperative WBA with collagen (2 and 5 mg/ml) showed significantly higher postoperative cardiac enzyme levels (CK, CK-MB and LD) than those of low response group (n = 31). Conclusions: In patients who take aspirin and undergoing off -pump CABG, the preoperative platelet response to collagen is correlated with postoperative myocardial injury.