Neuromuscular monitoring of a patient with Charcot-Marie-Tooth disease; which monitoring technique is adequate? - A case report and literature review

BACKGROUND

Charcot-Marie-Tooth disease (CMTD) is a hereditary polyneuropathy associated with a life-threatening risk of pulmonary complications.

CASE

A 61-year-old male with CMTD for 40 years was admitted for the drainage of an abscess in his left ankle. Total intravenous anesthesia was administered, and an electromyography device was attached to the hand for neuromuscular monitoring; however, the response was not measured. Kinemyography and acceleromyography devices were attached to both hands, and responses were obtained. After neuromuscular blockade (NMB) with rocuronium 0.6 mg/kg, the train-of-four (TOF) response on kinemyography was normally measured, but the post-tetanic count on acceleromyography consistently showed 0 during anesthesia. Sugammadex 200 mg was injected to reverse the NMB. After 5 min, the TOF ratios for kinemyography and acceleromyography exceeded 90%. The patient recovered without any complications.

CONCLUSIONS

For CMTD patients, acceleromyography or kinemyography is superior to electromyography, and sugammadex can be used to reverse NMB successfully.

Tranexamic acid - a promising hemostatic agent with limitations: a narrative review

Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been used for several decades to reduce blood loss during surgery and after trauma. TXA was traditionally used to reduce bleeding in various clinical settings such as menorrhagia, hemophilia, or other bleeding disorder . Numerous studies have demonstrated the efficacy of TXA in reducing blood loss and the need for transfusions. Interest in the potential applications of TXA beyond its traditional use has been growing recently, with studies investigating the use of TXA in postpartum hemorrhage, cardiac surgery, trauma, neurosurgery, and orthopedic surgery. Despite its widespread use and expanding indications, data regarding the safe and appropriate use of TXA is lacking. Recent clinical trials have found various potential risks and limitations in the long-term benefits of TXA. This narrative review summarizes the clinical applications and limitations of TXA.

Some considerations on the dependence to numerical schemes of Lagrangian radionuclide transport models for the aquatic environment

Lagrangian models present several advantages over Eulerian models to simulate the transport of radionuclides in the aquatic environment in emergency situations. A radionuclide release is simulated as a number of particles whose trajectories are calculated along time and thus these models do not require a spatial discretization (although it is always required in time). In this paper we investigate the dependence of a Lagrangian model output with the grid spacing which is used to calculate concentrations from the final distribution of particles, with the number of particles in the simulation and with the interpolation schemes which are required because of the discrete nature of the water circulation data used to feed the model. Also, a Lagrangian model may describe the exchanges of radionuclides between phases (liquid and solid), which is done in terms of transition probabilities. The dependence of these probabilities with time step is analyzed as well. It was found that the optimum grid size used to calculate concentrations should be carefully checked, and that temporal interpolation is more significant than spatial interpolation to obtain a more accurate solution. A method to estimate the number of particles required to have a certain accuracy level is proposed. Finally, it was found that for low sediment concentrations and small radionuclide k_d, exact equations for the transition probabilities should be used; and that phase transitions introduce a stability condition as in Eulerian models.

The effect of 6% hydroxyethyl starch 130/0.4 preloading on the blood glucose levels in diabetic patients undergoing orthopedic surgery with spinal anesthesia: a randomized pilot study

BACKGROUND

Perioperative hyperglycemia can occur in surgical patients and may increase postoperative morbidity and mortality, especially in patients with diabetes. Therefore, we conducted the present study to evaluate whether the administration of 6% hydroxyethyl starch (HES)-130/0.4 increases blood glucose levels in patients with diabetes.

METHODS

Forty patients undergoing lower limb surgery under spinal anesthesia were randomly allocated into two groups according to the fluids administered 20 min before spinal anesthesia (Group L, lactated Ringer's solution; Group H, 6% HES-130/0.4). Patient characteristics, intraoperative variables, blood glucose levels, mean blood pressure (MBP), and heart rate (HR) were recorded at five time-points (0, 20, 60, 120, and 240 min).

RESULTS

A total of 39 patients were analyzed (Group L, n = 20; Group H, n = 19). The amount of intraoperative fluid was significantly higher in Group L than in Group H (718.2 ml vs. 530.0 ml, P = 0.010). There were no significant differences in the changes in blood glucose levels, HR, or MBP between the two groups (P = 0.737, P = 0.896, and P = 0.141, respectively). Serial changes in mean blood glucose levels from baseline also showed no significant differences between the groups (P = 0.764).

CONCLUSIONS

There were no significant changes in blood glucose levels when lactated Ringer's solution or 6% HES-130 was used. When compared to the lactated Ringer's solution, no evidence that 6% HES-130/0.4 produces hyperglycemia in diabetic patients could be found. Further evaluation of larger populations is needed.

Determination of optimal tip position of peripherally inserted central catheters using electrocardiography - a retrospective study

Background

Accurate tip positioning of a peripherally inserted central catheter (PICC) is crucial to ensuring optimal drug delivery and avoiding potential complications. The main objective of this study was to evaluate the amplitude ratios of intravascular ECG (ivECG) and body surface ECG (exECG) when the correct tip position was confirmed by chest X-ray (CXR).

Methods

This retrospective study analyzed ivECG, exECG, and CXR of 278 patients who underwent a PICC placement procedure. The tip-to-carina distance (TCD) was measured using vertebral body units (VBU) on CXR, and tip locations were categorized as follows: Zone 1, malposition as TCD <0.8 VBU; Zone 2, suboptimal as 0.8 VBU ≤ TCD < 1.5 VBU; Zone 3, optimal as 1.5 VBU ≤ TCD ≤2.4 VBU; Zone 4, deep as TCD > 2.4 VBU. The amplitude ratios between ivECG and exECG and within ivECG of the corresponding waves were calculated and compared in each Zone.

Results

The ivECG/exECG amplitude ratios of P-wave (Piv/Pex) and QRS-complex (QRiv/QRex and RSiv/RSex) in Zone 3 were significantly higher than in Zones 1 and 2 (adjusted P<0.05). The amplitude ratios of the P-wave and QRS-complex of the ivECG (Piv/QRiv and Piv/RSiv) were significantly lower in Zone 3 than in Zones 1 and 2 (adjusted P<0.001). The calculated TCD using stepwise multiple regression analysis was estimated to be 1.121 + 0.078 × Piv/Pex - 0.172 × Piv/QRiv.

Conclusions

The amplitude ratios between ivECG and exECG and within ivECG (Piv/Pex and Piv/QRiv) can help determine catheter tip positioning during the PICC catheterization procedure. However, caution is required for accurate positioning of the PICC tip.

Optimal Insertion Depth of Gastric Decompression Tube with a Thermistor for Patients Undergoing Laparoscopic Surgery in Trendelenburg Position

Monitoring core temperature is crucial for maintaining normothermia during general anesthesia. Insertion of a gastric decompression tube (GDT) may be required during laparoscopic surgery. Recently, a newly designed GDT with a thermistor for monitoring esophageal temperature has been introduced. The purpose of the present study was to evaluate the optimal insertion depth of a GDT with a thermistor. Forty-eight patients undergoing elective laparoscopic surgery in the Trendelenburg position were included in the study. The GDT was inserted to a depth of nose-earlobe-xiphoid distance (NEX) + 12 cm and withdrawn sequentially, 2 cm at a time, at 5-min intervals. Temperatures of the GDT thermistor were compared with the core temperature of the tympanic membrane (TM) using Bland and Altman analysis. The correlation between optimal insertion depth of the GDT and anatomical distance (cricoid cartilage to the carina, CCD; carina to the left hemidiaphragm, CLHD) was evaluated, and a mathematical model to predict the optimal insertion depth of the GDT with a thermistor was calculated. Temperatures of TM and GDT thermistor at NEX + 4 cm showed good agreement and strong correlation, but better agreement and stronger correlation were seen at the actual location with the most minor temperature differences. The optimal insertion depth of the GDT was estimated as -15.524 + 0.414 × CCD - 0.145 × CLHD and showed a strong correlation with the actual GDT insertion depth (correlation coefficient 0.797, adjusted R² = 0.636). The mathematical formula using CCD and CLHD would be helpful in determining the optimal insertion depth of a GDT with a thermistor.

Therapeutic hypothermia for acute myocardial infarction: a narrative review of evidence from animal and clinical studies

Myocardial infarction (MI) is the leading cause of death from coronary heart disease and requires immediate reperfusion therapy with thrombolysis, primary percutaneous coronary intervention, or coronary artery bypass grafting. However, myocardial reperfusion therapy is often accompanied by cardiac ischemia/reperfusion (I/R) injury, which leads to myocardial injury with detrimental consequences. The causes of I/R injury are unclear, but are multifactorial, including free radicals, reactive oxygen species, calcium overload, mitochondria dysfunction, inflammation, and neutrophil-mediated vascular injury. Mild hypothermia has been introduced as one of the potential inhibitors of myocardial I/R injury. Although animal studies have demonstrated that mild hypothermia significantly reduces or delays I/R myocardium damage, human trials have not shown clinical benefits in acute MI (AMI). In addition, the practice of hypothermia treatment is increasing in various fields such as surgical anesthesia and intensive care units. Adequate sedation for anesthetic procedures and protection from body shivering has become essential during therapeutic hypothermia. Therefore, anesthesiologists should be aware of the effects of therapeutic hypothermia on the metabolism of anesthetic drugs. In this paper, we review the existing data on the use of therapeutic hypothermia for AMI in animal models and human clinical trials to better understand the discrepancy between perceived benefits in preclinical animal models and the absence thereof in clinical trials thus far.

Sec-O-glucosylhamaudol mitigates inflammatory processes and autophagy via p38/JNK MAPK signaling in a rat neuropathic pain model

Background

This study investigated the effect of intrathecal Sec-O-glucosylhamaudol (SOG) on the p38/c-Jun N-terminal kinase (JNK) signaling pathways, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB)-related inflammatory responses, and autophagy in a spinal nerve ligation (SNL)-induced neuropathic pain model.

Methods

The continuous administration of intrathecal SOG via an osmotic pump was performed on male Sprague–Dawley rats (n = 50) with SNL-induced neuropathic pain. Rats were randomized into four groups after the 7th day following SNL and treated for 2 weeks as follows (each n = 10) Group S, sham-operated; Group D, 70% dimethylsulfoxide; Group SOG96, SOG at 96 μg/day; and Group SOG192, SOG at 192 μg/day. The paw withdrawal threshold (PWT) test was performed to assess neuropathic pain. Western blotting of the spinal cord (L5) was performed to measure changes in the expression of signaling pathway components, cytokines, and autophagy. Additional studies with naloxone challenge (n = 10) and cells were carried out to evaluate the potential mechanisms underlying the effects of SOG.

Results

Continuous intrathecal SOG administration increased the PWT with p38/JNK mitogen-activated protein kinase (MAPK) pathway and NF-κB signaling pathway inhibition, which induced a reduction in proinflammatory cytokines with the concomitant downregulation of autophagy.

Conclusions

SOG alleviates mechanical allodynia, and its mechanism is thought to be related to the regulation of p38/JNK MAPK and NF-κB signaling pathways, associated with autophagy during neuroinflammatory processes after SNL.

Development of a dynamic food chain model for assessment of the radiological impact from radioactive releases to the aquatic environment

The software tool POSEIDON-R was developed for modelling the concentration of radionuclides in water and sediments as well as uptake and fate in the aquatic environment and marine organisms. The software has been actively advanced in the aftermath of the Fukushima Dai-ichi accident. This includes development of an uptake model for the benthic food chain, a kinetic-allometric compartment model for fish and recent advancements for the application of ³H. This work will focus on the food chain model development and its extension to key artificial radionuclides in radioecology such as ³H. Subsequently, the model will be applied to assess the radiological dose for marine biota from ³H, ⁹⁰Sr, ¹³¹I, ¹³⁴Cs and ¹³⁷Cs released during and after the Fukushima Dai-ichi accident. The simulation results for ³H, ⁹⁰Sr, ¹³¹I, ¹³⁴Cs and ¹³⁷Cs obtained from the coastal box (4-4 km) located at the discharge area of the Fukushima Dai-ichi NPP, and the surrounding regional box (15-30 km) are compared with measurements. The predictions are by and large consistent with experimental findings, although good validation for ³H, ⁹⁰Sr and ¹³¹I is challenging due to lack of data. On the basis of the model predictions a dose assessment for pelagic and benthic fish is carried out. Maximum absorbed dose rates in the coastal box and the regional box are respectively 6000 and 50 μGy d^-1 and are found in the pelagic non-piscivorous fish. Dose rates exceeding ICRP's derived consideration levels of 1 mGy d^-1 are only found in the direct vicinity of the release and shortly after the accident. During the post-accidental phase absorbed dose rates consistently fall to levels where no deleterious effects to the marine biota are expected. The results also demonstrate the prolonged dose rate from ¹³⁴Cs and ¹³⁷Cs, particularly for benthic organisms, due to caesium's affinity with sediment, re-entry of caesium from the sediment into the food chain and external exposure from its high energetic gamma emissions. Uptake of non-organic tritium (HTO) and organically bound tritium (OBT) is modelled and shows some accumulation of OBT in the marine organism. However, dose rates from tritium, even during the accident, are low.

Dexmedetomidine decreased the post-thyroidectomy bleeding by reducing cough and emergence agitation - a randomized, double-blind, controlled study

Background

Bleeding after thyroidectomy occurs due to violent coughing during emergence. Dexmedetomidine is helpful for the smooth emergence and suppression of cough. The purpose of the present study was to compare the effects of dexmedetomidine on postoperative bleeding after thyroidectomy.

Methods

Randomized, double-blind, controlled trials were conducted in female patients (ASA I–II, aged 20 to 60 years). The patients were randomly allocated into two groups. Approximately 15 min before the end of the surgery, dexmedetomidine was administered (0.6 µg/kg/h) without a loading dose in group D (n = 69), and normal saline was administered in group S (n = 70) at the same infusion rate. Hemodynamic data, coughing reflex, extubation time, Ramsay sedation scale (RSS), and recovery time were assessed during the administration of the study drugs and recovery from anesthesia. The amount of postoperative hemorrhage was measured for 3 days.

Results

Data from a total of 139 patients were analyzed. The incidence of severe cough was significantly lower in group D than in group S (4.3 % vs. 11.5 %, P = 0.022). The emergence agitation in the postanesthetic care unit was significantly lower in group D than in group S (P = 0.01). Postoperative bleeding was significantly lower in group D than in group S until the second postoperative day (P = 0.015).

Conclusions

Dexmedetomidine can be helpful in decreasing bleeding after thyroidectomy by reducing coughing and emergence agitation.

Trial registration

This study was registered at http://clinicaltrials.gov (registration number NCT02412150, 09/04/2015).

Effective dose of intravenous oxycodone depending on sex and age for attenuation of intubation-related hemodynamic responses

Background/aim

Preoperative intravenous oxycodone may help to prevent or attenuate intubation-related hemodynamic responses (IRHRs), but its pharmacokinetics differs according to age and sex. Therefore, we investigated the 95% effective dose (ED₉₅) of intravenous oxycodone for attenuating all IRHRs, depending on the age and sex of the study population.

Materials and methods

All patients were allocated to one of 6 groups: 1) 20–40 year old males, 2) 41–65yearold males, 3) 66–80 year old males, 4) 20–40 year old females, 5) 41–65yearold females, and 6) 66–80 year old females (groups YM, OM, EM, YF, OF, and EF, respectively). Using Dixon’s up-and-down method, the first patient in each group was slowly injected with intravenous oxycodone (0.1 mg kg^-1) 20 min before intubation. The subsequent patient received the next oxycodone dose, which was decreased or increased by 0.01 mg kg^-1, depending on the “success” or “failure” of attenuation of all IRHRs to within 20% of the baseline values at 1 min after intubation in the previous patient. After obtaining 8 crossover points, predictive ED₉₅ was estimated with probit regression analysis.

Results

ED₉₅ varied greatly according to age and sex. ED₉₅was 0.133 mg kg^-1, 0.181 mg kg^-1, 0.332 mg kg^-1, 0.183 mg kg^-1, 0.108 mg kg^-1, and 0.147 mg kg^-1in groups YM, OM, EM, YF, OF, and EF, respectively.

Conclusion

ED₉₅ is higher in males with increasing age but is ambiguous for females. ED₉₅ is higher in males than in females over 40 years of age but is higher in females than in males under 41 years of age. However, after considering the age and sex of the study population, these results can be used as reference doses for further studies to verify the clinical effects of oxycodone for attenuating all IRHRs.

Capillary leak syndrome and disseminated intravascular coagulation after kidney transplantation in a patient with hereditary angioedema - A case report

Background

Hereditary angioedema (HAE) is a rare disease caused by the deficiency of C1 esterase inhibitor. HAE has a risk of life-threatening complications such as capillary leak syndrome (CLS) and disseminated intravascular coagulation (DIC).

Case

A 42-year-old male patient with HAE presented for deceased-donor kidney transplantation. Prophylactic fresh frozen plasma (FFP) was given before surgery because of the risk of edema development. With careful management during anesthesia, there were no problems during surgery. However, generalized edema, hypotension, hypoalbuminemia, massive drainage of serosanguineous fluids from the intraabdominal space, and DIC occurred on the day after surgery. CLS was suspected and sustained hypotension with generalized edema became worse despite treatment with albumin, danazol, FFP, and vasoactive drugs. The patient’s condition worsened despite intensive care and he died due to shock.

Conclusions

The anesthesiologist should prepare for the critical complications of HAE and prepare the appropriate treatment options.

The Optimizing Background Infusion Mode Decreases Intravenous Patient-Controlled Analgesic Volume and Opioid Consumption Compared to Fixed-Rate Background Infusion in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Study

Background and objectives: The fixed-rate continuous background infusion mode with bolus dosing is a common modality for intravenous patient-controlled analgesia (PCA). However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM) where the background injection rate varies depending on the patient’s bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated to either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data on bolus demand count, total infused volume, and background infusion rate were downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (p = 0.621), decreasing with time in both groups (p < 0.001). The bolus demand count was not significantly different between groups throughout (p = 0.756). The mean total cumulative infused PCA volume was lower in group OBIM (84.0 (95% confidence interval: 78.9−89.1) mL) than in group TBIM (102 (97.8−106.0) mL; p < 0.001). The total cumulative opioid dose in fentanyl equivalents, after converting sufentanil to fentanyl using an equipotential dose ratio, was lower in group OBIM (714.1 (647.4−780.9) μg) than in group TBIM (963.7 (870.5−1056.9) μg); p < 0.001). The background infusion rate was significantly different between groups throughout the study period (p < 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour and lower from the 18th to the 48th postoperative hour. Conclusions: The OBIM combined with bolus dosing reduces the cumulative PCA volume and opioid consumption compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing laparoscopic cholecystectomy.

Clinically relevant concentrations of dexmedetomidine may reduce oxytocin-induced myometrium contractions in pregnant rats

BACKGROUND

Recently, there have been some trials to use dexmedetomidine in the obstetric field but concerns regarding the drug include changes in uterine contractions after labor. We aimed to evaluate the effects of dexmedetomidine on the myometrial contractions of pregnant rats.

METHODS

In a pilot study, the contraction of the myometrial strips of pregnant Sprague-Dawley rats in an organ bath with oxytocin at 1 mU/ml was assessed by adding dexmedetomidine from 10-6 to 10-2 M accumulatively every 20 min, and active tension and the number of contractions were evaluated. Then, changes in myometrial contractions were evaluated from high doses of dexmedetomidine (1.0 × 10-4 to 1.2 × 10-3 M). The effective concentrations (EC) for changes in uterine contractions were calculated using a probit model.

RESULTS

Active tension and the number of contractions were significantly decreased at 10-3 M and 10-4 M dexmedetomidine, respectively (P < 0.05). A complete loss of contractions was seen at 10-2 M. Dexmedetomidine (1.0 × 10-4 to 1.2 × 10-3 M) decreased active tension and the number of contractions in a concentration-dependent manner. The EC95 of dexmedetomidine for inhibiting active tension and the number of contractions was 5.16 × 10-2 M and 2.55 × 10-5 M, respectively.

CONCLUSIONS

Active tension of the myometrium showed a significant decrease at concentrations of dexmedetomidine higher than 10-3 M. Thus, clinical concentrations of dexmedetomidine may inhibit uterine contractions. Further research is needed for the safe use of dexmedetomidine in the obstetrics field.

Antinociceptive effects of intrathecal cimifugin treatment: a preliminary rat study based on formalin test

Background

Cimifugin is one of the components of the root of Saposhnikovia divaricata. The extract derived from S. divaricata is traditionally used as an analgesic. This study was conducted to evaluate the analgesic effect of intrathecal cimifugin in the formalin test.

Methods

Male Sprague–Dawley rats (n = 20) were randomized into four groups for intrathecal administration of 70% dimethylsulfoxide and various doses of cimifugin (100 μg, 300 μg, and 1,000 μg). The typical flinch response after the injection of 5% formalin into the hind paw was assessed in two distinct phases: phase 1 until 10 min, and phase 2 from 10 min to 60 min. ED₅₀ values were calculated via linear regression.

Results

Intrathecal cimifugin significantly reduced the flinch response in both phases of the formalin test. Significant antinociceptive effects of cimifugin were found with the dose of 300 μg in phase 1 and the dose of 100 μg in phase 2. The ED₅₀ value (95% confidence intervals) of intrathecal cimifugin was 696.1 (360.8–1,342.8) μg during phase 1 and 1,242.8 (42.0–48,292.5) μg during phase 2.

Conclusions

Intrathecal cimifugin has an antinociceptive effect against formalin-induced pain. Cimifugin has an anti-inflammatory effect at low concentrations, and non-inflammatory analgesic effect at higher concentrations.

Advantages and pitfalls of clinical application of sugammadex

Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.

Conus Medullaris Syndrome Due to Missed Thoracolumbar Spinal Fracture in a Patient with Ankylosing Spondylitis who Underwent Hip Surgery

Ankylosing spondylitis (AS) is vulnerable to fracture, and the missed diagnosis can lead to neurological deterioration. Herein, we present the conus medullaris syndrome due to aggravation of the missed spinal fracture in an 85-year-old woman with AS who underwent hip surgery. She underwent osteosynthesis in a supine position with supports under her shoulders and head due to spine deformity with AS, but was fully supine without supports after surgery. She showed complete paraplegia at postoperative 12 h. The re-reading radiological imaging showed the missed spinal fracture, of which the deteriorated dislocation was revealed on the re-examined radiological evaluation. This deterioration was not recovered ultimately despite an emergent surgery. A thorough preoperative assessment is essential to prevent the missed diagnosis of spinal fracture and minimise deterioration due to its dislocation, with specific spine precaution during transport, transfer and positioning.

Effect of gastric decompression on postoperative vomiting in pediatric patients undergoing strabismus surgery: a randomized controlled study

Background

Postoperative vomiting (POV) is one of the most serious complications in pediatric patients undergoing strabismus surgery. This study was conducted to test the hypothesis that gastric decompression (GD) could prevent POV caused by gastric distension after mask ventilation.

Methods

A total of 60 pediatric patients (ASA PS I-II, aged one to 10 years) were randomly allocated to two groups; Group D (n = 30) and Group C (n = 30). Induction of anesthesia was performed with careful face mask ventilation with 100% O₂ (3 L/min) and sevoflurane 3 vol% to limit airway pressure below 20 cmH₂O. Endotracheal intubation was done after confirming adequate neuromuscular blockade. Then, the patients in Group D received GD, while patients in Group C did not. After the surgery, POV was assessed during the emergence from anesthesia in the operating room and postanesthetic care unit (30 min and 60 min).

Results

During the emergence, POV was significantly decreased in Group D compared to Group C (Group D 3.3% vs. Group C 30.0%, P = 0.006). The odds ratio analysis showed a lower incidence of POV in Group D (odds ratio = 0.080; 95% confidence limit: 0.009-0.685) during the emergence period. There was no significant difference in the incidence of POV in the postanesthetic care unit (Group D 6.7% vs. Group C 4.3% at 30 min, P = 1.000; 0% in both groups at 60 min).

Conclusions

GD reduced the incidence of POV in pediatric patients undergoing strabismus surgery during emergence.

P643 A case of Fabry cardiomyopathy refractory to enzyme replacement therapy; the importance of early diagnosis and treatment in Fabry cardiomyopathy

A 56-year-old male was referred in order to identify Fabry disease after his older brother was confirmed as Fabry disease of cardiac variant type. He had been treated with hypertrophic cardiomyopathy (HCMP) five years ago. He didn’t have a history of hypertension. Blood pressure was 118/65 mmHg and pulse rate was 75 beats per minute. Serum creatinine was 1.07 mg/dl and estimated glomerular filtration rate was 75.2 ml/min. Cardiac enzymes including CK-MB and troponin-T were normal. There was no proteinuria on urinalysis. A 12-leads electrocardiogram revealed normal sinus rhythm with severe left ventricular hypertrophy (LVH) and strain pattern. Transthoracic echocardiogram (TTE) showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 17 mm with normal systolic function (left ventricular ejection fraction (LVEF), 56%). TTE also revealed left ventricular outflow tract obstruction with systolic anterior motion of mitral valve. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 7mm). Also, echocardiography revealed findings of diastolic dysfunction; left atrial enlargement, mitral inflow of a pseudo-normal pattern on pulsed wave Doppler image and an increased left ventricular filling pressure on tissue Doppler image (E/e’=20). Cardiac magnetic resonance imaging (MRI) revealed diffuse LV and RV hypertrophy and preserved LV systolic function with hypokinesia of mid-septal LV wall. Delayed hyper-enhancement (DHE) was not found within entire myocardium. A coronary CT angiography was performed because of regional wall motion abnormality but did not show any significant stenoses. He was confirmed as Fabry disease with the same genetic mutation as his brother. He did not present symptoms and signs of any other organs besides only myocardial hypertrophy. He received enzyme replacement therapy (ERT) with intravenous agalsidase-beta every other week via outpatient department for 3 years. Recently, TTE was performed and showed diffuse severe concentric LVH of an average ventricular wall thickness increased to 19 mm despite regularly ERT. Focal intramural and subepicardial DHE was newly developed at LV basal lateral and septal wall on cardiac MRI. Neutralizing antibody against agalsidase -beta was not found in serum.

Fabry disease of cardiac variant type can be delayed in diagnostic aspect because of absence of typical symptoms and signs. Despite the absence of neutralizing antibody, ERT did not prevent both further myocardial hypertrophy and myocardial fibrosis in patient with advanced myocardial hypertrophy caused by delayed diagnosis of Fabry disease. Suspicion of Fabry disease through detailed history taking including family history in patients with diffuse ventricular hypertrophy on an echocardiography can lead to early diagnosis and treatment and can result in improvement in a clinical outcome.

Gabexate mesilate ameliorates the neuropathic pain in a rat model by inhibition of proinflammatory cytokines and nitric oxide pathway via suppression of nuclear factor-κB

Background

This study examined the effects of gabexate mesilate on spinal nerve ligation (SNL)-induced neuropathic pain. To confirm the involvement of gabexate mesilate on neuroinflammation, we focused on the activation of nuclear factor-κB (NF-κB) and consequent the expression of proinflammatory cytokines and inducible nitric oxide synthase (iNOS).

Methods

Male Sprague-Dawley rats were used for the study. After randomization into three groups: the sham-operation group, vehicle-treated group (administered normal saline as a control), and the gabexate group (administered gabexate mesilate 20 mg/kg), SNL was performed. At the 3rd day, mechanical allodynia was confirmed using von Frey filaments, and drugs were administered intraperitoneally daily according to the group. The paw withdrawal threshold (PWT) was examined on the 3rd, 7th, and 14th day. The expressions of p65 subunit of NF-κB, interleukin (IL)-1, IL-6, tumor necrosis factor-α, and iNOS were evaluated on the 7th and 14th day following SNL.

Results

The PWT was significantly higher in the gabexate group compared with the vehicle-treated group (P < 0.05). The expressions of p65, proinflammatory cytokines, and iNOS significantly decreased in the gabexate group compared with the vehicle-treated group (P < 0.05) on the 7th day. On the 14th day, the expressions of p65 and iNOS showed lower levels, but those of the proinflammatory cytokines showed no significant differences.

Conclusions

Gabexate mesilate increased PWT after SNL and attenuate the progress of mechanical allodynia. These results seem to be involved with the anti-inflammatory effect of gabexate mesilate via inhibition of NF-κB, proinflammatory cytokines, and nitric oxide.

The relaxant effect of nicardipine on the isolated uterine smooth muscle of the pregnant rat

Background

Nicardipine, a calcium channel blocker, is used to treat hypertension in pregnancy or preterm labor. The current study was conducted to investigate the relaxant effects of nicardipine on the isolated uterine smooth muscle of the pregnant rat.

Methods

We obtained uterine smooth muscle strips from pregnant female SD rats. After uterine contraction with oxytocin 10 mU/ml, we added nicardipine (10⁻¹² to 10⁻⁸ M) accumulatively every 20 min. We recorded active tension and frequency of contraction, and calculated EC₅ (effective concentration of 5% reduction), EC₂₅, EC₅₀, EC₇₅, and EC₉₅ of active tension and frequency of contraction using a probit model.

Results

Nicardipine (10⁻¹² to 10⁻⁸ M) decreased active tension and frequency of contraction in a concentration-dependent manner. The EC₅₀ and EC₉₅ of nicardipine in the inhibition of active tension of the uterine smooth muscle were 2.41 × 10⁻¹⁰ M and 3.06 × 10⁻⁷ M, respectively. The EC₅₀ and EC₉₅ of nicardipine in the inhibition of frequency of contraction of the uterine smooth muscle were 9.04 × 10⁻¹¹ and 4.18 × 10⁻⁷ M, respectively.

Conclusions

Nicardipine relaxed and decreased the frequency of contraction of the uterine smooth muscle in a concentration-dependent pattern. It might be possible to adjust the clinical dosage of nicardipine in the obstetric field based on our results, but further clinical studies are needed to confirm them.

Dexmedetomidine as a non-triggering anesthetic agent in a patient with MELAS syndrome and systemic sepsis - A case report

Background

The selection of anesthetic agents is important in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome patient because serious and unexpected complications can occur after anesthetic exposure.

Case

A 30-year-old man with MELAS syndrome and sepsis underwent colectomy. Propofol was administered by step-wise until target effect-site concentration (Ce) 1.0 μg/ml and stopped for the loss of consciousness and to avoid hemodynamic instability. After the loss of consciousness, total intravenous anesthesia (TIVA) using dexmedetomidine (1.0 μg/ml/h) and remifentanil (1–4 ng/ml of Ce) was performed for the maintenance of anesthesia to avoid malignant hyperthermia and mitochondrial dysfunction. During the surgery, the bispectral index score stayed between 26 and 44, and increased to 97 after the end of anesthesia.

Conclusions

TIVA with dexmedetomidine and remifentanil as non-triggering anesthetic agents in patients with MELAS syndrome and systemic sepsis may have advantages to decrease damages associated with mitochondrial stress and metabolic burden.

Effect of different doses of intravenous oxycodone and fentanyl on intubation-related hemodynamic responses: A prospective double-blind randomized controlled trial (CONSORT)

BACKGROUND

Intubation using direct laryngoscopy is a risky and painful procedure that is associated with undesirable hemodynamic changes such as tachycardia, hypertension, and arrhythmia. Recently, intravenous oxycodone was introduced and used for the control of acute postoperative pain and to attenuate intubation-related hemodynamic responses (IRHRs), but there is insufficient information regarding its proper dosage. We investigated the attenuating effects of different doses of oxycodone and fentanyl on IRHRs.

METHODS

For calculating oxycodone effective dose (ED95), which attenuated all IRHR changes to less than 20% over baseline values in 95% of male patients at 1 minute after intubation, oxycodone 0.1 mg/kg was injected for the first patient 1 hour before intubation, and the next dose for each subsequent patient was determined by the response of the previous patient using Dixon up-and-down method with an interval of 0.01 mg/kg. After obtaining the predictive oxycodone ED95, 148 patients were randomly allocated to groups receiving normal saline (group C), oxycodone ED95 (group O1), oxycodone 2 × ED95 (group O2), or fentanyl 2 μg/kg (group F). We recorded the incidence of "success" as a less than 20% change from baseline values in all IRHRs 1 minute after intubation.

RESULTS

The predictive oxycodone ED95 was 0.091 (0.081-0.149) mg/kg. The incidence of "success" was highest in group O2 (75.7%), followed by group O1 (62.2%) and group F (45.9%) with significant differences between the groups (P < .001). The systolic, diastolic, mean arterial pressure, and heart rate were not significantly different among groups after administration of either oxycodone or fentanyl. The percentage hemodynamic changes of the group O2 were significantly lower than those of groups F and O1, but the absolute percentage hemodynamic changes were not significantly different among groups F, O1, and O2. The recalculated oxycodone ED95 with probit analysis (0.269 mg/kg) was needed to prevent any arterial pressure and heart rate changes.

CONCLUSIONS

Oxycodone 0.182 mg/kg is more effective in attenuating all IRHRs than fentanyl 2 μg/kg with safe hemodynamic changes. Further research is required to determine if the recalculated oxycodone ED95 (0.269 mg/kg) is also effective and hemodynamically safe for preventing all IRHRs.

Effect of sec-O-glucosylhamaudol on mechanical allodynia in a rat model of postoperative pain

Background

This study was performed in order to examine the effect of intrathecal sec-O-glucosylhamaudol (SOG), an extract from the root of the Peucedanum japonicum Thunb., on incisional pain in a rat model.

Methods

The intrathecal catheter was inserted in male Sprague-Dawley rats (n = 55). The postoperative pain model was made and paw withdrawal thresholds (PWTs) were evaluated. Rats were randomly treated with a vehicle (70% dimethyl sulfoxide) and SOG (10 μg, 30 μg, 100 μg, and 300 μg) intrathecally, and PWT was observed for four hours. Dose-responsiveness and ED50 values were calculated. Naloxone was administered 10 min prior to treatment of SOG 300 μg in order to assess the involvement of SOG with an opioid receptor. The protein levels of the δ-opioid receptor, κ-opioid receptor, and μ-opioid receptor (MOR) were analyzed by Western blotting of the spinal cord.

Results

Intrathecal SOG significantly increased PWT in a dose-dependent manner. Maximum effects were achieved at a dose of 300 μg at 60 min after SOG administration, and the maximal possible effect was 85.35% at that time. The medial effective dose of intrathecal SOG was 191.3 μg (95% confidence interval, 102.3–357.8). The antinociceptive effects of SOG (300 μg) were significantly reverted until 60 min by naloxone. The protein levels of MOR were decreased by administration of SOG.

Conclusions

Intrathecal SOG showed a significant antinociceptive effect on the postoperative pain model and reverted by naloxone. The expression of MOR were changed by SOG. The effects of SOG seem to involve the MOR.

Fukushima 137Cs releases dispersion modelling over the Pacific Ocean. Comparisons of models with water, sediment and biota data

A number of marine radionuclide dispersion models (both Eulerian and Lagrangian) were applied to simulate ¹³⁷Cs releases from Fukushima Daiichi nuclear power plant accident in 2011 over the Pacific at oceanic scale. Simulations extended over two years and both direct releases into the ocean and deposition of atmospheric releases on the ocean surface were considered. Dispersion models included an embedded biological uptake model (BUM). Three types of BUMs were used: equilibrium, dynamic and allometric. Model results were compared with ¹³⁷Cs measurements in water (surface, intermediate and deep layers), sediment and biota (zooplankton, non-piscivorous and piscivorous fish). A reasonable agreement in model/model and model/data comparisons was obtained.

Effect of intraoperative infusion of sufentanil versus remifentanil on postoperative shivering in Korea: a prospective, double-blinded, randomized control study

Background/aim

The number of published papers that compare the incidence of sufentanil- and remifentanil-related postoperative shivering is insufficient. We investigated the incidence of postoperative shivering after total intravenous anesthesia with either sufentanil or remifentanil in patients who underwent elective surgery.

Materials and methods

Eighty-three patients, with a physical status classified as American Society of Anesthesiologists I or II, were randomly allocated to either the remifentanil–propofol (RP group, n = 40) or sufentanil–propofol (SP group, n = 43) group. The primary endpoint was the incidence of postoperative shivering 1 h after entering the recovery room. The secondary endpoints were intraoperative core temperatures of the esophagus and tympanic membrane at 30 min after the induction of anesthesia and at the end of surgery.

Results

The overall postoperative shivering incidence was not significantly different between the RP (15%) and SP (11.6%) groups (P = 0.651). The intraoperative temperatures and their changes (the temperature 30 min after induction minus that after surgery) as measured at the distal esophagus and tympanic membrane were not significantly different between the RP and SP groups.

Conclusion

The incidence of postoperative shivering related to sufentanil was less than that related to remifentanil, with no significant differences in the intraoperative core temperatures.

Nefopam downregulates autophagy and c-Jun N-terminal kinase activity in the regulation of neuropathic pain development following spinal nerve ligation

Background

Neurodegeneration is associated with changes in basal cellular function due to the dysregulation of autophagy. A recent study introduced the involvement of autophagy during spinal nerve ligation (SNL). Nefopam has shown potential for reducing neuropathic pain, but the underlying mechanisms are unknown. Here, we investigated the effects of nefopam on neuropathic pain development following SNL, focusing on the involvement of autophagy.

Methods

The functional role of nefopam in capsaicin-induced autophagy was assessed by human glioblastoma M059 K cells. The neuropathic pain model was used to determine whether the effect of nefopam on pain control was mediated through autophagy control. Neuropathic pain was induced by L5 and L6 SNL in male rats randomized into three groups: Group S (sham-operated), Group C (received normal saline), and Group E (received nefopam). A behavioral test using a von Frey was examined. Expression changes of autophagy in response to nefopam was analyzed in spinal cord tissues (L4-L6) by immunoblotting and immunohistochemistry.

Results

The paw withdrawal threshold examined on days 3, 5, 7, and 14 post-SNL was significantly higher in Group E than in Group C. SNL increased the levels of microtubule-associated protein 1 light chain 3B (LC3B-1), with concomitant reduction of sequestosome 1 (SQTSM1/p62), compared with Group S, indicating that SNL induced autophagy. These effects were reversed by nefopam injection, and the results were confirmed by immunohistochemistry for LC3-I/II. Furthermore, SNL-mediated JNK activation was markedly decreased following nefopam injection. Hematoxylin and eosin staining on Day 14 post-SNL revealed that SNL caused lymphocyte infiltration and oligodendrocyte localization in the substantia gelatinosa of the dorsal gray horn, which were reduced by nefopam injection.

Conclusion

Collectively, the mode of action of nefopam on neuropathic pain appears to be associated with downregulation of phospho-JNK and autophagy, as well as modulation of the immune response.

Combination of extracorporeal membrane oxygenation and inline hemofiltration for the acute hyperkalemic cardiac arrest in a patient with Duchenne muscular dystrophy following orthopedic surgery -a case report

Background

Duchenne muscular dystrophy (DMD) is the most common childhood muscular dystrophy that anesthesiologists can encounter in the operation room, and patients with DMD are susceptible to complications such as rhabdomyolysis, hyperkalemic cardiac arrest, and hyperthermia during the perioperative period. Acute onset of hyperkalemic cardiac arrest is a crisis because of the difficulty in achieving satisfactory resuscitation owing to the sustained hyperkalemia accompanied by rhabdomyolysis.

Case

We here report a case of a 13-year-old boy who had multiple leg fractures and other trauma after a car accident and who had suffered from acute hyperkalemic cardiac arrest. He was refractory to cardiopulmonary resuscitation and showed sustained hyperkalemia. With extracorporeal membrane oxygenation and in-line hemofiltration, he recovered from repeated cardiac arrest and hyperkalemia.

Conclusions

Combining ECMO and in-line hemofiltration might be a safe and effective technique for refractory hyperkalemic cardiac arrest and rhabdomyolysis in patients with DMD.

Effect of dexamethasone on the onset time and recovery profiles of cisatracurium

BACKGROUND

The effect of dexamethasone injection on cisatracurium-induced neuromuscular block was compared according to different injection time points.

METHODS

One hundred seventeen patients were randomly assigned to three groups: 8 mg of dexamethasone injected intravenously 2-3 h before anesthesia (group A), just before anesthesia induction (group B), and at the end of surgery (control group). Three minutes after anesthesia induction, intubation was performed without neuromuscular blockers, and acceleromyography was initiated. All patients received 0.05 mg/kg cisatracurium; the onset time and recovery profiles were recorded.

RESULTS

Eighty patients were finally enrolled. The onset time (median [interquartile range], seconds) was significantly hastened in group A (520.0 [500.0-560.0], n = 30) compared to that in group B (562.5 [514.0-589.0], n = 22) (P = 0.008) and control group (586.5 [575.0-642.5], n = 28) (P < 0.001). The onset time in group B was faster than the control group (P = 0.015). The recovery time [mean (95% CI) minutes] was significantly hastened in group A [28.5 (27.3-29.6)] compared to that in group B [32.3 (31.0-33.6)] (P < 0.001) and control group [30.9 (29.9-31.8)] (P = 0.015). The total recovery time was significantly hastened more in group A [47.1 (45.5-48.6)] than group B [52.8 (51.6-54.0) minutes] (P < 0.001) and control group [50.5 (48.7-52.3) minutes] (P = 0.008).

CONCLUSIONS

A single dose of 8 mg of dexamethasone hastened the onset and total recovery times of cisatracurium-induced block by approximately 15 and 9%, respectively if administered 2-3 h prior to surgery.

Antinociceptive effect of intrathecal sec-O-glucosylhamaudol on the formalin-induced pain in rats

BACKGROUND

The root of Peucedanum japonicum Thunb., a perennial herb found in Japan, the Philippines, China, and Korea, is used as an analgesic. In a previous study, sec-O-glucosylhamaudol (SOG) showed an analgesic effect. This study was performed to examine the antinociceptive effect of intrathecal SOG in the formalin test.

METHODS

Male Sprague-Dawley rats were implanted with an intrathecal catheter. Rats were randomly treated with a vehicle and SOG (10 µg, 30 µg, 60 µg, and 100 µg) before formalin injection. Five percent formalin was injected into the hind-paw, and a biphasic reaction followed, consisting of flinching and licking behaviors (phase 1, 0-10 min; phase 2, 10-60 min). Naloxone was injected 10 min before administration of SOG 100 µg to evaluate the involvement of SOG with an opioid receptor. Dose-responsiveness and ED50 values were calculated.

RESULTS

Intrathecal SOG showed a significant reduction of the flinching responses at both phases in a dose-dependent manner. Significant effects were showed from the dose of 30 µg and maximum effects were achieved at a dose of 100 µg in both phases. The ED50 value (95% confidence intervals) of intrathecal SOG was 30.3 (25.8-35.5) µg during phase 1, and 48.0 (41.4-55.7) during phase 2. The antinociceptive effects of SOG (100 µg) were significantly reverted at both phases of the formalin test by naloxone.

CONCLUSIONS

These results demonstrate that intrathecal SOG has a very strong antinociceptive effect in the formalin test and it seems the effect is related to an opioid receptor.

Modelling of marine radionuclide dispersion in IAEA MODARIA program: Lessons learnt from the Baltic Sea and Fukushima scenarios

State-of-the art dispersion models were applied to simulate (137)Cs dispersion from Chernobyl nuclear power plant disaster fallout in the Baltic Sea and from Fukushima Daiichi nuclear plant releases in the Pacific Ocean after the 2011 tsunami. Models were of different nature, from box to full three-dimensional models, and included water/sediment interactions. Agreement between models was very good in the Baltic. In the case of Fukushima, results from models could be considered to be in acceptable agreement only after a model harmonization process consisting of using exactly the same forcing (water circulation and parameters) in all models. It was found that the dynamics of the considered system (magnitude and variability of currents) was essential in obtaining a good agreement between models. The difficulties in developing operative models for decision-making support in these dynamic environments were highlighted. Three stages which should be considered after an emergency, each of them requiring specific modelling approaches, have been defined. They are the emergency, the post-emergency and the long-term phases.

Effect of hydroxyethyl starch on blood glucose levels

Background

Hydroxyethyl starch (HES), a commonly used resuscitation fluid, has the property to induce hyperglycemia as it contains large ethyl starch, which can be metabolized to produce glucose. We evaluated the effect of 6% HES-130 on the blood glucose levels in non-diabetic patients undergoing surgery under spinal anesthesia.

Methods

Patients scheduled to undergo elective lower limb surgery were enrolled. Fifty-eight patients were divided into two groups according to the type of the main intravascular fluid used before spinal anesthesia (Group LR: lactated Ringer's solution, n = 30 vs. Group HES: 6% hydroxyethyl starch 130/0.4, n = 28). Blood glucose levels were measured at the following time points: 0 (baseline), 20 min (T1), 1 h (T2), 2 h (T3), 4 h (T4), and 6 h (T6).

Results

Mean blood glucose levels at T5 in the LR group and T4, T5 in the HES group, increased significantly compared to baseline. There were no significant changes in the serial differences of mean blood glucose levels from baseline between the two groups.

Conclusions

Administration of 6% HES-130 increased blood glucose levels within the physiologic limits, but the degree of glucose increase was not greater than that caused by administration of lactated Ringer's solution. In conclusion, we did not find evidence that 6% HES-130 induces hyperglycemia in non-diabetic patients.

Inter-comparison of dynamic models for radionuclide transfer to marine biota in a Fukushima accident scenario

We report an inter-comparison of eight models designed to predict the radiological exposure of radionuclides in marine biota. The models were required to simulate dynamically the uptake and turnover of radionuclides by marine organisms. Model predictions of radionuclide uptake and turnover using kinetic calculations based on biological half-life (TB1/2) and/or more complex metabolic modelling approaches were used to predict activity concentrations and, consequently, dose rates of (90)Sr, (131)I and (137)Cs to fish, crustaceans, macroalgae and molluscs under circumstances where the water concentrations are changing with time. For comparison, the ERICA Tool, a model commonly used in environmental assessment, and which uses equilibrium concentration ratios, was also used. As input to the models we used hydrodynamic forecasts of water and sediment activity concentrations using a simulated scenario reflecting the Fukushima accident releases. Although model variability is important, the intercomparison gives logical results, in that the dynamic models predict consistently a pattern of delayed rise of activity concentration in biota and slow decline instead of the instantaneous equilibrium with the activity concentration in seawater predicted by the ERICA Tool. The differences between ERICA and the dynamic models increase the shorter the TB1/2 becomes; however, there is significant variability between models, underpinned by parameter and methodological differences between them. The need to validate the dynamic models used in this intercomparison has been highlighted, particularly in regards to optimisation of the model biokinetic parameters.

Effects of dexmedetomidine on smooth emergence from anaesthesia in elderly patients undergoing orthopaedic surgery

BACKGROUND

Intraoperative dexmedetomidine may decrease postoperative emergence agitation in elderly patients due to its sedative effect. In this study, we evaluated the effect of adjuvant dexmedetomidine on smooth emergence from anaesthesia after orthopaedic surgery in elderly patients.

METHODS

A total 115 patients (ASA I-II, aged over 65 years) were randomly allocated into four groups. Anaesthesia was maintained with either sevoflurane or total intravenous anaesthesia (TIVA) comprising propofol and remifentanil. Patients were also administered either dexmedetomidine (0.4 μg kg(-1) hr(-1); SD and TD) intraoperatively or normal saline (SN or TN) as a control. The bispectral index (BIS) score was maintained from 40-60 intraoperatively. All anaesthetics and dexmedetomidine were discontinued at surgical conclusion, and the recovery times (durations to a BIS = 60, 70, and 80; eye opening; and extubation) were measured. The mean arterial pressure, heart rate, Ricker's agitation-sedation scale (RSAS), visual analogue scale (VAS) for pain, and incidences of emergence agitation and postoperative nausea and vomiting (PONV) were measured in the recovery room.

RESULTS

Dexmedetomidine significantly decreased the RSAS score in the SD and TD groups, and a calm state postoperatively occurred more frequently in these groups than in the control groups. The heart rate and incidence of emergence agitation were lower in the dexmedetomidine groups. Recovery time was higher in the SD group than in the SN group, and no significant differences occurred between the TN and TD groups. The VAS score was lower in the SD group than in the SN group, and the PONV did not differ regardless of the use of dexmedetomidine.

CONCLUSIONS

Dexmedetomidine may be an effective intraoperative adjuvant for a reducing emergence agitation and smooth emergence from anaesthesia after orthopaedic surgery in elderly patients.

TRIAL REGISTRATION

Current Controlled Trials NCT01851005 .

Clinical evaluation of a newly designed fluid warming kit on fluid warming and hypothermia during spinal surgery

BACKGROUND

The Mega Acer Kit® (MAK) is a newly designed heated and humidified breathing circuit that warms fluid passing through the circuit lumen. In this study, we investigated the system's efficacy for the perioperative prevention of hypothermia and fluid warming.

METHODS

Ninety patients undergoing spinal surgery were enrolled in this study and randomly assigned to 3 groups based on the fluid warming device used: no fluid warming system (Group C, n = 30), via a Standard Ranger (Group R, n = 30), or via the MAK (Group M, n = 30). Distal esophageal temperatures (Teso) and infusion fluid temperature (TF) were recorded at 15 min intervals for duration of 180 min during surgery. If Teso was < 35.0℃, a forced-air convective warming device was used.

RESULTS

Final Teso values were 34.8 ± 0.3℃, 35.1 ± 0.1℃, and 35.8 ± 0.3℃ in groups C, R, and M, respectively (P < 0.01). Teso was significantly higher in group M when compared with that in groups C and R throughout the study period (P < 0.05). The number of patients requiring a forced-air convective warming device was significantly lower in group M (n = 0) when compared with that in groups R (n = 17) and C (n = 30) (P < 0.05). The final infusion fluid temperature was higher in group M when compared with that in groups C and R throughout the study period (35.4 ± 1.0 vs. 23.0 ± 0.3 and 32.8 ± 0.6℃; P < 0.01).

CONCLUSIONS

The MAK is more effective for preventing hypothermia and for warming fluid than the Standard Ranger.

Position does not affect the optic nerve sheath diameter during laparoscopy

Background

Increase in intracranial pressure (ICP) is one of the physiologic changes during laparoscopic surgery, which is known to be associated with positional changes. Changes of ICP can be measured directly by invasive method, but ultrasonographic measurement of optic nerve sheath diameter (ONSD) is known to be a rapidly applicable technique for evaluating ICP. The aim of this study is to investigate the change of ONSD according to the positional change during laparoscopic surgery.

Methods

Female patients scheduled to undergo laparoscopic surgery were enrolled. Fifty-seven patients were assigned according to the position during surgery (Group T: gynecological surgery, Trendelenburg position, n = 27 vs. Group RT: laparoscopic cholecystectomy, Reverse trendelenburg position, n = 30). After induction of anesthesia, ONSD, PaCO₂, end-tidal carbon dioxide (ETCO₂), and mean arterial pressure (MAP) were measured. Parameters were measured at 6 time points during surgery.

Results

There were no significant differences in the demographic data of patients, procedure time, and anesthesia. After pneumoperitoneum and positional change, ONSD, ETCO₂, and MAP increased in both groups until 15 min and returned to the baseline. However, no significant differences in changes of ONSD, PaCO₂, ETCO₂, and MAP were observed between two groups.

Conclusions

ONSD during laparoscopic surgery with pneumoperitoneum increased slightly until 15 minutes, but there were no significant differences according to the position. Increases in ICP during laparoscopic surgery with short period of pneumoperitoneum would be small in disregard of position in patients without intracranial pathology.

Dispersion and fate of ⁹⁰Sr in the Northwestern Pacific and adjacent seas: global fallout and the Fukushima Dai-ichi accident

The 3D compartment model POSEIDON-R was applied to the Northwestern Pacific and adjacent seas to simulate the transport and fate of (90)Sr in the period 1945-2010 and to perform a radiological assessment on the releases of (90)Sr due to the Fukushima Dai-ichi nuclear accident for the period 2011-2040. The contamination due to runoff of (90)Sr from terrestrial surfaces was taken into account using a generic predictive model. A dynamical food-chain model describes the transfer of (90)Sr to phytoplankton, zooplankton, molluscs, crustaceans, piscivorous and non-piscivorous fishes. Results of the simulations were compared with observation data on (90)Sr for the period 1955-2010 and the budget of (90)Sr activity was estimated. It was found that in the East China Sea and Yellow Sea the riverine influx was 1.5% of the ocean influx and it was important only locally. Calculated concentrations of (90)Sr in water, bottom sediment and marine organisms before and after the Fukushima Dai-ichi accident are in good agreement with available experimental measurements. The concentration of (90)Sr in seawater would return to the background levels within one year after leakages were stopped. The model predicts that the concentration of (90)Sr in fish after the Fukushima Dai-ichi accident shall return to the background concentrations only 2 years later due to the delay of the transfer throughout the food web and specific accumulation of (90)Sr. The contribution of (90)Sr to the maximal dose rate due to the FDNPP accident was three orders of magnitude less than that due to (137)Cs, and thus well below the maximum effective dose limits for the public.