Hyun Joo Kim

Perioperative administration of pregabalin for pain after robot-assisted endoscopic thyroidectomy: a randomized clinical trial

BackgroundPerioperative administration of pregabalin, which is effective for neuropathic pain, might reduce early postoperative and chronic pain. This randomized, double-blinded, placebo-controlled trial (Clinical Trials.gov ID NCT00905580) was designed to investigate the efficacy and safety of pregabalin for reducing both acute postoperative pain and the development of chronic pain in patients after robot-assisted endoscopic thyroidectomy.MethodsNinety-nine patients were randomly assigned to groups that received pregabalin 150xa0mg or placebo 1 h before surgery, with the dose repeated after 12 h. Assessments of pain and side effects were performed 48 h postoperatively. The incidences of chronic pain and hypoesthesia in the anterior chest were recorded 3xa0months after surgery.ResultsNinety-four patients completed the study. Verbal numerical rating scale scores for pain and the need for additional analgesics were lower in the pregabalin group (nxa0=xa047) than the placebo group (nxa0=xa047) during 48 h postoperatively (Pxa0<xa00.05). However, incidences of sedation and dizziness were higher in the pregabalin group (Pxa0<xa00.05). There were no differences between the groups in the incidences of chronic pain and chest hypoesthesia at 3xa0months after surgery.ConclusionsPerioperative administration of pregabalin (150xa0mg twice per day) was effective in reducing early postoperative pain but not chronic pain in patients undergoing robot-assisted endoscopic thyroidectomy. Caution should be taken regarding dizziness and sedation.

The effect of epidural administration of dexamethasone on postoperative pain: a randomized controlled study in radical subtotal gastrectomy

Background Epidurally administered dexamethasone may reduce the incidence and severity of postoperative pain. We investigated whether postoperative pain could be alleviated by preoperative or postoperative epidural dexamethasone administration in patients undergoing major abdominal surgery. Methods Ninety patients (age 30-77 with American Society of Anesthesiologists physical status I and II) undergoing radical subtotal gastrectomy were randomly allocated to three groups using computer generated randomization. In all groups, 10 ml of 0.25% ropivacaine was injected epidurally before the start and at the end of the operation. In Group I, a bolus ropivacaine epidural without dexamethasone was administered. In Group II, dexamethasone (5 mg) was added to the ropivacaine bolus epidural before the start of operation. In Group III, the same amount of dexamethasone was given with the ropivacaine epidural at the end of operation. Effort and resting VAS, the use of rescue analgesics and any complications noted during the procedure were evaluated. Results VAS and requirements of rescue analgesics were significantly lower in Groups II and III when compared to Group I. There were no difference in the incidence of nausea and vomiting between groups, but an itching sensation was frequent in Group III. Conclusions The administration of 5 mg of dexamethasone epidurallly, before or after operation, could reduce the pain and analgesic requirement after radical subtotal gastrectomy.

Folding and anion-binding properties of an indolocarbazole dimer with urea appendages

An indolocarbazole dimer with the urea functional group was prepared as an anion receptor which contained eight NH hydrogen bonds donors. Two indolocarbazole units were coupled through a butadiynyl linker to allow for helical folding of the resulting dimer by intramolecular hydrogen bonding and dipole–dipole attractions as proven in the 1H NMR spectroscopy. The dimer was found to bind anions (Cl− , Br− , N3 − , AcO− , and ) by multiple hydrogen bonds in 10% (v/v) MeOH–acetone, showing high selectivity for sulphate ion. The 1H NMR spectra clearly demonstrated that only indolocarbazole NH protons were involved in the hydrogen bonding with small anions such as chloride, but all of the existing indolocarbazole and urea NHs participated in the hydrogen bonding with sulphate ion. This difference in the binding mode might be responsible for the high affinity and selectivity towards sulphate ion.

Multiple cerebral infarction and paradoxical air embolism during hepatectomy using the Cavitron Ultrasonic Surgical Aspirator -A case report-

A venous air embolism and paradoxical air embolism (PAE) are serious complications in patients undergoing a hepatectomy. We report a case of PAE and cerebral infarctions in a patient undergoing a hepatic resection using a Cavitron Ultrasonic Surgical Aspirator (CUSA®). A 65-year-old woman underwent a left lobe hepatectomy. During the middle phase of the liver resection with CUSA®, there was a sudden decrease in arterial blood pressure, end-tidal carbon dioxide and SpO2. With resuscitation, intraoperative ultrasonography revealed massive air emboli in both her left and right heart, which lasted for 40 min. The hepatectomy was completed after the disappearance of the air emboli from her heart. After surgery, her mental status was stuporous. The brain CT and MRI revealed multiple acute cerebral infarctions. Finally, she died from septic shock. This case highlights the need for anesthetists and surgeons to be aware of the potential for CUSA®-related massive PAE.

Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: incidence, risk factors and blind repositioning techniques.

BackgroundDouble-lumen endobronchial tubes (DLTs) are commonly advanced into the mainstem bronchus either blindly or by fiberoptic bronchoscopic guidance. However, blind advancement may result in misplacement of left-sided DLTs into the right bronchus. Therefore, incidence, risk factors, and blind repositioning techniques for right bronchial misplacement of left-sided DLTs were investigated.MethodsThis was an observational cohort study performed on the data depository consecutively collected from patients who underwent intubation of left-sided DLTs for 2xa0years. Patients’ clinical and anatomical characteristics were analyzed to investigate risk factors for DLT misplacements with logistic regression analysis. Moreover, when DLTs were misplaced into the right bronchus, the bronchial tube was withdrawn into the trachea and blindly readvanced without rotation, or with 90° or 180° counterclockwise rotation while the patient’s head was turned right.ResultsDLTs were inadvertently advanced into the right bronchus in 48 of 1135 (4.2xa0%) patients. DLT misplacements occurred more frequently in females, in patients of short stature or with narrow trachea and bronchi, and when small-sized DLTs were used. All of these factors were significantly inter-correlated each other (Pu2009<u20090.001). In 40 of the 48 (83.3xa0%) patients, blind repositioning was successful.ConclusionsSmaller left-sided DLTs were more frequently misplaced into the right mainstem bronchus than larger DLTs. Moreover, we were usually able to reposition the misplaced DLTs into the left bronchus by using the blind techniques.Trial registrationClinicalTrials.gov Identifier: NCT01371773.

Assisted head extension minimizes the frequency of dental contact with laryngoscopic blade during tracheal intubation.

OBJECTIVESnWe hypothesized that the assisted maintenance of head extension would reduce the frequency of direct contact between the laryngoscope blade and the maxillary incisors during tracheal intubation.nnnMETHODSnSixty-eight patients undergoing elective surgical procedures under general anesthesia were enrolled in this prospective, randomized, controlled crossover study. A single experienced anesthesiologist performed the simulated tracheal intubations with a classic Macintosh laryngoscope. After reaching the sniffing position during direct laryngoscopy, tracheal intubations with and without maintaining the head extension (by an assistant) were simulated twice in each patient in random order. The occurrence of dental contact with the laryngoscope blade was recorded during the simulated tracheal intubation. The distance between the laryngoscopic blade and maxillary central incisors was assessed using a digital caliper. The angle of head extension and the glottic view were also evaluated.nnnRESULTSnThe frequency of dental contact was lower with the assisted head extension than without it (25/68 [37%] vs 67/68 [99%], P < .001). The blade-to-tooth distance was longer with assistance than without it (1.8 ± 1.9 [0-8] mm vs 0.0 ± 0.1 [0-1] mm, P < .001). The angle of head extension was greater with assistance than without it (26.6° ± 5.8° [6.0°-37.4°] vs 19.9° ± 5.4° [3.4°-31.8°], P < .001). No significant difference was observed between 2 simulated tracheal intubations with regard to the glottic views.nnnCONCLUSIONnThe assisted maintenance of head extension during the simulation of tracheal intubation reduced the frequency of dental contact with the laryngoscopic blade without compromising the laryngoscopic views. The results of this study suggest that assisted head extension during tracheal intubation may reduce the possibility of unexpected dental injury.

Effect of combining a recruitment maneuver with protective ventilation on inflammatory responses in video-assisted thoracoscopic lobectomy: a randomized controlled trial

BackgroundWe hypothesized that the addition of a recruitment maneuver to protective ventilation (PVRM) would result in lower pulmonary and systemic inflammatory responses than traditional ventilation or protective ventilation (PV) alone in patients undergoing lung surgery.MethodsSixty patients who underwent scheduled thoracoscopic lobectomy were randomly assigned to three groups: traditional ventilation, PV, or PVRM. Ventilations were performed using a tidal volume of 10xa0mL/kg for the traditional ventilation group and either 8xa0mL/kg (two-lung) or 6xa0mL/kg (one-lung, OLV) with a positive end-expiratory pressure of 5xa0cm H2O for the PV and PVRM groups. The RM was performed 10xa0min after the start of OLV. Fiberoptic bronchoalveolar lavage (BAL) was performed twice in dependent and non-dependent lungs: before the start and immediately after the end of OLV. Blood samples were collected at the same time points. The levels of cytokines, including TNF-α, IL-1β, IL-6, IL-8, and IL-10, were measured.ResultsAfter OLV, the level of TNF-α in the BAL fluid of dependent lungs was significantly higher in the PV than in the PVRM group (Pu2009=u20090.049), whereas IL-1β, IL-6, IL-8, and IL-10 levels were not significantly different among the groups. In non-dependent lung BAL fluid, no cytokines were significantly different among the groups. After OLV, IL-10 serum levels were significantly higher in the traditional ventilation than in the PVRM group (Pu2009=u20090.027).ConclusionsLower inflammatory responses in the ventilated lung and serum were observed with PVRM than with traditional ventilation or PV alone. Larger multi-center clinical trials are warranted to confirm the effects of different ventilatory strategies on postoperative outcomes.

Effects of long periods of pneumoperitoneum combined with the head-up position on heart rate-corrected QT interval during robotic gastrectomy: an observational study

Objective Pneumoperitoneum and the head-up position reportedly stimulate the sympathetic nervous system, potentially increasing the risk of cardiac arrhythmia. We evaluated the effects of a long duration of pneumoperitoneum in the head-up position on the heart rate-corrected QT (QTc) interval during robotic gastrectomy. Methods This prospective observational study involved 28 patients undergoing robotic gastrectomy. The QTc interval was recorded at the following time points: before anaesthetic induction (baseline); 10 minutes after tracheal intubation; 1, 5, 30, 60, and 90 minutes after pneumoperitoneum induction in the head-up position; after pneumoperitoneum desufflation in the supine position; and at the end of surgery. The primary outcome was the QTc interval, which was measured 90 minutes after pneumoperitoneum combined with the head-up position. Results Compared with baseline, the QTc interval was significantly prolonged at 1 and 60 minutes after pneumoperitoneum, peaked at 90 minutes, and was sustained and notably prolonged until the end of surgery. However, no considerable haemodynamic changes developed. Conclusion A long period of carbon dioxide pneumoperitoneum application in a head-up position significantly prolonged the QTc interval during robotic gastrectomy. Therefore, diligent care and close monitoring are required for patients who are susceptible to developing ventricular arrhythmia. Trial Registration: Registered at ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT02604979; Registration number NCT02604979

Anesthetics Mechanisms: A Review of Putative Target Proteins at the Cellular and Molecular Level

Despite widespread clinical use of anesthetics, the exact mechanisms of anesthetic action are unclear. In terms of physiological action, a broad mechanism of general anesthesia including perturbations of neurotransmission has been suggested. However, the mechanism of anesthetic action at the molecular level is less clear. Specifically, how anesthetics affect neurons and glial cells and which proteins they interact with remains to be explored. Several recent studies have investigated the molecular interactions between proteins and anesthetics. In this review, we summarize the molecular mechanisms of anesthetic action in the intracellular signaling pathways of neuronal and glial cells.

Determination of the appropriate oropharyngeal airway size in adults: Assessment using ventilation and an endoscopic view

Introduction: Size 9 and 8 airways for men and women, respectively, have been proposed as most appropriate based on endoscopy. However, a limitation of this guideline is that ventilation was not assessed. Methods: In this retrospective review of prospectively collected data, 149 patients requiring tracheal intubation for general anesthesia were included. The adequacy for manual and pressure‐controlled mechanical ventilation and views at the distal end of each airway was assessed using a fiber‐optic bronchoscope with various airway sizes (7, 8, 9, 10, and 11). Results: For men, size 9, 10, and 11 airways permitted clear manual and adequate mechanical ventilation; size 7 and 8 airways caused partially obstructed manual and inadequate mechanical ventilation. On endoscopy, size 7 and 8 airways caused complete obstruction by the tongue; size 10 and 11 airways either touched or passed beyond the tip of the epiglottis. For women, the size 7 airway caused partially obstructed manual and inadequate mechanical ventilation; size 9 and 10 airways provided clear manual and adequate mechanical ventilation. The size 8 airway permitted clear manual ventilation, though mechanical ventilation was inadequate in one patient. On endoscopy, the size 7 airway caused complete obstruction in >50% of women; size 9, 10, and 11 airways either touched or passed beyond the tip of the epiglottis. Conclusions: With respect to adequate ventilation in conjunction with an acceptable endoscopic view, size 9 and size 8 oropharyngeal airways appear to be the most appropriate sizes for clinical use in men and women, respectively.