Arunotai Siriussawakul

A Randomized Clinical Trial Testing the Anti-Inflammatory Effects of Preemptive Inhaled Nitric Oxide in Human Liver Transplantation

Decreases in endothelial nitric oxide synthase derived nitric oxide (NO) production during liver transplantation promotes injury. We hypothesized that preemptive inhaled NO (iNO) would improve allograft function (primary) and reduce complications post-transplantation (secondary). Patients at two university centers (Center A and B) were randomized to receive placebo (n = 20/center) or iNO (80 ppm, n = 20/center) during the operative phase of liver transplantation. Data were analyzed at set intervals for up to 9-months post-transplantation and compared between groups. Patient characteristics and outcomes were examined with the Mann-Whitney U test, Student t-test, logistic regression, repeated measures ANOVA, and Cox proportional hazards models. Combined and site stratified analyses were performed. MELD scores were significantly higher at Center B (22.5 vs. 19.5, p<0.0001), surgical times were greater at Center B (7.7 vs. 4.5 hrs, p<0.001) and warm ischemia times were greater at Center B (95.4 vs. 69.7 min, p<0.0001). No adverse metabolic or hematologic effects from iNO occurred. iNO enhanced allograft function indexed by liver function tests (Center B, p<0.05; and p<0.03 for ALT with center data combined) and reduced complications at 9-months (Center A and B, p = 0.0062, OR = 0.15, 95% CI (0.04, 0.59)). ICU (p = 0.47) and hospital length of stay (p = 0.49) were not decreased. iNO increased concentrations of nitrate (p<0.001), nitrite (p<0.001) and nitrosylhemoglobin (p<0.001), with nitrite being postulated as a protective mechanism. Mean costs of iNO were

Clinical experience with intraoperative jugular venous oximetry during pediatric intracranial neurosurgery

1,020 per transplant. iNO was safe and improved allograft function at one center and trended toward improving allograft function at the other. ClinicalTrials.gov with registry number 00582010 and the following URL:http://clinicaltrials.gov/show/NCT00582010.

Inadvertent Venous Air Embolism from Pressure Infuser Bag Confirmed by Transesophageal Echocardiography

To report our institutional experience with intraoperative jugular venous oximetry during pediatric intracranial surgery to guide anesthetic care.

A validation study of the intubation difficulty scale for obese patients

Most reports on the topic of venous air embolism (VAE) deal primarily with surgical procedures where the operative site is above the level of the heart. Accidental administration of air while using a pressure infuser bag is rare. We report a case of cardiovascular collapse while applying pressure over a hard plastic bottle for rapid fluid infusion. Massive air bubbles in the right side of the heart were confirmed by intraoperative transesophageal echocardiography (TEE). This case demonstrates that TEE plays an important role in prompt diagnosis and management of VAE in anesthetized patients. The patient gave written permission to the authors to publish this report.

Effects of supplemental oxygen on maternal and neonatal oxygenation in elective cesarean section under spinal anesthesia: a randomized controlled trial.

STUDY OBJECTIVE An intubation difficulty scale (IDS) is the most commonly used tool to pronounce difficult intubation among obese patients in research area. There have not been any studies on assessing the use of IDS. The objectives were to determine the performance of the IDS among obese patients to define difficult tracheal intubation (DI) according to the subjective assessment of the difficulty experienced and to identify their optimal cutoff points. DESIGN Cross-sectional study. SETTING Tertiary care hospital. PATIENTS Adult obese Thai patients who underwent conventional endotracheal intubation. MEASUREMENTS Data of subjective assessment of the difficulty experienced by category-easy, somewhat difficult, and difficult-were collected from experienced anesthetic personnel who performed endotracheal intubation. IDS scores were collected by research assistants. MAIN RESULTS There were 552 obese patients recruited. The incidence of somewhat DI was 14.3% and that of DI was 2.2%. The overall performance of the IDS using area under the receiver operating characteristic curves of somewhat DI is 0.99 with 95% confidence interval (CI) of 0.98 and 0.99 and that of DI is 1 (95% confidence interval, 1-1). For somewhat DI, the optimal cutoff point is 2; it provides sensitivity and specificity of 100% and 92%. The IDS scores of 5 indicate DI which had sensitivity and specificity of 100% and 100%. CONCLUSIONS The IDS remains a good tool to declare DI among obese patients. It is recommended that a score of 2 or higher is an optimal cutoff point to indicate somewhat DI and a score of 5 or higher is an optimal cutoff point to indicate DI.

The performance of neck circumference and other airway assessment tests for the prediction of difficult intubation in obese parturients undergoing cesarean delivery

The use of supplemental oxygen in uncomplicated cesarean deliveries under spinal anesthesia has been thoroughly investigated during recent decades. The aim of this study was to determine the benefits for both mother and infant of administering supplemental, low-dose oxygen via a nasal cannula versus having no supplement (i.e., room air only). Healthy parturients at term undergoing elective cesarean section under spinal anesthesia were randomly allocated into two groups: an oxygen group (n = 170), who received 3 LPM oxygen via a nasal cannula; and a room-air group (n = 170), who were assigned to breathe room air. Maternal oxygen saturation was measured continuously by using pulse oximeter. The desaturation was determined by oxygen saturation <94% over 30 seconds. Umbilical cord gases and Apgar scores were collected followed delivery of the infant. All maternal desaturation events occurred in 12 parturients assigned to the room-air group. Most events were concurrent with hypotension. The umbilical venous partial pressure of oxygen was significantly higher in the oxygen group. The other blood gas measurements and Apgar scores were not significantly different between the two groups. Based on our findings, the use of supplemental oxygen could prevent maternal desaturation resulting from receiving sedation and intraoperative hypotension.

The Performance of the Intubation Difficulty Scale among Obese Parturients Undergoing Cesarean Section

BACKGROUND Pregnancy and obesity each increase the chance of difficult tracheal intubation. This study assessed the performance of the neck circumference and other bedside tests in predicting difficult intubation, and aimed to identify the optimal cutoff point of the test(s) with the highest performance. METHODS Parturients with a body mass index ≥30kg/m2, undergoing a cesarean delivery employing conventional tracheal intubation, were enrolled. Preoperative neck circumference, sternomental distance and modified Mallampati test were examined. Difficult intubation was defined as intubation difficulty scale score ≥5. RESULTS Five hundred and seventy parturients of mean body mass index 34.1 (±SD 3.8) kg/m2 were recruited. The incidence of difficult intubation was 3.5%. The performance of the neck circumference test, conducted with the patient sitting or supine, and using the area under the receiver operating characteristic (ROC) curves, was 0.6 (95% CI 0.5 to 0.7) and 0.6 (95% CI 0.4 to 0.7) respectively. The area under the ROC for the modified Mallampati test was 0.6 (95% CI 0.5 to 0.7) and for the sternomental distance test was 0.7 (95% CI 0.6 to 0.8). A sternomental distance less than 14.5cm, and a ratio of neck circumference in the sitting position to sternomental distance of greater than or equal to 2.7, were optimal cutoff points to identify difficult intubation. CONCLUSION The neck circumference, the sternomental distance, the modified Mallampati test and the ratio of neck circumference to the sternomental distance show limited performance as screening tests to predict difficult intubation among obese parturients.

Epidural Analgesia for Perioperative Upper Abdominal Surgery

Background. There have not yet been any studies to validate the intubation difficulty scale (IDS) in obese parturients. Objectives of this study were to determine the performance of the IDS in defining difficult intubation (DI) and to identify the optimal cutoff points of the IDS among obese parturients. Methods. This was a prospective observational study. Parturients with a body mass index ≥ 30 kg/m2 who underwent cesarean section utilizing endotracheal intubation were enrolled. The intubating performers were asked to assess the difficulty of endotracheal intubation and categorize it as easy, somewhat DI, and DI. Main Results. A total of 517 parturients were recruited with a mean BMI of 33.9 kg/m2. The incidence of some degree of DI was 14.5%. The area under the receiver operating characteristic curves of the IDS for detecting somewhat DI and DI was 1.0. The optimal cutoff point to define somewhat DI was ≥3 and DI was ≥5, which both had sensitivity and specificity of 100%. Conclusions. The IDS scoring is a good tool for defining DI among obese parturients. The IDS scores of ≥3 and ≥5 are the optimal cutoff points to define somewhat DI and DI, respectively.

Predictive performance of a multivariable difficult intubation model for obese patients

Uncontrolled postoperative pain and the pathophysiologic response to surgery following upper abdominal surgery may cause significant complications of many organ systems. Perioperative thoracic epidural analgesia (TEA), especially with a local anesthetic-based analgesic solution, can decrease the incidence of postoperative morbidity and mortality. In the case of the cardiovascular system, TEA may decrease the incidence of postoperative myocardial infarction by providing a favorable redistribution of coronary blood flow, attenuating the stress response, hypercoagulability and postoperative pain. As for the respiratory system, TEA provides superior analgesia, allowing patients to do deep breathing exercises and early ambulation. In a recent cohort study of 541 patients with chronic obstructive pulmonary disease, it was reported that TEA offered a preventive effect for postoperative pneumonia and a decrease in 30-day mortality. Stress-induced sympathetic outflow causes ileus and prolonged hospital stay. (van Lier et al., 2011) TEA can facilitate the return of gastrointestinal motility without contributing to anastomotic bowel dehiscence. Finally, TEA improves postoperative analgesia, resulting in increased patient satisfaction. (Hurley & Wu, 2009)

Perioperative glycaemic control for preterm infant with transient neonatal hyperglycaemia and gastroschisis

Background A predictive model of scores of difficult intubation (DI) may help physicians screen for airway difficulty to reduce morbidity and mortality in obese patients. The present study aimed to set up and evaluate the predictive performance of a newly developed, practical, multivariate DI model for obese patients. Methods A prospective multi-center study was undertaken on adults with a body mass index (BMI) of 30 kg/m2 or more who were undergoing conventional endotracheal intubation. The BMI and 10 preoperative airway tests (namely, malformation of the teeth in the upper jaw, the modified Mallampati test [MMT], the upper lip bite test, neck mobility testing, the neck circumference [NC], the length of the neck, the interincisor gap, the hyomental distance, the thyromental distance [TM] and the sternomental distance) were examined. A DI was defined as one with an intubation difficulty scale (IDS) score ≥ 5. Results The 1,015 patients recruited for the study had a mean BMI of 34.2 (standard deviation: 4.3 kg/m2). The proportions for easy intubation, slight DI and DI were 81%, 15.8% and 3.2%, respectively. Drawing on the results of a multivariate analysis, clinically meaningful variables related to obesity (namely, BMI, MMT, and the ratio of NC to TM) were used to build a predictive model for DI. Nevertheless, the best model only had a fair predictive performance. The area under the receiver operating characteristic curve (AUC) was 0.71 (95% confidence interval 0.68–0.84). Conclusions The predictive performance of the selected model showed limited benefit for preoperative screening to predict DI among obese patients.