Ya-n Chu

Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial.

OBJECTIVE To test in a prospective randomized study the hypothesis that use of thromboelastography (TEG) decreases blood transfusion during major surgery. MATERIAL AND METHODS Twenty-eight patients undergoing orthotopic liver transplantation were recruited over 2 years. Patients were randomized into 2 groups: those monitored during surgery using point-of-care TEG analysis, and those monitored using standard laboratory measures of blood coagulation. Specific trigger points for transfusion were established in each group. RESULTS In patients monitored via TEG, significantly less fresh-frozen plasma was used (mean [SD], 12.8 [7.0] units vs 21.5 [12.7] units). There was a trend toward less blood loss in the TEG-monitored patients; however, the difference was not significant. There were no differences in total fluid administration and 3-year survival. CONCLUSION Thromboelastography-guided transfusion decreases transfusion of fresh- frozen plasma in patients undergoing orthotopic liver transplantation, but does not affect 3-year survival.

Intraoperative administration of tramadol for postoperative nurse-controlled analgesia resulted in earlier awakening and less sedation than morphine in children after cardiac surgery

In adults, intraoperative administration of tramadol could result in earlier recovery and less sedation than morphine. In this controlled, randomized, double-blind study, we investigated whether an intraoperative initial dose of tramadol could cause more rapid awakening from general anesthesia, less sedation, and earlier tracheal extubation than morphine in children during the immediate postoperative period. Forty children aged 1–6 yr, scheduled for atrial or ventricular septal defect repair and tracheal extubation in the pediatric intensive care unit, were randomly allocated to receive morphine, initial dose 0.2 mg/kg, or tramadol 2 mg/kg given at the end of sternal closure, followed by nurse-controlled analgesia (bolus 0.02 mg/kg of morphine and 0.2 mg/kg of tramadol) with background infusions (0.015 mg · kg−1 · h−1 for morphine and 0.15 mg · kg−1 · h−1 for tramadol). Postoperatively, children receiving tramadol had earlier awakening from general anesthesia (P = 0.02) and were less sedated at 1 and 2 h postoperatively (P = 0.03 and P = 0.01, respectively). Tracheal extubation was earlier in the tramadol group (P = 0.01). Lengths of pediatric intensive care unit stay did not differ between groups. Times to first trigger of nurse-controlled analgesia bolus and objective pain scores during the 48 h observation period were comparable between groups. The incidence of desaturation and emesis were similar between groups. The patients ate well and did not differ on Day 1 or Day 2.

Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery

Plasma‐containing products are given during the pre‐anhepatic stage of liver transplant surgery to correct abnormal thromboelastogram (TEG) values and prevent blood loss due to coagulation defects. However, evidence suggests that abnormal TEG results do not always predict bleeding. We questioned what effect using higher TEG values to initiate treatment would have on blood loss. A single transfusion protocol was used for all patients who underwent liver transplantation between 2007 and 2010. Thirty‐eight patients received coagulation products when standard TEG cutoff values were exceeded, whereas another 39 patients received coagulation products when the TEG values were 35% greater than normal. The results of postoperative coagulation tests for total blood loss and the use of blood products were compared for the 2 groups. When the critical TEG values for transfusion were higher, significantly fewer units of fresh frozen plasma (5.58 ± 6.49 versus 11.53 ± 6.66 U) and pheresis platelets (1.84 ± 1.33 versus 3.55 ± 1.43 U) were used. There were no differences in blood loss or postoperative blood product use. In conclusion, the use of higher critical TEG values to initiate the transfusion of plasma‐containing products is not associated with increased blood loss. Further testing is necessary to identify what TEG value predicts bleeding due to a deficit in coagulation factors. Liver Transpl 18:1254–1258, 2012.

Fluid management guided by stroke volume variation failed to decrease the incidence of acute kidney injury, 30-day mortality, and 1-year survival in living donor liver transplant recipients.

Background: Low central venous pressure (CVP) produced by fluid restriction has been applied to liver transplant recipients in order to decrease blood loss. However, CVP is not reliable for monitoring intravascular volume and ventricular filling. In addition, doubts remain over the association between fluid restriction and acute kidney injury (AKI). We tested the utility of stroke volume variation (SVV), derived from the FloTrac/Vigileo system, as a decision‐making tool in fluid management. We examined the differences in fluid administration, urine output, postoperative AKI, and 30‐day and 1‐year survival rates between liver transplant recipients with fluid management guided by SVV and CVP. Methods: We retrospectively collected data on our liver transplant recipients with a Model for End‐stage Liver Disease score less than 30 and serum creatinine lower than 1.5 mg/dL from 2007 to 2010. Recipients in 2007 and 2008 who received CVP‐guided fluid management served as the control group. Recipients in 2009 and 2010 who received fluid administration triggered by SVV were recruited as the study group. The estimated blood loss, urine output, and fluid administered during the operation were recorded. Renal function was assessed using the RIFLE criteria on postoperative days 1 and 5. We also recorded the 30‐day and 1‐year survival. Results: Significantly more diuretic use and urine output were noted in the control group in spite of similar fluid administration. However, there was no significant difference in blood loss, AKI, or 30‐day and 1‐year survival rates. Conclusion: The outcomes of living donor liver transplant patients who had fluid therapy guided by an SVV less than 10% were similar to those of patients who were given fluids to reach a CVP of 10 mmHg. Our findings suggest that the two measures of vascular filling are similar in liver transplant recipients with demographic characteristics similar to those of our patients.

Thoracic epidural anesthesia for a polymyositis patient undergoing awake mini-thoracotomy and unroofing of a huge pulmonary bulla.

General anesthesia with one-lung ventilation is a conventional anesthetic strategy for most chest surgery, including resection of pulmonary bullae. However, this anesthetic management may cause alveolar barotrauma, hemodynamic instability, pulmonary atelectasis and long-term ventilator dependency. Here, we report a 64-year-old female with polymyositis and bronchiolitis obliterans organizing pneumonia who was scheduled for surgical intervention for a huge pulmonary bulla over the right upper lung. Under thoracic epidural anesthesia, with the patient maintaining clear consciousness and spontaneous breathing, a mini-thoracotomy was accomplished to unroof and partially resect the bulla. There were no perioperative complications, and the patient was satisfied with the anesthetic care. Pulmonary function tests and daily physical performance also improved postoperatively.

Lateral medullary syndrome after prone position for general surgery.

IMPLICATIONS We describe postoperative lateral medullary syndrome with myoclonic spasm. Improper head rotation during positioning in the anesthetized patient might obstruct the flow of the vertebral artery at the neck and result in diminished perfusion of the associated regions in patients with a history of cervical spinal trauma.

Neonatal nociception elevated baseline blood pressure and attenuated cardiovascular responsiveness to noxious stress in adult rats.

Neonatal nociception has significant long‐term effects on sensory perception in adult animals. Although neonatal adverse experience affect future responsiveness to stressors is documented, little is known about the involvement of early nociceptive experiences in the susceptibility to subsequent nociceptive stress exposure during adulthood. The aim of this study is to explore the developmental change in cardiovascular regulating activity in adult rats that had been subjected to neonatal nociceptive insults. To address this question, we treated neonatal rats with an intraplantar injection of saline (control) or carrageenan at postnatal day 1. The carrageenan‐treated rats exhibited generalized hypoalgesia at basal state, and localized hyperalgesia after re‐nociceptive challenge induced by intraplantar injections of complete Freunds adjuvant (CFA) as adults. Then we recorded baseline cardiovascular variables and 24‐h responsiveness to an injection of CFA in the free‐moving adult rats with telemetric technique.

Reversal of Mivacurium Chloride: Edrophonium of Spontaneous Recovery in Microscopic Laryngeal Surgery

BACKGROUND A double-blind, randomized study was designed to compare the recovery manner of mivacurium infusion with or without edrophonium reversal in microscopic laryngeal surgery. Neuromuscular blockade was quantified using the train-of-four stimuli to the ulnar nerve and quantification of the ratio of the fourth twitch to the first twitch. METHODS With the approval of the Human Studies Committee of the Taipei Veterans General Hospital and patient informed consent, 40 healthy (ASA I or II) patients with age from 24 to 54 years, undergoing microscopic laryngeal surgery were randomly selected for study. Mivacurium chloride 0.2 mg/kg was given intravenously, and then it was given in continuous infusion to maintain muscle relaxation at 90% twitch block during the procedure. At the end of operation, mivacurium infusion was terminated. In a double-blind manner, group I patients (n = 20) received intravenous edrophonium 1 mg/kg and atropine 0.01 mg/kg for reversal when T1 was at 10% recovery whereas patients in Group II (n = 20) received placebo in the same manner. Mean infusion rate, recovery index (RI50, time from T1 25% to T1 50%; RI75, time from T1 25% to T1 75%), extubation time, and discharge time between groups were compared. Nausea, vomiting, and dysrhythmias were also documented until the patient was discharged from hospital. RESULTS The demographic data between two groups were similar. The recovery index (RI75) for group I was shorter than that of placebo group (5.3 +/- 2.19 min vs. 7.3 +/- 0.9 min) and the difference was statistically significant (P = 0.017). There were no statistically significant differences in mean infusion rate, incidence of nausea and vomiting, and discharge time from the POR. The incidence of tachycardia or arrhythmia in group I was significantly greater than that in group placebo. CONCLUSIONS Mivacurium, a short-acting nondepolarizing agent, is a suitable muscle relaxant for patients receiving microscopic laryngeal surgery. Recovery time with the use of edrophonium as reversal agent was shorter than with placebo, but extubation and discharge time did not differ in two groups. The time which could be saved by the use of edrophonium for reversal of mivacurium to hasten the maximal recovery appears to be less than a few minutes. Therefore, clinically, the value of routine use of edrophonium to obtain a faster recovery does not outweigh its demerits of cost and risk and is not worthy of recommendation.

Intraoperative wake-up test in a deaf-mute adolescent undergoing scoliosis surgery

We present our experience in intraoperative wake-up test in a deaf-mute feminine teenager who underwent spine surgery for correction of lordoscoliosis. Inadequate comprehension of the preoperative instructions, together with higher threshold of arousal in deaf-mutism may possibly contribute to lingering of the test. The report implicated direct, painful stimulation of the tested limbs, rather than indirect cues, such as flap on the dorsum of hands would be required for performance of wake-up test in the deaf-mute patients.

Application of an ultrasound-guided low-approach insertion technique in three types of totally implantable access port

Background: Totally implantable access ports (TIAPs) are alternatives to central venous catheters for patients requiring chemotherapy. Since January 2003, we have used a central approach two‐point incision technique to insert TIAPs. Following advances in ultrasound technique and clinical experience for tunneled dialysis catheter placement, we modified the central approach to a low‐approach technique. Methods: From January 2009 to June 2010, patients consulted for TIAP insertion in our department were enrolled in our study. Different brands and materials of central venous catheters of TIAPs were inserted by the low‐approach two‐point incision technique (Phase I) or the low‐approach one‐point incision technique (Phase II). The insertion time, failure rate, procedural and late complications, degree of satisfaction, and cosmetic scores were recorded. Results: Ninety‐seven patients and 107 patients were implanted via the two‐point and one‐point low‐approach techniques, respectively, with different kinds of TIAP. No matter which type of TIAP was used, the success rate in both phases was 100% without procedural complications using the low‐approach technique. The average time for device insertion was 30 minutes for the two‐point incision technique used during Phase I and 26–28 minutes for the one‐point incision technique used during Phase II. Satisfaction and cosmetic scores were high. Conclusion: Our study highlights a revised technique for placement of TIAP systems of differing types of material or size. Not only was the curvature of the device catheter smooth, but patients were satisfied with the cosmetic appearance.