Ten-min prewarming for breast surgery

Purpose : We evaluated the effect of 10-min prewarming on core temperature maintenance during general anesthesia. Patients : We randomized 40 women scheduled for breast cancer surgery into 10-min Prewarming and Control groups. In the Prewarming group, a forced-air warming system was used to warm the patients at 43℃ for 10 min immediately before general anesthesia induction. In the Control group, the patients were kept warm using cotton thermal blankets for 10 min. We measured tympanic temperature every 15 min from anesthesia induction for 90 min. Findings : Since two patients deviated from the protocol, we used the data of 38 patients (Prewarming [n = 18] and Control [n = 20]). There was a significant between-group difference in changes in core temperature (P = 0.03), including a significant difference in core temperature decrease during the first 60 min from anesthesia induction (Prewarming : −0.3 [0.3] ℃ vs. Control : −0.6 [0.2] ℃, P = 0.02). In addition, the duration of normal core temperature maintenance was significantly longer in the Prewarming group (66 [34] min vs. 39 [32] min, P = 0.01). Conclusions : Ten-min prewarming decreases core temperature loss and contribute to maintaining normal core temperature during breast surgery

Comparison of hemodynamics during induction of general anesthesia with remimazolam and target-controlled propofol in middle-aged and elderly patients : a single-center, randomized, controlled trial

Background Remimazolam confers a lower risk of hypotension than propofol. However, no studies have compared the efficacy of remimazolam and propofol administered using target-controlled infusion (TCI). This study aimed to investigate hemodynamic effects of remimazolam and target-controlled propofol in middle-aged and elderly patients during the induction of anesthesia. Methods Forty adults aged 45–80 years with the American Society of Anesthesiologists Physical Status 1–2 were randomly assigned to remimazolam or propofol group (n = 20 each). Patients received either remimazolam (12 mg/kg/h) or propofol (3 μg/mL, TCI), along with remifentanil for inducing anesthesia. We recorded the blood pressure, heart rate (HR), and estimated continuous cardiac output (esCCO) using the pulse wave transit time. The primary outcome was the maximum change in mean arterial pressure (MAP) after induction. Secondary outcomes included changes in HR, cardiac output (CO), and stroke volume (SV). Results MAP decreased after induction of anesthesia in both groups, without significant differences between the groups (− 41.1 [16.4] mmHg and − 42.8 [10.8] mmHg in remimazolam and propofol groups, respectively; mean difference: 1.7 [95% confidence interval: − 8.2 to 4.9]; p = 0.613). Furthermore, HR, CO, and SV decreased after induction in both groups, without significant differences between the groups. Remimazolam group had significantly shorter time until loss of consciousness than propofol group (1.7 [0.7] min and 3.5 [1.7] min, respectively; p < 0.001). However, MAP, HR, CO, and SV were not significantly different between the groups despite adjusting time until loss of consciousness as a covariate. Seven (35%) and 11 (55%) patients in the remimazolam and propofol groups, respectively, experienced hypotension (MAP < 65 mmHg over 2.5 min), without significant differences between the groups (p = 0.341). Conclusions Hemodynamics were not significantly different between remimazolam and target-controlled propofol groups during induction of anesthesia. Thus, not only the choice but also the dose and usage of anesthetics are important for hemodynamic stability while inducing anesthesia. Clinicians should monitor hypotension while inducing anesthesia with remimazolam as well as propofol

プロポフォールと比較してデスフルランは胸腔鏡下肺葉切除術中の肺の虚脱を改善させ手術時間を短縮する

Background: This study evaluated whether desflurane improved lung collapse during one-lung ventilation (OLV) more than propofol, and whether it could reduce the operation time of video-assisted thoracic surgery. Methods: Sixty patients undergoing lobectomy by video-assisted thoracic surgery (VATS) were randomly assigned to general anesthesia with desflurane or propofol. Lungs were inspected by thoracoscope at 10, 30, and 60 min after initiation of OLV. After surgery, the Lung Collapse Score, a composite of lung color and volume assessments, was assigned by two clinicians blinded to the anesthetic regimen. The primary outcome was operation time. The secondary outcome included the complication rate. Results: Of the 60 participants, 50 completed the study, 26 in Desflurane group and 24 in Propofol group. The Lung Collapse Scores at 30 and 60 min after OLV initiation were significantly better in Desflurane group than in Propofol group, and operation time was significantly shorter in Desflurane group (214 (57) min vs. 262 (72) min [mean (SD)], difference in means, -48; 95% CI, -85 to -11; P = 0.01). The incidence of multiple complications was 1/26 (3%) and 6/24 (25%) in Desflurane and Propofol group, respectively (relative risk, 0.1; 95% CI, 0.02 to 1.18; P = 0.04). Conclusions: Desflurane improved lung collapse during OLV and significantly shortened VATS lobectomy operation time compared to propofol in our studied patients. Desflurane resulted in fewer postoperative complications. Thus, desflurane may be an appropriate anesthetic during lobectomy by VATS requiring OLV

Fogarty catheter for OLV of a neonate

Here, we report two cases involving a neonate and child in which a slip joint section was used to thread a Fogarty catheter into the endotracheal tube for one-lung ventilation (OLV). Both the neonate and infant required OLV, and were placed under general anesthesia. A Fogarty catheter was used for OLV. The Fogarty catheter was passed into the intraluminal side of the endotracheal tube through a slip joint section. OLV was maintained successfully without severe air leakage or Fogarty catheter displacement. The neonate had been intubated pre-operatively with a 3.5-mm inner diameter endotracheal tube, and we used that tube. These cases indicate that the technique can be applied to pre-operatively intubated patients and does not require surgeons to exchange endotracheal tubes. Use of the slip joint section technique facilitates Fogarty catheter fixation without additional dead space

レミフェンタニル麻酔中の１％糖負荷が高齢者の代謝に与える影響 : 無作為対照比較試験

Background: Previous studies showed that remifentanil-induced anesthesia can inhibit surgical stress response in non-diabetic adult patients and that low-dose glucose loading during anesthesia may attenuate fat catabolism. However, little is known about the influence of glucose loading on metabolism in elderly patients, whose condition may be influenced by decreased basal metabolism and increased insulin resistance. We hypothesized that, in elderly patients, intraoperative low glucose infusion may attenuate the catabolism of fat without causing harmful hyperglycemia during remifentanil-induced anesthesia. Methods: Elderly, non-diabetic patients scheduled to undergo elective surgery were enrolled and randomized to receive no glucose (0G group) or low-dose glucose infusion (0.1 g/kg/hr. for 1 h followed by 0.05 g/kg/hr. for 1 h; LG group) during surgery. Glucose, adrenocorticotropic hormone (ACTH), 3-methylhistidine (3-MH), insulin, cortisol, free fatty acid (FFA), creatinine (Cr), and ketone body levels were measured pre-anesthesia, 1 h post-glucose infusion, at the end of surgery, and on the following morning. Results: A total of 31 patients (aged 75–85) were included (0G, n = 16; LG, n = 15). ACTH levels during anesthesia decreased significantly in both groups. In the LG group, glucose levels increased significantly after glucose loading but hyperglycemia was not observed. During surgery, ketone bodies and FFA were significantly lower in the LG group than the 0G group. There were no significant differences in insulin, Cr, 3-MH, and 3-MH/Cr between the two groups. Conclusion: Remifentanil-induced anesthesia inhibited surgical stress response in elderly patients. Intraoperative low-dose glucose infusion attenuated catabolism of fat without inducing hyperglycemia

Anesthetic Care of a Patient with AFE

Two types of amniotic fluid embolism (AFE) have been described : cardiopulmonary collapse type and disseminated intravascular coagulation (DIC) type, with the latter proposed as uterine type. This report describes a healthy 28-year-old woman who developed AFE during a cesarean section. Because of a previous cesarean section, the patient underwent an elective cesarean section, under combined spinal-epidural anesthesia, at 38 weeks of pregnancy. She began coughing 5 minutes after delivery of the fetus, subsequently becoming unconscious and developing glossoptosis and bradycardia. Her blood pressure decreased to 76/43 mmHg, and AFE was suspected. Her uterus was atonic, and she experienced persistent noncoagulant bleeding, with a final blood loss of 6300 ml. Considerable blood transfusion was required. The patient survived, and she and her baby were discharged without any sequelae on the eighth postoperative day. This patient met the Japanese criteria for clinical AFE, with an obstetrical DIC score of 21 meeting the criteria for obstetrical DIC. Early diagnosis and treatment likely resulted in patient survival

High‐Density Lipoprotein Engineering for Eye‐Drop Treatment of Age‐Related Macular Degeneration

Eye-drop treatments of age-related macular degeneration (AMD) are desirable; however, no clinically approved eye drop has been reported to date. This study aim to evaluate the therapeutic activity of eye-drop instillation of a high-density lipoprotein (HDL) variant bearing a cell-penetrating peptide and neovasculature-targeted peptide (AsnGlyArg [NGR] peptide) in a mouse model at a dose of 0.6–0.85 µg protein/eye drop. The results reveal that the activity of the abovementioned variant was >10-fold higher than that of the previous variant lacking an NGR peptide. In addition, the anti-inflammatory activity, cholesterol-efflux capacity, and antiangiogenic activity of reconstituted HDL are significantly augmented by the attachment of these two peptides. The mechanism underlying this dramatic improvement is likely the expression of CD13, an NGR peptide receptor, on the cornea and conjunctiva in mice. CD13 mRNA/protein expression is also detected in cultured human corneal and conjunctival cells. These results demonstrate that NGR peptide is an unprecedented class of an absorption enhancer on the eye surface. Thus, HDL engineering is a potential strategy for developing eye drops to treat neovascular AMD by enhancing the ocular surface absorption and HDL functionalities

A case of placenta percreta with massive hemorrhage during cesarean section

We describe a case of a 39-year-old woman diagnosed with placenta percreta complicated by massive hemorrhage during a cesarean section. At 27 weeks of gestation, she underwent an emergency cesarean section under general anesthesia for vaginal bleeding and an intrauterine infection. Soon after delivery, a massive hemorrhage was encountered while attempting to separate the placenta percreta from the bladder wall. Although total abdominal hysterectomy and partial cystectomy were performed, massive hemorrhaging persisted. Bleeding was finally controlled following bilateral internal iliac artery embolization. We used a cell salvage device and a rapid infuser for hemodynamics stabilization. Total blood loss was 47,000 mL, and anesthesia time was 12 h and 47 min. The patient was discharged on the 32nd postoperative day without major complications. Placenta accreta can be associated with life-threatening hemorrhage and it is vital to plan accordingly preoperatively