Jeong Jin Min

Does remote ischaemic preconditioning with postconditioning improve clinical outcomes of patients undergoing cardiac surgery? Remote Ischaemic Preconditioning with Postconditioning Outcome Trial

AIMSnThe aim of this study was to evaluate whether remote ischaemic preconditioning (RIPC) combined with remote ischaemic postconditioning (RIPostC) improves the clinical outcomes of patients undergoing cardiac surgery.nnnMETHODS AND RESULTSnFrom June 2009 to November 2010, 1280 patients who underwent elective cardiac surgery were randomized into the RIPC with RIPostC group or the control group in the morning of the surgery. In the RIPC with RIPostC group, four cycles of 5-min ischaemia and 5-min reperfusion were administered twice to the upper limb-before cardiopulmonary bypass (CPB) or coronary anastomoses for RIPC and after CPB or coronary anastomoses for RIPostC. The primary endpoint was the composite of major adverse outcomes, including death, myocardial infarction, arrhythmia, stroke, coma, renal failure or dysfunction, respiratory failure, cardiogenic shock, gastrointestinal complication, and multiorgan failure. Remote ischaemic preconditioning with RIPostC did not reduce the composite outcome compared with the control group (38.0 vs. 38.1%, respectively; P = 0.998) and there was no difference in each major adverse outcome. The intensive care unit and hospital stays were not different between the two groups. However, in the off-pump coronary artery bypass surgery subgroup, multivariate logistic regression analysis revealed that RIPC with RIPostC was related to increased composite outcome (odds ratio: 1.54; 95% confidence interval: 1.02-2.30; P = 0.038).nnnCONCLUSIONnRemote ischaemic preconditioning with RIPostC by transient upper limb ischaemia did not improve clinical outcome in patients who underwent cardiac surgery.

Effect of palonosetron on the QTc interval in patients undergoing sevoflurane anaesthesia

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

Pulmonary Protective Effects of Remote Ischaemic Preconditioning with Postconditioning in Patients Undergoing Cardiac Surgery Involving Cardiopulmonary Bypass: A Substudy of the Remote Ischaemic Preconditioning with Postconditioning Outcome trial.

BACKGROUNDnThe RISPO (Remote Ischemic Preconditioning with Postconditioning Outcome) trial evaluated whether remote ischaemic preconditioning (RIPC) combined with remote ischaemic postconditioning (RIPostC) improves the clinical outcomes of patients undergoing cardiac surgery. This substudy of the RISPO trial aimed to evaluate the effect of RIPC with RIPostC on pulmonary function in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).nnnMETHODSnSixty-five patients were enrolled (32: control and 33: RIPC-RIPostC). In the RIPC-RIPostC group, four cycles of 5min ischaemia and 5min reperfusion were administered before and after CPB to the upper limb. Peri-operative PaO2/FIO2 ratio, intra-operative pulmonary shunt, and dynamic and static lung compliance were determined.nnnRESULTSnThe mean PaO2/ FIO2 was significantly higher in the RIPC-RIPostC group at 24h after surgery [290 (96) vs. 387 (137), p=0.001]. The incidence of mechanical ventilation for longer than 48h was significantly higher in the control group (23% vs. 3%, p<0.05). However, there were no significant differences in other pulmonary profiles, post-operative mechanical ventilation time, and duration of intensive care unit stay.nnnCONCLUSIONSnIn our study, RIPC-RIPostC improved the post-operative 24h PaO2/FIO2 ratio. Remote ischaemic preconditioning-Remote ischaemic postconditioning has limited and delayed pulmonary protective effects in cardiac surgery patients with CPB.

Intravenous palonosetron increases the incidence of QTc prolongation during sevoflurane general anesthesia for laparotomy

Background Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. Methods We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. Results The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P < 0.001). The changes in the QTc intervals were not different between the two groups (P = 0.41). However, six patients in the palonosetron group showed a QTc interval > 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. Conclusions Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.

Anesthetic management of a patient with Mounier-Kuhn syndrome undergoing off-pump coronary artery bypass graft surgery -A case report-

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.

Comparison of the neutral and retracted shoulder positions for infraclavicular subclavian venous catheterization: a randomized, non-inferiority trial

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

Effects of Palonosetron on Perioperative Cardiovascular Complications in Patients Undergoing Noncardiac Surgery With General Anesthesia: A Retrospective Cohort Study

We retrospectively investigated whether palonosetron administered during the induction of general anesthesia is associated with an increased risk of perioperative cardiovascular complications in a single tertiary center cohort consisting of 4,517 palonosetron‐exposed patients and 4,517 propensity score‐matched patients without palonosetron exposure. The primary endpoint was a composite of perioperative cardiovascular complications, including intraoperative cardiac arrhythmia, intraoperative cardiac death, and myocardial injury within the first postoperative week, and there was no significant difference between the groups (odds ratio [OR]u2009=u20091.04; 95% confidence interval [CI]u2009=u20090.92–1.19). As secondary endpoints, intraoperative cardioversion, cardiac compression, use of cardiovascular drugs, postoperative hospital stay, and in‐hospital mortality showed no differences between the groups. However, the palonosetron group showed decreased intraoperative hypotension (ORu2009=u20090.88; 95% CIu2009=u20090.79–0.97) and length of postoperative intensive care unit (ICU) stay (4.26u2009±u20099.86 vs. 6.14u2009±u200916.75; Pu2009=u20090.026). Palonosetron did not increase the rate of perioperative cardiovascular complications, and can therefore be used safely during anesthetic induction.

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

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

An undiagnosed pseudoaneurysm found during arterial catheterization in a Takayasu arteritis patient

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