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Background Despite previous reports suggesting that pressure support ventilation facilitates weaning from mechanical ventilation in the intensive care unit, few studies have assessed its effects on recovery from anesthesia. The authors hypothesized that pressure support ventilation during emergence from anesthesia reduces postoperative atelectasis in patients undergoing laparoscopic surgery using the Trendelenburg position. Methods In this randomized controlled double-blinded trial, adult patients undergoing laparoscopic colectomy or robot-assisted prostatectomy were assigned to either the pressure support (n = 50) or the control group (n = 50). During emergence (from the end of surgery to extubation), pressure support ventilation was used in the pressure support group versus intermittent manual assistance in the control group. The primary outcome was the incidence of atelectasis diagnosed by lung ultrasonography at the postanesthesia care unit (PACU). The secondary outcomes were Pao2 at PACU and oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively. Results Ninety-seven patients were included in the analysis. The duration of emergence was 9 min and 8 min in the pressure support and control groups, respectively. The incidence of atelectasis at PACU was lower in the pressure support group compared to that in the control group (pressure support vs. control, 16 of 48 [33%] vs. 28 of 49 [57%]; risk ratio, 0.58; 95% CI, 0.35 to 0.91; P = 0.024). In the PACU, Pao2 in the pressure support group was higher than that in the control group (92 ± 26 mmHg vs. 83 ± 13 mmHg; P = 0.034). The incidence of oxygen saturation measured by pulse oximetry less than 92% during 48 h postoperatively was not different between the groups (9 of 48 [19%] vs. 11 of 49 [22%]; P = 0.653). There were no adverse events related to the study protocol. Conclusions The incidence of postoperative atelectasis was lower in patients undergoing either laparoscopic colectomy or robot-assisted prostatectomy who received pressure support ventilation during emergence from general anesthesia compared to those receiving intermittent manual assistance. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Current guidelines recommend delaying noncardiac surgery for 6 months after drug eluting stent implantation. However, this recommendation is largely based on limited evidence and various event definitions. Whether early surgery within 6 months of coronary stent implantation increases myocardial injury in patients with normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) has not yet been investigated. This retrospective study assessed patients who received coronary stent implantation and underwent noncardiac surgery (vascular, abdominal, or thoracic) between 2010 and 2017 with normal preoperative hs-cTnI (n = 186). Patients were divided into early (within 6 months of PCI) and late (after 6 months of PCI) groups. The primary endpoint was the incidence of myocardial injury as diagnosed by hs-cTnI within 3 days post-operation. The secondary outcomes were myocardial infarction, stent thrombosis, emergent coronary revascularization, major bleeding (bleeding requiring transfusion or intracranial bleeding), stroke, renal failure, heart failure, or death within 30 days post-operation. Inverse probability treatment weighting (IPTW) was carried out to adjust for the intergroup baseline differences. Myocardial injury occurred in 28.6% (8/28) and 27.8% (44/158) of the early and late groups, respectively, with no difference between groups (odds ratio [OR] 1.067, 95% confidence interval [CI] 0.404, 2.482; p = 0.886). Secondary outcomes did not differ between the groups. IPTW analysis also showed no differences in myocardial injury and secondary outcomes between the groups. In conclusion, early surgery within 6 months after coronary stent implantation did not increase the incidence of myocardial injury in patients with normal preoperative hs-cTnI.

Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.

We conducted a single-center retrospective study to evaluate the effects of intraoperative hypotension (IOH) on postoperative myocardial injury during major noncardiac surgery in patients with prior coronary stents with preoperatively normal cardiac troponin I levels. Although IOH is assumed to increase the risk of postoperative myocardial injury in patients with prior coronary stents, the level and duration of hazardous low blood pressure have not been clarified. Of 2517 patients with prior coronary stents undergoing noncardiac surgery between January 2010 and March 2017, we analyzed 195 undergoing major surgery (vascular, abdominal, and thoracic surgery) who had a normal preoperative high-sensitivity cardiac troponin I (hs-cTnI) level and were followed up postoperatively within 3 days. Postoperative myocardial injury was defined as a hs-cTnI level greater than the 99th percentile reference value. Primary IOH exposure was defined as a decrease of ≥ 50%, 40%, or 30% from the preinduction mean blood pressure. Additional definition of IOH was absolute mean blood pressure

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure–guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure–guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation. Methods In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6 ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure–PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3. Results Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92). Conclusions Application of driving pressure–guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.

Background Sevoflurane and desflurane are widely used in balanced anaesthesia in combination with opioid analgesics. The opioid remifentanil is frequently chosen because of its extremely rapid pharmacokinetics. However, intraoperative high-dose remifentanil is associated with increased postoperative pain and rescue analgesic use owing to acute tolerance and opioid-induced hyperalgesia. This study aimed to compare intraoperative remifentanil requirements during equi-minimum alveolar concentration (MAC) sevoflurane and desflurane anaesthesia via surgical pleth index-guided remifentanil administration. Methods Eighty-two subjects undergoing laparoscopic cholecystectomy were randomly allocated to two groups receiving either sevoflurane (n=40) or desflurane (n=42). Anaesthesia was maintained with the assigned inhaled anaesthetics and remifentanil. End-tidal anaesthetic concentration was maintained at age-corrected 1.0 MAC, and remifentanil infusion was continuously adjusted to achieve a surgical pleth index of 20–50. Mean remifentanil infusion rate, which was the primary outcome of the study, was calculated as the total infused remifentanil dose per kg body weight per minute of total operative time. Results Mean remifentanil infusion rate [mean (standard deviation)] was significantly higher in the sevoflurane group than in the desflurane group [0.192 (0.064) vs. 0.099 (0.033) μg kg−1 min−1; difference, 0.093 (95% confidence interval, 0.071–0.115); P Conclusions During equi-MAC anaesthesia of 1.0 MAC, sevoflurane and desflurane did not show similar intraoperative remifentanil consumption under surgical pleth index-guided opioid administration. Further studies using other monitors with different measuring mechanisms are warranted to determine the cause of this difference. Clinical trial registration NCT02830243 ( ClinicalTrials.gov ).

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4–5 ml.kg−1.h−1 according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg−1.h−1), Cutoff (4–5 ml.kg−1.h−1) and High (≥6 ml.kg−1.h−1) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35–0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4–5 ml.kg−1.h−1 was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.

Objective Postoperative delirium is associated with longer hospital stay and increased morbidities. Patients undergoing esophagectomy have a high chance of developing postoperative delirium because of their advanced age, comorbidities, and intensive care unit care. In this study, we investigated the risk factors of early postoperative delirium in patients undergoing esophagectomy, focusing on perioperative fluid type to test the hypothesis that colloids with high oncotic pressure and anti-inflammatory action would decrease the incidence of postoperative delirium compared with crystalloids. Methods All patients who underwent esophagectomy from 2010 to 2015 in a tertiary care center were reviewed in this retrospective study (n = 1041). Patients who showed positive Confusion Assessment Method or received haloperidol within 4 days postoperatively were enrolled as those with postoperative delirium (+). Multivariable logistic regression was performed to identify risk factors for postoperative delirium. Incidence of postoperative delirium was compared among crystalloids, hydroxyethyl starch, and albumin groups after propensity score matching. Results The incidence of delirium within postoperative 4 days was 22.7%. Infusion of hydroxyethyl starch was an independent risk factor (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.09-2.14; P = .0151). Other risk factors were age (OR, 1.04; 1.02-1.06, per year; P = .0002), preoperative cerebrovascular disease (OR, 2.18; 1.15-4.12; P = .0170), pulmonary dysfunction (OR, 1.85; 1.33-2.58; P = .0003), and transfusion (OR, 1.76; 1.22-2.53; P = .0023). Propensity score matching analysis confirmed that administration of hydroxyethyl starch, but not albumin, is related to postoperative delirium. Conclusions Old age, preoperative cerebrovascular disease, pulmonary dysfunction, transfusion, and hydroxyethyl starch administration were related to early postoperative delirium. If colloid must be administered, albumin is preferred to hydroxyethyl starch.

Objective Hypoxemia is common during one-lung ventilation (OLV) for thoracic surgery. When hypoxemia occurs, surgery is interrupted for rescue ventilation. Apneic oxygen insufflation (AOI), which provides O 2 without applying pressure, may prevent hypoxemia and does not interrupt surgery. The aim of this study was to determine the effectiveness of the AOI technique for preventing hypoxemia during OLV in thoracic surgery. Methods Patients undergoing open or thoracoscopic pulmonary lobectomy from September to December 2015 were included. Patients were assigned randomly to a non-AOI group or an AOI group (n = 45 each). OLV was initiated and at the 15-minute mark (OLV15), patients in the AOI group received oxygen insufflation at 3 L/min to the nonventilated lung for 30 minutes (OLV45). The primary endpoint was the occurrence of hypoxemia (SaO 2 Results The demographic and operative data were similar between the 2 groups. The incidence of hypoxemia was greater in the non-AOI than the AOI group (18% vs 0%; P = .009). ΔPaO 2 (the difference in partial pressure of oxygen in arterial blood between OLV 45 and 15 minutes) was smaller in the AOI than the non-AOI group (−29 mm Hg vs −69 mm Hg; P = .005). Duration of surgery and incidence of complications did not vary between groups. Conclusions AOI decreases the incidence of hypoxemia and improves arterial oxygenation during OLV for open and thoracoscopic surgery. AOI may be a valuable option to prevent hypoxemia. It can be used before relying on continuous positive airway pressure or intermittent two-lung ventilation and result in fewer interruptions in surgery.

Background Postoperative delirium (POD) is one of messy complications related with increased mortality and hospital costs. Patients undergoing esophagectomy are more in danger of delirium than other kinds of surgeries. We investigated the impact of robot-assisted thoracoscopic esophagectomy on the incidence of POD compared with open transthoracic esophagectomy. Materials and methods A retrospective review was completed for the patients who underwent esophagectomy from December 2, 2012 and April 15, 2015 (n=529). POD was assessed using Confusion Assessment Method for the Intensive Care Unit. The comparison of group differences between the robotic esophagectomy group (R group) and the open esophagectomy group (O group) was conducted with and without propensity score (PS) matching method. Univariate model was used for 247 PS-matched patients to calculate the odds ratio of potential risk factors of POD. Results The incidence rate of POD was significantly lower among R group patients than O group (30% vs. 42%; P=0.035) after PS matching method. The risk of POD in R group was 0.55-fold lower than that of O group. Operative time and intraoperative blood loss were also significantly lower in R group patients. Conclusions In conclusion, robotic thoracoscopic esophagectomy lowers the incidence of POD 0.55-fold compared with open transthoracic esophagectomy.

Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively (n = 980). Patients were divided into Steroid (n = 120) and Control (n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.

Background: Although corticosteroids were known to reduce acute respiratory distress syndrome (ARDS) after esophagectomy, the efficacy of corticosteroid remains debatable. Moreover, the risk of anastomosis leakage or infection, which relates to the administration of corticosteroid is another concern. Therefore, we compared the incidence of composite complications between patients who received or not the preventive administration of corticosteroid in esophagectomy. Methods: All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital, were reviewed in this retrospective study (n=1,041). Patients were divided into Steroid (n=120) and Control (n=860) groups based on the preventive administration of corticosteroid during surgery. The primary endpoint was the incidence of composite complications (acute respiratory distress syndrome, wound dehiscence, and infection). Comparison between the two groups was performed after adjustment of co-variables. Results: The incidence of composite complications was not different between Steroid and Control group (21.7% vs 17.4%, respectively; P=0.26). Incidence of complications in each category between Steroid and Control groups were not significantly different: acute respiratory distress syndrome (5.0% vs 3.8%; P=0.46), graft dehiscence (6.7% vs 4.8%; P=0.37), and infection (15.8% vs 12.8%; P=0.36). After propensity score matching, the difference between the groups was also not significant. In multivariable analysis, age, lower body mass index, diabetes mellitus and duration of operation were independent risk factors of composite complications. Additionally, intraoperative vasopressor was a risk factor of graft dehiscence (odds ratio, 2.06; 95% confidence interval, 1.03-4.12; P=0.0407). Conclusions: The preventive use of corticosteroid was not related to the incidence of composite complications after esophagectomy. Application of corticosteroid for prevention of acute respiratory distress syndrome is not recommended due to its lack of apparent benefit. Keywords: Acute respiratory distress syndrome, corticosteroid, esophagectomy.

Isoflurane has either neuroprotective or neurotoxic effects. High-dose oxygen is frequently used throughout the perioperative period. We hypothesized that hyperoxia will affect cell viability of rat pheochromocytoma (PC12) cells that were exposed to isoflurane and reactive oxygen species (ROS) may be involved. PC12 cells were exposed to 1.2% or 2.4% isoflurane for 6 or 24h respectively, and cell viability was evaluated. To investigate the effects of hyperoxia, PC12 cells were treated with 21%, 50%, or 95% oxygen and 2.4% isoflurane for 6h, and cell viability, TUNEL staining, ROS production, and expression of B-cell lymphoma 2 (BCL-2), BCL2-associated X protein (BAX), caspase-3 and beta-site APP cleaving enzyme (BACE) were measured. ROS involvement was evaluated using the ROS scavenger 2-mercaptopropiopylglycine (MPG). The viability of cells exposed to 2.4% isoflurane was lower than that of cells exposed to 1.2% isoflurane. Prolonged exposure (6h vs. 24h) to 2.4% isoflurane resulted in a profound reduction in cell viability. Treatment with 95% (but not 50%) oxygen enhanced the decrease in cell viability induced by 2.4% isoflurane alone. Levels of ROS, Bax, caspase-3 and BACE were increased, whereas expression of Bcl-2 was decreased, in cells treated with 95% oxygen plus 2.4% isoflurane compared with the control and 2.4% isoflurane plus air groups. MPG attenuated the effects of oxygen and isoflurane. In conclusion, isoflurane affects cell viability in a dose- and time-dependent manner. This effect is augmented by hyperoxia and may involve ROS, the mitochondrial apoptotic signaling pathway, and β-amyloid protein.

The prognostic nutritional index is a score that represents a patient's immune-nutritional status based on the lymphocyte count and serum albumin concentration. We hypothesized that preoperative prognostic nutritional index is associated with postoperative complications and long-term outcomes after curative resection of lung cancer.We retrospectively analyzed 1011 patients with pathologic stage I-III adenocarcinoma and squamous cell carcinoma who underwent open thoracotomy for curative resection of lung cancer. The preoperative prognostic nutritional index was calculated as follows based on preoperative laboratory data: 10 × serum albumin (g/dL) + 5 × total lymphocyte count (/nL). The cutoff value of prognostic nutritional index (cutoff value: 50) was obtained by receiver operating characteristics curve and patients were classified as high and low groups. Outcomes were compared with the use of propensity scores and inverse probability weighting adjustment to reduce treatment selection bias.The low group exhibited more postoperative complications (34% [96/285] vs 24% [174/726]; P = .002) especially pneumonia (13% [36/285] vs 6% [41/756]; P .001) and delirium (10% [29/285] vs 5% [36/726]; P = .002), and greater in-hospital mortality (4% [11/285] vs 1% [9/726]; P = .007) than the high group. A low prognostic nutritional index was associated with greater postoperative pulmonary complications [odds ratio, 1.7; 95% confidence interval, 1.3-2.3], lower recurrence-free survival (hazard ratio, 1.3; 95% confidence interval, 1.1-1.5), and overall survival (hazard ratio, 1.5; 95% confidence interval, 1.2-1.8) after balancing the covariables.The preoperative prognostic nutritional index was associated with postoperative pulmonary complications and long-term outcomes after curative resection of non-small cell lung cancer.

We investigated whether preventive use of dexmedetomidine during surgery was effective for reducing emergence agitation and postoperative delirium.In this double-blind randomized-controlled trial, 143 patients undergoing thoracoscopic lung resection surgery were randomly assigned to the dexmedetomidine-sevoflurane (DEX-Sevo, n = 73) or sevoflurane (Sevo, n = 70) groups. Dexmedetomidine or saline administration was started after inducing anesthesia and continued until the end of surgery at a fixed dose (0.5 µg·kgThe DEX-Sevo group showed less frequent emergence agitation than the Sevo group (13% vs 35%, respectively; relative risk, 0.38; 95% confidence interval [CI], 0.18 to 0.79; P = 0.011) but the incidence of delirium after discharge from the postanesthesia care unit was not different (25% vs 25%, DEX-Sevo vs Sevo). Both pro- and anti-inflammatory cytokines were lower in the DEX-Sevo group than in the Sevo group. Nevertheless, the interleukin (IL)6/IL10 ratio (median difference, 5.8; 95% CI,1.8 to 10.0; P = 0.012) and IL8/IL10 ratio (median difference, 0.8; 95% CI, 0.2 to 1.3; P = 0.007) were higher in the DEX-Sevo group than in the Sevo group, indicating a pro-inflammatory cytokine balance in the DEX-Sevo group. Norepinephrine and epinephrine levels were lower in the DEX-Sevo group than in the Sevo group (both, P0.001).Intraoperative dexmedetomidine reduced emergence agitation but not postoperative delirium in patients undergoing thoracic surgery. Dexmedetomidine seemed to affect emergence agitation through catecholamines, but not through an anti-inflammatory action. Trial registration Clinical Research Information Service (KCT 0001877); registered 7 April, 2016.RéSUMé: OBJECTIF: Nous avons cherché à savoir si l’utilisation préventive de dexmédétomidine au cours de la chirurgie pouvait réduire la survenue de l’agitation au réveil et du delirium postopératoire. MéTHODES: Dans cette étude randomisée, contrôlée à double insu, 143 patients subissant une résection pulmonaire par thoracoscopie ont été randomisés dans un groupe recevant dexmédétomidine-sévoflurane (DEX-Sévo, n = 73) ou dans un groupe recevant seulement du sévoflurane (Sévo, n = 70). L’administration de dexmédétomidine ou de solution saline a débuté après l’induction de l’anesthésie et a continué jusqu’à la fin de l’intervention à une dose fixe de 0,5 µg·kg

Background: The mortality and morbidity associated with video-assisted thoracoscopic (VATS) lung biopsy for interstitial lung disease (ILD) are not negligible. We evaluated whether non-intubated VATS lung biopsy, which avoids intubation and general anesthesia, can be safely performed in ILD subjects. Methods: This retrospective study compared the incidence of complications and surgical mortality between 25 consecutive intubated subjects and 10 non-intubated subjects (a total of 35 consecutive subjects) at a single institution. Results: No major surgical complications or deaths were reported in either group, and non-intubated VATS biopsies were safely performed in subjects with relatively low carbon monoxide diffusing capacity (P=0.08) or poor American Society of Anesthesiologists physical status scores (ASA) (P=0.02). Conclusions: These preliminary results suggest that non-intubated VATS lung biopsy is a safe and feasible option in patients with ILD.

In this in vivo and in vitro study, we aimed to investigate whether isoflurane preconditioning-induced neuronal protection is mediated by reactive oxygen species (ROS) signaling at the reperfusion stage. In the in vivo study, Sprague-Dawley rats were subjected to middle cerebral artery occlusion (MCAO) and in the in vitro study, rat pheochromocytoma (PC12) cells were subjected to oxygen glucose deprivation (OGD). Isoflurane preconditioning was carried out prior to MCAO or OGD and the ROS scavenger, N-2-mercaptopropiopylglycine (2-MPG), was administered at the start of reperfusion. Infarct volume, neurological severity score, and TUNEL staining were analyzed in the in vivo study and cell viability, Bcl-2/Bax ratio, cleaved caspase 3/caspase 3 ratio, and ROS fluorescence intensity were measured in the in vitro study. In the in vivo study, infarct volume, neurological severity score, and TUNEL-positive cell count were significantly decreased with preconditioning but were abrogated by administration of 2-MPG. In the in vitro study, cell viability and Bcl-2/Bax ratio were significantly increased with preconditioning, and cleaved caspase-3/caspase-3 ratio and ROS fluorescence intensity were significantly decreased. Administration of 2-MPG for 10 min abrogated this preconditioning effect, but it did not abolish the protection when administered for 60 min of reperfusion. Isoflurane preconditioning-induced protection was abolished by ROS scavengers at the start of reperfusion, indicating that ROS signaling can mediate the isoflurane preconditioning effect, which suggests that the time window can be important.

Stroke volume variation (SVV) and pulse pressure variation (PPV) are used as indicators of fluid responsiveness, but little is known about the usefulness of these dynamic preload indicators in thoracic surgery, which involves an open thoracic cavity and 1-lung ventilation (OLV). Therefore, we investigated whether SVV and PPV could predict fluid responsiveness, and whether the thresholds of these parameters should be adjusted for thoracic surgery.This was a prospective, controlled study conducted in a tertiary care center. Eighty patients scheduled for an elective lobectomy requiring OLV were included (n = 40, video-assisted thoracoscopic surgery (VATS); n = 40, open thoracotomy). Twenty minutes after opening the thoracic cavity, 7 mL/kg hydroxyethyl starch was administered for 30 minutes. Various hemodynamic parameters were measured before and after fluid challenge.Among the 80 patients enrolled in this study, 37% were fluid responders (increase in stroke volume index ≥10%). SVV before fluid challenge was not different between nonresponders and responders (mean ± SD: 7.1 ± 2.7% vs 7.4 ± 2.6%, P = .68). This finding was true regardless of whether the surgery involved open thoracotomy or VATS. PPV before fluid challenge showed the difference between nonresponders and responders (mean ± SD: 6.9 ± 3.0% vs 8.4 ± 3.2%; P = .045); however, the sensitivity and specificity of the threshold value (PPV = 7%) were low (58% and 62%, respectively) and the area under the receiver operating characteristics curve was only 0.63 (95% confidence interval, 0.52-0.74; P = .041).Dynamic preload indicators are not useful for predicting fluid responsiveness in VATS or open thoracic surgery.

Relapsing polychondritis (RP) is an uncommon disease that is characterized by inflammation and destruction of carti laginous structures. When tracheobronchial tree is involved, respiratory obstructive symptoms can occur. A 35-year-old man, with a previous diagnosis of RP, was scheduled for rigid bronchoscopy to relieve dyspnea, caused by subglottic stenosis. After laser splitting of the subglottic web, the spontaneous respiration of the patient was insufficient, and hypercar bia developed progressively even with assisted ventilation. After 20 minutes of aggressive hyperventilation to reduce endtidal CO2 level, sudden extreme tachycardia and hypotension developed. Ventilation rate was reduced and prolonged expiration time was allowed to alleviate a near-tampon status from dynamic hyperinflation. After the hemodynamic status was stabilized, the patient was transferred to the ICU for mechanical ventilation. He received ICU care for 30 days, and now, he was on supportive care on a ward, considering Y stent insertion to prevent luminal collapse from tracheobronchomalacia. (Korean J Anesthesiol 2013; 65: 569-573)

Variation in urogenital vessels is of interest to clinicians as well as anatomists since it has complex steps of urogenital development. We found 2 right and 3 left renal arteries, double right renal veins, the right testicular artery arisen from the right main renal artery, and the right testicular vein as a tributary of an additional right renal vein in a 57-year-old Korean male cadaver, whose cause of death was 'unknown'. The multiple vascular variations near the renal hilum are detectable in seemingly normal individuals and a deeper understanding of the complicated urogenital vasculature might be very important with its embryogenesis.

BACKGROUND: Although anesthetic-induced inhibition of lipopolysaccharide (LPS)-induced lung injury has been recognized, the underlying mechanism is obscure. Some studies suggest that reactive oxygen species (ROS) by isoflurane play a crucial role for anesthetic-induced protective effects on the brain or the heart; however, it still remains controversial. In this study, we examined the role of isoflurane-derived ROS in isoflurane-induced inhibition of lung injury and nuclear factor κB (NFκB) activation in LPS-challenged rat lungs. METHODS: Male Sprague-Dawley rats were subjected to inhalation of 1.0 minimum alveolar concentration of isoflurane for 60 minutes, and intratracheal LPS 0.1 mg was administered 60 minutes later. In some cases, ROS scavenger, 2-mercaptopropinyl glycine or N-acetylcysteine was given 30 minutes before isoflurane. ROS generation was measured by fluorometer before LPS challenge and 4 hours after. Isoflurane’s preconditioning effect was assessed by histologic examination, protein content, neutrophil recruitment, and determination of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 levels in bronchoalveolar lavage fluid and lung tissue. Western blotting measured phosphorylation of inhibitory κB α (ser 32/36), NFκB p65, and inducible nitric oxide synthase (iNOS). TNF-α and IL-6 mRNA expression and immunofluorescence staining for iNOS were also assessed. RESULTS: Isoflurane preconditioning reduced inflammatory lung injury and TNF-α, IL-1β, and IL-6 release in the lung. Isoflurane upregulated ROS generation before LPS but inhibited a ROS burst after LPS challenge. ROS scavenger administration before isoflurane abolished the isoflurane preconditioning effect as well as isoflurane-induced inhibition of phosphorylation of inhibitory κBα, NFκB p65, iNOS activation, and mRNA expression of TNF-α and IL-6 in acute LPS-challenged lungs. CONCLUSIONS: This study suggests a crucial role of upregulated ROS generation by isoflurane for modification of inflammatory pathways by isoflurane preconditioning in acute inflammation of the lung.

Background: Risk scoring system for thoracic surgery patients have not been widely used, as of recently. We tried to forge a risk scoring system that predicts the risk of postoperative complications in patients undergoing major thoracic surgery. We used a prolonged ICU stay as a representative of postoperative complications and tested various possible risk factors for its relation. Methods: Data from all patients who underwent major lung and esophageal cancer surgeries, between 2005 and 2007 in our hospital, were collected retrospectively (n = 858). Multiple logistic regression analysis was performed with various possible risk factors to build the risk scoring system for prolonged ICU stay (> 3 days). Results: A total of 9% of patients exhibited more than 3 days of ICU stay. Age, operation name, preoperative lung injury, no epidural analgesia, and predicted post operative forced expiratory volume in 1 second (ppoFEV1) were the risk factors for prolonged ICU stay, by multivariable analysis (P < 0.05). Risk score, p was derived from the formula: logit(p/[1-p]) = -5.39 + 0.06 × age + 1.12 × operation name(2) + 1.52 × operation name(3) + 1.32 × operation name(4) + 1.56 × operation name(5) + 1.30 × preoperative lung injury + 0.72 × no epidural analgesia - 0.02 × ppoFEV1 [Age in years, operation name(2): pneumonectomy, operation name(3): esophageal cancer operation, operation name(4): completion pneumonectomy, operation name(5): extended operation, preoperative lung injury(+), epidural analgesia(-), ppoFEV1 in %]. Conclusions: Age, operation name, preoperative lung injury, epidural analgesia, and ppoFEV1 can predict postoperative morbidity in thoracic surgery patients. (Korean J Anesthesiol 2012; 63: 527-532)

Increased intraocular pressure (IOP) during surgery can result in serious ophthalmic complications. We hypothesized that carbon dioxide (CO₂) insufflation of the neck during endoscopic thyroidectomy would constrict the jugular veins mechanically, causing elevated venous pressure and thus elevated IOP. We compared IOP changes at each step of open thyroidectomy (OT) versus robot-assisted endoscopic thyroidectomy (RET) METHODS: Perioperatively, IOP was measured at six time points in patients undergoing OT (n = 18) or RET with CO₂ insufflation (n = 19). Anesthesia, ventilatory strategy, intravenous infusions, and surgical positioning were standardizedIn both groups, induction of anesthesia reduced IOP, but surgical positioning with the neck in extension had no effect on IOP. In the OT group, IOP remained unchanged during anesthesia. In the RET group, CO₂ insufflation significantly increased IOP to an average of 3.6 ± 3.0 mmHg higher than the previous measurement (P0.001), and this IOP increase persisted immediately before gas deflation. These elevated IOP values during CO₂ insufflation in the RET group were significantly higher than those at corresponding time points in the OT group. However, these elevated IOP values were similar to the pre-anesthetic baseline IOP CONCLUSION: CO₂ insufflation of the neck at pressure of 6 mmHg increased the IOP significantly compared with open thyroidectomy. However, this increase in IOP could be balanced by an anesthetic-induced IOP-lowering effect, thereby having no clinical significance in patients with normal IOP undergoing robot-assisted endoscopic thyroidectomy.

Fluid is usually restricted during thoracic surgery, and vasoactive agents are often administered to maintain blood pressure. One-lung ventilation (OLV) decreases arterial oxygenation; thus oxygen delivery to the brain can be decreased. In this study, we compared phenylephrine and dopamine with respect to maintaining cerebral oxygenation during OLV in major thoracic surgery. Sixty-three patients undergoing lobectomies were randomly assigned to the dopamine (D) or phenylephrine (P) group. The patients’ mean arterial pressure was maintained within 20% of baseline by a continuous infusion of dopamine or phenylephrine. Maintenance fluid was kept at 5 mL/kg/h. The depth of anesthesia was maintained with desflurane 1MAC and remifentanil infusion under bispectral index guidance. Regional cerebral oxygen saturation (rScO2) and hemodynamic variables were recorded using near-infrared spectroscopy and esophageal cardiac Doppler. The rScO2 was higher in the D group than the P group during OLV (OLV 60 min: 71 ± 6% vs 63 ± 12%; P = 0.03). The number of patients whose rScO2 dropped more than 20% from baseline was 0 and 6 in the D and P groups, respectively (P = 0.02). The D group showed higher cardiac output, but lower mean arterial pressure than the P group (4.7 ± 1.0 vs 3.9 ± 1.2 L/min; 76.7 ± 8.1 vs 84.5 ± 7.5 mm Hg; P = 0.02, P = 0.02). Among the variables, age, hemoglobin concentration, and cardiac output were associated with rScO2 by correlation analysis. Dopamine was superior to phenylephrine in maintaining cerebral oxygenation during OLV in thoracic surgery.

Background Protective ventilation strategy has been shown to reduce ventilator-induced lung injury in patients with ARDS. In this study, we questioned whether protective ventilatory settings would attenuate lung impairment during one-lung ventilation (OLV) compared with conventional ventilation in patients undergoing lung resection surgery. Methods One hundred patients with American Society of Anesthesiology physical status 1 to 2 who were scheduled for an elective lobectomy were enrolled in the study. During OLV, two different ventilation strategies were compared. The conventional strategy (CV group, n = 50) consisted of F io 2 1.0, tidal volume (V t ) 10 mL/kg, zero end-expiratory pressure, and volume-controlled ventilation, whereas the protective strategy (PV group, n = 50) consisted of F io 2 0.5, V t 6 mL/kg, positive end-expiratory pressure 5 cm H2O, and pressure-controlled ventilation. The composite primary end point included Pa o 2/F io 2 o 2), Pa co 2, and peak inspiratory pressure (PIP) were repeatedly measured. Results During OLV, although 58% of the PV group needed elevated F io 2 to maintain an Sp o 2 > 95%, PIP was significantly lower than in the CV group, whereas the mean Pa co 2 values remained at 35 to 40 mm Hg in both groups. Importantly, in the PV group, the incidence of the primary end point of pulmonary dysfunction was significantly lower than in the CV group (incidence of Pa o 2/F io 2 Conclusion Compared with the traditional large V t and volume-controlled ventilation, the application of small V t and PEEP through pressure-controlled ventilation was associated with a lower incidence of postoperative lung dysfunction and satisfactory gas exchange. Trial registry Australian New Zealand Clinical Trials Registry; No.: ACTRN12609000861257; URL: www.anzctr.org.au

Lee JJ, Kim GS, Kim JA, Kim S-J, Kang JG, Kim GH, Jung HH. Improvement of sleep-related breathing disorder in patients with end-stage renal disease after kidney transplantation. Clin Transplant 2011: 25: 126–130. © 2009 John Wiley & Sons A/S. Abstract: Sleep-related breathing disorder (SRBD) is a common symptom of end-stage renal disease (ESRD). The aim of this study was to determine whether kidney transplantation improves SRBD. Twenty-four patients with ESRD, who were admitted for kidney transplantation, underwent a sleep study using a portable ventilation effort recorder on the night before transplantation. Of these patients, 20 could repeat the overnight monitoring two wk after the transplantation. The median apnea-hypopnea index (AHI) of the 20 patients was 13.5 (range, 2–40), and significantly reduced to 4.5 (range, 0–20) after transplantation (p = 0.003). This reduction was most prominent in 12 patients with SRBD, for whom the median AHI fell from 22 (range, 10–40) to 6.5 (range, 1–20; p = 0.010). SRBD improvement, defined as an AHI equal to or >50% and/or reduced to

Background: Coughing is a side effect of opioids that is rarely studied. Here, we evaluated the incidence of remifentanil induced coughing during anesthesia induction in an attempt to identify its risk factors and to examine the preventive effects of lidocaine and salbutamol. Methods: A total of 237 patients scheduled to undergo general anesthesia were allocated randomly into three groups. Group C received no medication, while Group L received 2% lidocaine at 0.5 mg/kg intravenously 1 minute prior to remifentanil infusion and Group S inhaled one metered aerosol puff of salbutamol 15 minutes prior to entering the operating room. Remifentanil was infused at 5 ng/ml by target controlled infusion and coughing was measured for five minutes and graded as none, mild, moderate, or severe based on the number of coughs. Results: The incidences of coughing were 30.4%, 25.3%, and 35.4% in Groups C, L, and S, respectively. The incidences, onset times, and severity of coughing did not differ significantly among groups. In addition, multivariate analysis showed that non-smoking and a lower body weight were risk factors of remifentanil-induced coughing (odds ratio, 8.13; P = 0.024, 1.11, and 0.004, respectively). Conclusions: The incidence of remifentanil-induced coughing was 30%. A total of 0.5 mg/kg lidocaine and 1 metered aerosol puff of salbutamol did not prevent coughing. Non-smoking and low body weight were found to be risk factors of remifentanil-induced coughing. (Korean J Anesthesiol 2010; 59: 319-322)

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient-controlled analgesia (IV-PCA) with IV-PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV-PCA group (n = 20) and IV-PCA-only group (n = 20). Patients in the ITM+IV-PCA group received morphine sulfate (400 microg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV-PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV-PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV-PCA (fentanyl) were significantly less in the ITM+IV-PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV-PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV-PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement.

This study was designed to determine whether early gabapentin treatment has a protective analgesic effect on neuropathic pain and compared its effect to the late treatment in a rat neuropathic model, and as the potential mechanism of protective action, the alpha(2)delta(1)-subunit of the voltage-dependent calcium channel (alpha(2)delta(1)-subunit) was evaluated in both sides of the L5 dorsal root ganglia (DRG). Neuropathic pain was induced in male Sprague-Dawley rats by a surgical ligation of left L5 nerve. For the early treatment group, rats were injected with gabapentin (100 mg/kg) intraperitoneally 15 min prior to surgery and then every 24 hr during postoperative day (POD) 1-4. For the late treatment group, the same dose of gabapentin was injected every 24 hr during POD 8-12. For the control group, L5 nerve was ligated but no gabapentin was administered. In the early treatment group, the development of allodynia was delayed up to POD 10, whereas allodynia was developed on POD 2 in the control and the late treatment group (p0.05). The alpha(2)delta(1)-subunit was up-regulated in all groups, however, there was no difference in the level of the alpha(2)delta(1)-subunit among the three groups. These results suggest that early treatment with gabapentin offers some protection against neuropathic pain but it is unlikely that this action is mediated through modulation of the alpha(2)delta(1)-subunit in DRG.

Acute lung injury/acute respiratory distress syndrome (ALI / ARDS) is the most serious pulmonary complication after lung resection. This study investigated the incidence and outcome of patients with ALI / ARDS who required mechanical ventilation within one week of undergoing pneumonectomy for primary lung cancer and analysed the risk factors. We retrospectively reviewed the medical records of 146 patients who underwent pneumonectomy for primary lung cancer between May 2001 and April 2006. Preoperative, perioperative and postoperative clinical data were analysed. Post-pneumonectomy ALI / ARDS developed within the first postoperative week in 18 (12%) patients. Patients who developed ALI / ARDS had a longer hospital duration of stay (median [interquartile range], 26 [18 to 75] vs. 8 [7 to 11] days; P < 0.001) and higher in-hospital mortality (12 [67%] vs. 0 [0%]; P < 0.001). In an univariate analysis, post-pneumonectomy ALI / ARDS was associated with larger tidal volume (V(T)) and higher airway pressure (P(aw)) during one-lung ventilation (V(T) 8.2 [7.5 to 9.0] vs. 7.7 [6.9 to 8.2] ml/kg predicted body weight, P = 0.016; P(aw), 28.9 [27.6 to 30.0] vs. 27.2 [25.6 to 28.5] cmH2O, P = 0.001). V(T) during two-lung ventilation was also greater in patients who developed ALI / ARDS (P = 0.014) than in those who did not, but P(aw) during two-lung ventilation did not differ (P = 0.950). In a multiple logistic regression analysis, post-pneumonectomy ALI / ARDS was independently associated with a larger V(T) (OR 3.37 per 1 ml/kg predicted body weight increase; 95% confidence interval 1.65 to 6.86) and higher P(aw) (OR 2.32 per 1 cmH2O increase; 95% confidence interval 1.46 to 3.67) during the period of one-lung ventilation. In conclusion, a large V(T) and high P(aw) during one-lung ventilation were associated with an increased risk of post-pneumonectomy ALI / ARDS in primary lung cancer patients.

Various volatile anesthetics have been used in hepatectomy in living donors, and their effects on major organs have been extensively evaluated. However, the impact of total intravenous anesthesia (TIVA) on postoperative liver and renal functions after large liver resections has been less extensively investigated than that of volatile agents. The aim of this study was to compare the postoperative hepatic and renal functions between volatile anesthesia with desflurane and TIVA with propofol-remifentanil in living donors undergoing right hepatectomy. Seventy adult patients were randomly allocated into 2 groups: the desflurane group (n = 35) and TIVA group (n = 35). Aspartate aminotransferase, alanine aminotransferase, prothrombin time (PT), albumin, total bilirubin (TB), blood urea nitrogen (BUN), creatinine (Cr), BUN/Cr ratio, estimated glomerular filtration rate (GFR), platelet count, and hemoglobin levels were analyzed in the preoperative period, immediately after the operation, and on the first, second, third, fifth, seventh, and thirtieth postoperative days (PODs). Most of the liver function test results were not significantly different between the 2 groups. However, PT (international normalized ratio) and TB were significantly greater on POD 5 in the TIVA group. Among the renal function tests, Cr was significantly higher and estimated GFR was significantly lower on POD 1 in the TIVA group. The platelet counts and hemoglobin levels were similar between the 2 groups. In conclusion, the results of our study suggest that living related donors for liver transplant may have a better outcome following anesthesia with desflurane. However, further testing will be necessary to prove this hypothesis.

Object Stable hemodynamics, normocapnia, and adequate pain relief are considered important factors in the reduction of neurological complications in pediatric patients undergoing encephaloduroarteriomyosynangiosis (EDAMS) operations for the treatment of moyamoya disease. A preoperative skull block may reduce hemodynamic fluctuations and hypo- or hyperventilation due to emergence delirium or oversedation and provide adequate pain relief, thereby reducing postoperative morbidity. Methods Pediatric patients (age 3–13 years) undergoing EDAMS surgery for moyamoya disease were randomly divided into a nerve block (NB) group (18 cases) or control group (21 cases). The treatment group patients received a preoperative NB (0.25% 5–8 ml bupivacaine mixed with 20–40 mg methylprednisolone) targeting the supraorbital, supratrochlear, auriculotemporal, and posterior auricular nerves. Patients in the control group did not receive NB. General anesthesia with sevoflurane was induced in both groups. Results In the NB group, stable hemodynamic parameters were obtained with a lower sevoflurane concentration than in the control group. For delirious awakening, the odds ratio in the control group was 4.9 compared with the NB group. Pain and analgesic requirement were higher in the control patients than in the NB-treated patients during the postanesthesia care unit stay. However, the arterial CO2 tension in the postanesthesia care unit did not differ between the 2 groups. The odds ratio in the control group for the rate of morbidity (cerebral infarction and reversible ischemic neurological deficits) during the first 24 hours following the operation was 3.2 compared with the NB group. Conclusions The use of skull block during EDAMS surgery provided easy hemodynamic control, calm awakening, and better pain relief and may be related to the reduced postoperative morbidity.