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Background: The precise underlying mechanism of antioxidant effects of dexmedetomidine-induced neuroprotection against cerebral ischemia has not yet been fully elucidated. Activation of Nuclear factor erythroid 2-related factor (Nrf2) and Heme Oxygenase-1 (HO-1) represents a major antioxidant-defense mechanism. Therefore, we determined whether dexmedetomidine increases Nrf2/HO-1 expression after global transient cerebral ischemia and assessed the involvement of Protein Kinase C (PKC) in the dexmedetomidine-related antioxidant mechanism. Methods: Thirty-eight rats were randomly assigned to five groups: sham (n...=...6), ischemic (n...=...8), chelerythrine (a PKC inhibitor; 5...mg.kg-1 IV administered 30...min before cerebral ischemia) (n...=...8), dexmedetomidine (100.....g.kg-1 IP administered 30...min before cerebral ischemia (n...=...8), and dexmedetomidine...+...chelerythrine (n...=...8). Global transient cerebral ischemia (10...min) was applied in all groups, except the sham group; histopathologic changes and levels of nuclear Nrf2 and cytoplasmic HO-1 were examined 24...hours after ischemia insult. Results: We found fewer necrotic and apoptotic cells in the dexmedetomidine group relative to the ischemic group (p...

Background Prompt insertion and placement of supraglottic airway (SGA) devices in the correct position are required to secure the airway. This meta-analysis was performed to validate the usefulness of the 90° rotation technique as compared with the standard digit-based technique for the insertion of SGA devices in anesthetized patients in terms of insertion success rate, insertion time, and postoperative complications. Methods A literature search of PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science was conducted. Randomized controlled trials, without limitations on publication period, language, journal, or region, until July 2021, that compared the 90° rotation and the standard digit-based techniques for insertion of SGA devices in anesthetized patients were included. Results The first-attempt (risk ratio [RR]: 1.16, 95% CI [1.09, 1.25], P < 0.001) and overall success rates (RR: 1.06, 95% CI [1.03, 1.09], P < 0.001) were significantly higher in the 90° rotation group. The insertion time was shorter in the 90° rotation group (mean difference: −4.42 s, 95% CI [−6.70, −2.15 s], P < 0.001). The incidences of postoperative sore throat (RR: 0.63, 95% CI [0.49, 0.83], P < 0.001) and blood staining (RR: 0.28, 95% CI [0.20, 0.39], P < 0.001) were lower in the 90° rotation group. Conclusions The use of the 90° rotation technique increases the success rate of SGA device insertion and decreases postoperative complications as compared with that of the standard digit-based technique in anesthetized patients.

Abstract Background Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot-assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy. Methods This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence. Results A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4–5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5–3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8–3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5–2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence. Conclusions RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Abstract Background Sugammadex reduces postoperative complications. We sought to determine whether it could reduce the length of hospital stay, post-anesthetic recovery time, unplanned readmission, and charges for patients who underwent robot-assisted laparoscopic prostatectomy (RALP) when compared to neostigmine. Methods This was a retrospective observational study of patients who underwent RALP between July 2012 and July 2017, in whom rocuronium was used as a neuromuscular blocker. The primary outcome was the length of hospital stay after surgery in patients who underwent reversal with sugammadex when compared to those who underwent reversal with neostigmine. The secondary outcomes were post-anesthetic recovery time, hospital charges, and unplanned readmission within 30 days after RALP. Results In total, 1430 patients were enrolled. Using a generalized linear model in a propensity score-matched cohort, sugammadex use was associated with a 6% decrease in the length of hospital stay (mean: sugammadex 7.7 days vs. neostigmine 8.2 days; odds ratio [OR] 0.94, 95% confidence interval [CI] [0.89, 0.98], P = 0.008) and an 8% decrease in post-anesthetic recovery time (mean: sugammadex 36.7 min vs. neostigmine 40.2 min; OR 0.92, 95% CI [0.90, 0.94], P

Abstract Background This study aimed to investigate the association between preadmission glucocorticoid (GC) therapy and 30-day mortality in critically ill patients following admission to an intensive care unit (ICU). We aimed to determine whether this association differed according to daily GC dosage and type. We conducted a retrospective cohort study of adult patients admitted to a single tertiary academic hospital ICU from January 2012 to December 2017. We classified the patients regularly undergoing oral GC therapy as preadmission GC users, and those with no history of GC use were classified as non-GC users. Results The study included 24,929 patients, of whom 816 (3.3%) were preadmission GC users. Thirty-day mortality in preadmission GC users (173 of 816 patients) was 21.2% compared to 8.8% (2113 of 24,113 patients) in non-GC users. Multivariate Cox regression analysis showed that preadmission GC users had a 1.62-fold increase in 30-day mortality compared to non-GC users [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.29–2.03, P 5 mg of prednisolone in preadmission GC users showed 1.45-fold (HR 1.45, 95% CI 1.03–2.03, P = 0.033) and 1.67-fold (HR 1.67, 95% CI 1.25–2.24, P = 0.001) increases, respectively, in 30-day mortality after ICU admission. Moreover, prednisolone, methylprednisolone, and dexamethasone users in the preadmission GC users group showed 1.56-fold (HR 1.56, 95% CI 1.21–2.01, P = 0.001), 1.90-fold (HR 1.90, 95% CI 1.12–3.25, P = 0.018), and 1.30-fold (HR 1.30, 95% CI 1.05–1.50, P = 0.042) increases, respectively, in 30-day mortality compared to non-GC users. Conclusion Preadmission GC use among critically ill patients was associated with an increased 30-day mortality after ICU admission compared to non-GC use. This association was more prevalent in preadmission GC users with diabetes mellitus and in preadmission GC users who took > 5 mg/day of prednisolone and methylprednisolone.

Background Socioeconomic status (SES) is closely associated with health outcomes, including mortality in critically ill patients admitted to intensive care unit (ICU). However, research regarding this issue is lacking, especially in countries where the National Health Insurance System is mainly responsible for health care. This study aimed to investigate how the SES of ICU patients in South Korea is associated with mortality. Methods This was a retrospective observational study of adult patients aged ≥20 years admitted to ICU. Associations between SES-related factors recorded at the time of ICU admission and 30-day and 1-year mortalities were analyzed using univariable and multivariable Cox regression analyses. Results A total of 6,008 patients were included. Of these, 394 (6.6%) died within 30 days of ICU admission, and 1,125 (18.7%) died within 1 year. Multivariable Cox regression analysis found no significant associations between 30-day mortality after ICU admission and SES factors (P>0.05). However, occupation was significantly associated with 1-year mortality after ICU admission. Conclusions Our study shows that 30-day mortality after ICU admission is not associated with SES in the National Health Insurance coverage setting. However, occupation was associated with 1-year mortality after ICU admission.

Abstract Background Whether perioperative hyperchloremia can induce postoperative acute kidney injury (AKI) is controversial. We investigated the association between perioperative hyperchloremia and postoperative AKI in patients admitted to the intensive care unit (ICU) after surgery. Methods We performed a retrospective observational study of patients admitted to the surgical ICU at a single tertiary care hospital between January 2011 and June 2016. Our primary objective was to determine whether hyperchloremia or an increase in serum chloride levels was associated with postoperative AKI. Perioperative hyperchloremia was defined as serum chloride levels ≥ 110 mmol·L− 1 during postoperative days (PODs) 0–3. The increase in serum chloride levels was defined as the difference between preoperative and maximum postoperative serum chloride levels during the first 3 days after surgery. Results Of the 7991 patients included in the final analysis, 1876 (23.5%) developed hyperchloremia during PODs 0–3, and 1187 (14.9%) developed postoperative AKI. Exposure to hyperchloremia during the first 3 days after surgery was not associated with postoperative AKI (odds ratio, 1.09; 95% confidence interval, 0.80–1.49; P = 0.571). However, among patients with preoperative chronic kidney disease stage ≥ 3 (estimated glomerular filtration rate 6 mmol·L− 1 in serum chloride levels than in patients with an increase ≤ 1 mmol·L− 1 (odds ratio, 1.42; 95% confidence interval, 1.09–1.84; P = 0.009). In addition, the incidence of postoperative AKI stage ≥ 2 was not associated with exposure to hyperchloremia or with the increase in serum chloride levels during PODs 0–3, regardless of preoperative kidney function. Conclusions Exposure to perioperative hyperchloremia is not associated with postoperative AKI in surgical ICU patients. However, in patients with moderate-to-severe chronic kidney disease (stage ≥ 3), a substantial perioperative increase in serum chloride levels may reflect a higher risk of AKI.

The preemptive multimodal pain protocols used in total knee arthroplasty (TKA) often cause emesis postoperatively. We investigated whether palonosetron prophylaxis reduces postoperative nausea and vomiting (PONV) in high-risk patients after TKA.We randomized 120 female patients undergoing TKA to receive either palonosetron (0.075 mg, intravenous) or no antiemetic prophylaxis (0.9% saline, control group). All patients were given spinal anesthesia, a continuous femoral nerve block, and fentanyl-based intravenous patient controlled analgesia. Patients undergoing staged bilateral TKA were assigned to one group for the first knee and the other group for the second knee. The overall incidence of PONV, the incidences of both nausea and vomiting, severity of nausea, complete response, requirement for rescue antiemetics, pain level, opioid consumption, and satisfaction scores were evaluated during three periods: 0-2, 2-24, and 24-48 h postoperatively. We also compared PONV and pain between the first and second TKA.The incidence of PONV during the first 48 h was lower in the palonosetron group compared with the controls (22 vs. 41%, p = 0.028), especially 2-24 h after surgery, as was the nausea and vomiting respectively. The severity of nausea was lower in the palonosetron group (p = 0.010). The complete response rate (93 vs. 73%, p = 0.016) and satisfaction score (84 ± 12 vs. 79 ± 15, p = 0.032) were higher in the palonosetron group during 2-24 h after surgery. Patients who underwent a second operation complained of more severe pain, and consumed more opioids than those of the first operation. There was no difference in the incidence of PONV between the first and second operations.Palonosetron prophylaxis reduced the incidence and severity of PONV in high-risk patients managed with multimodal pain protocol for 48 h, notably 2-24 h after TKA.

BackgroundHydroxyethyl starch (HES) solutions are used as plasma expanders for correcting hypovolemia, but can lead to impaired coagulation. We evaluated the changes in hematological and hemostatic profiles with three types of HES.MethodsPatients were randomized to receive volume replacement with 10% pentastarch 260/0.45 in 0.9% saline (Group-PEN, n = 25), 6% tetrastarch 130/0.4 in 0.9% saline (Group-TETS, n = 25), or 6% tetrastarch 130/0.4 in a balanced electrolyte solution (Group-TETB, n = 25). Coagulation was assessed using rotational thromboelastometry (ROTEM®) and other laboratory tests were performed, including measurements of hematological and hemostatic parameters and electrolytes.ResultsPost-operative ROTEM® parameters changed toward hypocoagulable states in all groups. The post-operative parameters of EXTEM and FIBTEM were more impaired in Group-PEN than in Group-TETB. The percentage change in INTEM clot formation time (P = 0.004) and α-angle (P = 0.003) were smaller in Group-TETS and Group-TETB than in Group-PEN. The percentage change in the FIBTEM maximum clot firmness was greatest in Group-PEN (P = 0.011). The international normalized ratio of prothrombin time (P < 0.001) and the activated partial thromboplastin time (P < 0.001) were significantly prolonged in Group-PEN compared to those of Group-TETB.ConclusionsThe 6% HES 130/0.4 in a balanced electrolyte solution seemed to have less of an impact on blood coagulation than the 10% HES 260/0.45. No differences in hemostatic profile were observed between the balanced electrolyte and saline-based 6% HES 130/0.4.

BackgroundThis study was designed to determine the optimal anesthetic depth for the maintenance and recovery in interventional neuroradiology.MethodsEighty-eight patients undergoing interventional neuroradiology were randomly allocated to light anesthesia (n = 44) or deep anesthesia (n = 44) groups based on the value of the bispectral index (BIS). Anesthesia was induced with propofol, alfentanil, and rocuronium and maintained with 1-3% sevoflurane. The concentration of sevoflurane was titrated to maintain BIS at 40-49 (deep anesthesia group) or 50-59 (light anesthesia group). Phenylephrine was used to maintain the mean arterial pressure within 20% of preinduction values. Recovery times were recorded.ResultsThe light anesthesia group had a more rapid recovery to spontaneous ventilation, eye opening, extubation, and orientation (4.1 ± 2.3 vs. 5.3 ± 1.8 min, 6.9 ± 3.2 min vs. 9.1 ± 3.2 min, 8.2 ± 3.1 min vs. 10.7 ± 3.3 min, 10.0 ± 3.9 min vs. 12.9 ± 5.5 min, all P < 0.01) compared to the deep anesthesia group. The use of phenylephrine was significantly increased in the deep anesthesia group (768 ± 184 vs. 320 ± 82 µg, P < 0.01). More patients moved during the procedure in the light anesthesia group (6/44 [14%] vs. 0/44 [0%], P = 0.026).ConclusionsBIS values between 50 and 59 for interventional neuroradiology were associated with a more rapid recovery and favorable hemodynamic response, but also with more patient movement. We suggest that maintaining BIS values between 40 and 49 is preferable for the prevention of patient movement during anesthesia for interventional neuroradiology.

Stress-related cardiomyopathy can develop during the postoperative period due to surgery-related stress factors. However, the prevalence and risk factors for this condition are not yet known. During a retrospective, observational study, patients older than 19 years who underwent procedures from January 2011 to December 2015 at a tertiary hospital were included. The main aim was to identify the prevalence and related risk factors for postoperative stress-related cardiomyopathy. To estimate the incidence per risk factor, univariate and multivariate Poisson regression analyses were performed. During the 5-year period, 95,840 patients older than 19 years underwent 125,314 procedures, and the prevalence of postoperative stress-related cardiomyopathy was 17.74 per 100,000 (95% confidence interval, 9.31-26.17), with an in-hospital mortality of 23.5%. As a result, three risk factors were significantly associated: preoperative American Society of Anesthesiologists classification (incidence rate ratio, 5.901 for American Society of Anesthesiologists class 1-2 [ref] versus 3-6; 95% confidence interval,1.289-27.002; P = 0.022); preoperative body mass index (incidence rate ratio, 1.247 for increases of 18.5 [ref] to 30; 95% confidence interval, 1.067-1.458; P = 0.006); and preoperative serum sodium (incidence rate ratio, 0.830 for each increase of 10 mmol/L from 130; 95% confidence interval, 0.731-0.942; P = 0.004). The incidence rate ratio for age for each increase of 10 years from 50 years was 1.057, but it was not statistically significant (P = 0.064). Our study found that the prevalence of postoperative stress-related cardiomyopathy was 17.74 patients per 100,000 adult patients over the course of 5 years, with four cases of in-hospital mortality. Factors that increased the risk of postoperative stress-related cardiomyopathy included higher American Society of Anesthesiologists class (≥3), preoperative hyponatremia, and higher preoperative body mass index.

Robotic-assisted laparoscopic radical prostatectomy (RARP) needs a steep Trendelenburg position and a relatively high CO2 insufflation pressure, and patients undergoing RARP are usually elderly. These factors make intraoperative ventilatory care difficult and increase the risk of perioperative pulmonary complications. The aim was to determine the efficacy of recruitment manoeuvre (RM) on perioperative pulmonary complications in elderly patients undergoing RARP. A total of 60 elderly patients scheduled for elective RARP were randomly allocated to two groups after induction of anaesthesia; positive end expiratory pressure (PEEP) was applied during the operation without RM in the control group (group C) and after RM in the recruitment group (group R). The total number of patients who developed intraoperative desaturation or postoperative atelectasis was significantly higher in group C compared to group R (43.3% vs. 17.8%, P = 0.034). Intraoperative respiratory mechanics, perioperative blood gas analysis, and pulmonary function testing did not show differences between the groups. Adding RM to PEEP compared to PEEP alone significantly reduced perioperative pulmonary complications in elderly patients undergoing RARP.

Placenta previa totalis can cause life-threatening massive postpartum hemorrhage, and careful anesthetic management is essential. Preventive uterine artery embolization (UAE) before placental expulsion was introduced to reduce postpartum bleeding in cases of placenta previa totalis. We describe the case of a 40-year-old woman (gravida 0, para 0) with placenta previa totalis and uterine myomas who underwent intraoperative UAE, which was preoperatively planned at the strong recommendation of the anesthesiologist, immediately after delivery of a fetus and before removal of the placenta during cesarean delivery under spinal-epidural anesthesia. After confirming embolization of both uterine arteries, removal of the placenta resulted in moderate bleeding. The estimated blood loss was 2.5 L, and 5 units of red blood cells were transfused. The parturient was discharged uneventfully on postoperative day 4. This case shows that the bleeding risk is reduced by intraoperative UAE in a patient with placenta previa totalis, and anesthesiologists have an important role in a multidisciplinary team approach.

BackgroundSevoflurane and propofol are used widely for interventional neuroradiology (INR). Using the bispectral index (BIS), we compared the clinical properties of sevoflurane and propofol anesthesia in patients undergoing INR at comparable depths of anesthesia.MethodsThe patients were allocated randomly into two groups. The sevoflurane group received propofol (1.5 mg/kg), alfentanil (5 µg/kg), and rocuronium (0.6 mg/kg) for induction, and the propofol group was induced with a target effect-site concentration of propofol (4 µg/ml), alfentanil (5 µg/kg), and rocuronium (0.6 mg/kg). After intubation, anesthesia was maintained with sevoflurane or propofol with 67% nitrous oxide in 33% oxygen. Sevoflurane and propofol concentrations were titrated to maintain the BIS at 50-60. Phenylephrine or opioid was used to maintain the mean arterial pressure within 20% of the baseline values. The amounts of phenylephrine or alfentanil used, the number of patients showing movement during the procedure, and the recovery times were recorded.Results Compared to the propofol group, the sevoflurane group showed faster recovery in spontaneous ventilation, eye opening, extubation, and orientation (4 vs. 7 min, 7 vs. 9 min, 8 vs. 10 min, 10 vs. 14 min, respectively; P < 0.01). In the propofol group, significantly greater amounts phenylephrine were used (P < 0.05), and more patients moved during the procedure (P < 0.05).ConclusionsThe use of sevoflurane in maintaining anesthesia during INR was associated with faster recovery, less patient movement during the procedure, and a more stable hemodynamic response when compared to propofol.

OBJECTIVE:Dexmedetomidine is known to reduce the incidence of emergence agitation, which is a common complication after inhalational anesthesia like sevoflurane or desflurane in children. However, the dose of dexmedetomidine used for this purpose is reported variously and the most effective dose is not known. In this study, we tried to find the most effective dose of dexmedetomidine to reduce the incidence of emergence agitation in children undergoing strabismus surgery without the complications like oculocardiac reflex (OCR) or postoperative vomiting. METHODS:We randomized 103 pediatric patients aged 2-6 years and undergoing elective strabismus surgery into four groups. Anesthesia was induced with sevoflurane and maintained with desflurane. At the start of induction, dexmedetomidine, delivered at 0.25, 0.5, or 1 μg/kg, or saline was infused intravenously in the D0.25, D0.5, D1 groups, respectively. The primary outcome measure was the incidence of emergence agitation and the secondary outcome measure was the incidence of intraoperative OCR, postoperative vomiting, and desaturation events. RESULTS:The incidence of emergence agitation was 60, 48, 44, and 21% (P = 0.005) and the incidence of intraoperative OCR was 36, 36, 36, and 37% (P = 0.988) in the control, D0.25, D0.5, and D1 groups, respectively. And, postoperative vomiting rate and desaturation events were low in the all groups. CONCLUSION:Dexmedetomidine decreased the incidence of emergence agitation without increasing intraoperative oculocardiac reflex. Dexmedetomidine delivered at 1 μg/kg was more effective at reducing emergence agitation than lower doses in children undergoing strabismus surgery under desflurane anesthesia. TRIAL REGISTRATION:Clinical Research Information Service KCT0000141.

BackgroundThe aim of this study was to investigate the neuroprotective effects of sevoflurane after severe forebrain ischemic injury. We also examined the relationship between the duration of ischemia and neuronal cell death.MethodsMale Sprague-Dawley rats (300-380 g) were subjected to 6 (each n = 6) or 10 min (each n = 10) of near-complete forebrain ischemia while anesthetized with either 50 mg/kg of zoletil given intraperitoneally or inhaled sevoflurane (2.3%). Ischemia was induced by bilateral common carotid artery occlusion plus hemorrhagic hypotension (26-30 mmHg). Histologic outcomes were measured 7 days after ischemia in CA1 pyramidal cells of the rat hippocampus.ResultsThe mean percentage of necrotic cells in the hippocampal CA1 area decreased in the sevoflurane group compared to the zoletil group (25% vs. 40% after 6 min ischemia, respectively: P = 0.004 and 44% vs. 54% after 10 min of ischemia, respectively P = 0.03). The percentage of apoptotic cells was similar in all groups. The percentage of necrotic cells in each anesthetic groups was significantly higher in the 10 min ischemia group compared to the 6 min ischemia group (P = 0.004 in the sevoflurane group, P = 0.03 in the zoletil group).ConclusionsThe present data show that sevoflurane has neuroprotective effects in rats subjected to near-complete cerebral ischemia. Longer duration of ischemia is associated with more neuronal injury when compared to ischemia of shorter duration.

BackgroundThis randomized controlled study evaluated the efficacy of intravenous patient-controlled analgesia (IV-PCA) with fentanyl and ketorolac for neurosurgical patients, and compared the effectiveness of IV-PCA with intermittent analgesics injection.MethodsThe patients undergoing craniotomy were randomly assigned to two groups. Patients of group P (n = 53) received fentanyl (0.2 µg/kg/hr) and ketorolac (0.3 mg/kg/hr) via IV-PCA, and those of group N (n = 53) received intermittent fentanyl or ketorolac injection as needed. Pain was evaluated using a 0-10 visual analogue scale (VAS) at postoperative 1, 4, and 24 hr. The amount of infused analgesic drugs, Glasgow Coma Scale (GCS) score, systolic arterial pressure, heart rate, respiratory rate, and the incidence of nausea and miosis were measured at the same time points.ResultsAlthough VAS of pain (VASp) was comparable at postoperative 1 hr (P = 0.168) between the two groups, the group P had significantly lower VASp at postoperative 4 hr (P = 0.007) and 24 hr (P = 0.017). In group P, less analgesic drugs were administered at postoperative 1 hr, and more analgesic drugs were administered at postoperative 24 hr. There were no differences between two groups with respect to nausea, GCS, systolic arterial pressure, and heart rate. IV-PCA did not further incur respiratory depression or miosis.ConclusionsIV-PCA with fentanyl and ketorolac after craniotomy is more effective analgesic technique, without adverse events, than the intermittent administration of analgesics.

We encountered a case of a rupture of an endotracheal tube cuff during robot-assisted thyroid surgery in a 35-year-old male patient. Two hours after commencing surgery, the bellows of the ventilator were not filled and a rupture of the endotracheal tube cuff was suspected. Once the robot-manipulator is engaged, the position of the operating table cannot be altered without removing it from the patient. Reintubation with direct laryngoscopy was performed with difficulty in the narrow space between the patient's head and robot-manipulator without moving the robot away from the patient. The rupture of the endotracheal tube cuff was confirmed by observing air bubbles exiting from the balloon in water. The patient was discharged 3 days after surgery without complications. In robot-assisted thyroid surgery, a preoperative arrangement of the robot away from the patient's head to obtain easy access to the patient is essential for safe anesthetic care.

BackgroundNeck flexion has been shown to increase cranial spread of contrast agent when a small fixed volume was injected into the high thoracic epidural space. The purpose of this study was to evaluate the effect of volume of contrast medium on its distribution through the high thoracic epidural space during neck extension and flexion using the rabbit model.MethodsAn epidural catheter was introduced into the epidural space of New Zealand white rabbits with the tip located at the T3-4 intervertebral level. The neck was extended or flexed (n = 8 for each group), and the contrast medium was injected with the volume increasing by increments of 0.1 ml/kg, up to 0.3 ml/kg. The spread of contrast medium was determined by counting the number of vertebral body units using lateral epidurographic images.ResultsIn both groups, the total spread of contrast medium was similar, increasing continuously with injected volume. The cranial spread was greater in the flexion group than the extension group. However, the caudal spread was greater in the extension than in the flexion group. In the extension group, the contrast medium spread caudally about twice as far as it spread cranially, but there was no statistically significant difference between cranial and caudal spread in the flexion group.ConclusionsIn the high thoracic epidural space of rabbit, the contrast medium of varying doses showed limited cranial spread. The flexion of the neck increased cranial spread and extension of the neck increased caudal spread.

The anti-inflammatory actions of sevoflurane postconditioning are suggested as an important mechanism of sevoflurane postconditioning-induced neuroprotection against cerebral ischemia. Here, we determined whether the anti-inflammatory effects of sevoflurane postconditioning were mediated via inhibition of the toll-like receptor (TLR)-4/nuclear factor kappa B (NF-κB) pathway after global transient cerebral ischemia in rats. Forty-five rats were randomly assigned to five groups as follows: (1) control (10 min of ischemia, n = 10); (2) sevoflurane postconditioning (two periods of sevoflurane inhalation after ischemia for 10 min with a wash period of 10 min, n = 10); (3) resatorvid (intraperitoneal injection of a selective TLR-4 antagonist (3 mg/kg) 30 min before ischemia, n = 10); (4) sevoflurane postconditioning plus resatorvid (n = 10), and sham (n = 5). The numbers of necrotic and apoptotic cells in the hippocampal CA1 region, the expression levels of TLR-4, NF-κB, cleaved caspase-3, and tumor necrosis factor alpha (TNF-α) in the anterior part of each brain, and the serum levels of TNF-α, interleukin 6 (IL-6), and interleukin 1 beta (IL-1β) were assessed 1 day after ischemia. The necrotic cell counts and expression levels of TLR-4, NF-κB, caspase-3, and TNF-α in brain tissue as well as serum levels of pro-inflammatory cytokines (TNF-α, IL-6, and IL-1β) were significantly higher in the control group than in the other groups. Our findings suggest that the anti-inflammatory actions of sevoflurane postconditioning via inactivation of the TLR-4/NF-κB pathway and subsequent reduction in pro-inflammatory cytokine production, in part, contribute to sevoflurane postconditioning-induced neuroprotection after global transient cerebral ischemia in rats.

Neuromuscular block results in the loss of muscular tone in the upper airway, which might contribute to the increased postoperative airway morbidity followed by ProSeal laryngeal mask airway (PLMA) insertion. We compared the pharyngolaryngeal discomfort exerted by the PLMA according to the neuromuscular block. One hundred sixty patients undergoing surgery for breast disease or inguinal hernia were anesthetized with propofol and remifentanil by target controlled infusion. Rocuronium 0.6 mg/kg (NMBA group, n = 80) or normal saline (No-NMBA group, n = 80) was administered after the loss of consciousness, and one anesthesiologist inserted the PLMA. Postoperative pharyngolaryngeal discomfort was evaluated at postoperative 1 h. Traumatic event was recorded based on the blood trace on the surface of the PLMA cuff. Insertion time, insertion attempt number, sealing pressure, and fiberoptic brochoscopic grades were evaluated. Patients' characteristics and the PLMA insertion condition (insertion time, successful insertion attempt number, fiberoptic bronchoscopic grade, and sealing pressure) were similar between the two groups. The PLMA can be successfully inserted in non-paralyzed patients with less postoperative pharyngolaryngeal discomfort than when a neuromuscular blocking agent is used (13.8% vs. 30.0%, P = 0.021). The incidence of traumatic events is also reduced when no neuromuscular blocking agent is used (16.3% vs. 32.5%, P = 0.026). Regardless of whether or not a surgical procedure requires muscular relaxation, there is no need to administer neuromuscular blocking agents solely for the purpose of PLMA insertion.

Dendritic cells play an essential role in bridging innate and adaptive immunity by recognizing cellular stress including pathogen- and damage-associated molecular patterns and by shaping the types of antigen-specific T cell immunity. Although lidocaine is widely used in clinical settings that trigger cellular stress, it remains unclear whether such treatment impacts the activation of innate immune cells and subsequent differentiation of T cells. Here we showed that lidocaine inhibited the production of IL-6, TNFα and IL-12 from dendritic cells in response to toll-like receptor ligands including lipopolysaccharide, poly(I:C) and R837 in a dose-dependent manner. Notably, the differentiation of Th1 cells was significantly suppressed by the addition of lidocaine while the same treatment had little effect on the differentiation of Th17, Th2 and regulatory T cells in vitro. Moreover, lidocaine suppressed the ovalbumin-specific Th1 cell responses in vivo induced by the adoptive transfer of ovalbumin-pulsed dendritic cells. These results demonstrate that lidocaine inhibits the activation of dendritic cells in response to toll-like receptor signals and subsequently suppresses the differentiation of Th1 cell responses.

Guidewire-associated complications that occur during the process of central venous catheterization include its kinking, looping, knotting and breakage. The removal of a looped or knotted guidewire is problematic because it can cause vessel damage, major hemorrhage, or embolization of a fractured guidewire. We report a case of guidewire kinking and its successful removal under fluoroscopic guidance.

Anaphylaxis is an acute and fatal systemic allergic reaction to an allergen, and it can be an unpredictable and life-threatening cause during anesthesia. Latex is the second most common cause of anaphylaxis following the use of neuromuscular blocking agents during general anesthesia or surgery. We report on a 67-year-old male who had undergone surgery under general anesthesia without any problem but who presented with severe intraoperative anaphylaxis to latex surgical gloves. This case emphasizes the need for anesthesiologists to quickly diagnose and properly manage an allergic reaction in patients under general anesthesia.

This report describes a rare case of perioperative midazolam hypersensitivity in a patient without any history of allergy. A 39-year-old man was admitted for endoscopic pansinus surgery. During transportation to the operating room after injecting antibiotic and midazolam intravenously, the patient complained of shortness of breath. At 3 months after the event, an intradermal sensitivity test for midazolam proved positive indicating the incident was caused by midazolam hypersensitivity.

We present the case of a 57-year-old man who developed retroperitoneal hemorrhage due to unintentional arterial puncture during femoral artery cannulation for Guglielmi detachable coil embolization. On emergence from anesthesia, he developed severe hypotension. Computed tomographic angiogram of the abdomen showed retroperitoneal hematomas around the urinary bladder, liver, and spleen. Because femoral artery cannulation is a common procedure for intravascular embolization in neuroradiologic procedures, Clinicians should be aware of the development of severe hematomas as a consequence of femoral artery puncture.

Objective: We aimed to examine trends in critically ill neurology-neurosurgery (NNS) patients who were admitted to the intensive care unit (ICU) in South Korea and identify risk factors for in-hospital mortality after ICU admission in NNS patients. Methods: This nationwide population-based retrospective cohort study enrolled adult NNS adult patients admitted to the ICU from 2010 to 2019 extracted from the National Health Insurance Service in South Korea. The critically ill NNS patients were defined as those whose main admission departments were neurology or neurosurgery at ICU admission. The number of ICU admission, age, and total cost for hospitalization from 2010 to 2019 in critically ill NNS patients were examined as trend information. Moreover, multivariable logistic regression modeling was used to identify risk factors for in-hospital mortality among critically ill NNS patients. Results: We included 845474 ICU admission cases for 679376 critically ill NNS patients in South Korea between January 1, 2010 to December 31, 2019. The total number of ICU admissions among NNS patients was 79522 in 2010, which increased to 91502 in 2019. The mean age rose from 62.8 years (standard deviation [SD], 15.6) in 2010 to 66.6 years (SD, 15.2) in 2019, and the average total cost for hospitalization per each patient consistently increased from 6206.1 USD (SD, 5218.5) in 2010 to 10745.4 USD (SD, 10917.4) in 2019. In-hospital mortality occurred in 75455 patients (8.9%). Risk factors strongly associated with increased in-hospital mortality were the usage of mechanical ventilator (adjusted odds ratio [aOR], 19.83; 95% confidence interval [CI], 19.42-20.26; p<0.001), extracorporeal membrane oxygenation (aOR, 3.49; 95% CI, 2.42-5.02; p<0.001), and continuous renal replacement therapy (aOR, 6.47; 95% CI, 6.02-6.96; p<0.001). In addition, direct admission to ICU from the emergency room (aOR, 1.38; 95% CI, 1.36-1.41; p<0.001) and brain cancer as the main diagnosis (aOR, 1.30; 95% CI, 1.22-1.39; p<0.001) are also potential risk factors for increased in-hospital mortality. Conclusion: In South Korea, the number of ICU admissions increased among critically ill NNS patients from 2010 to 2019. The average age and total costs for hospitalization also increased. Some potential risk factors are found to increase in-hospital mortality among critically ill NNS patients. [ABSTRACT FROM AUTHOR]