Transversus Abdominis Plane Block Reduced Early Postoperative Pain after Robot-assisted Prostatectomy: a Randomized Controlled Trial

Analgesic effect of transversus abdominis plane block (TAP block) in lower major abdominal laparoscopic surgery with about 5 cm of maximum surgical scar has been controversial. We hypothesized that TAP block has benefits, so the analgesic effect of TAP block after robot-assisted laparoscopic prostatectomy (RALP) was evaluated. One hundred patients were enrolled in this prospective, double-blinded, randomized study. Standardized general anesthesia with wound infiltration on camera port and fentanyl dose limit of 3 mu g/kg was provided. Ultrasound-guided, single-shot subcostal TAP block with either 0.375% ropivacaine (Ropivacaine group, 48 patients) or normal saline (Control group, 52 patients) was performed by anesthesiologist in charge (34 anesthesiologists) after surgical procedure. Pain score using numerical rating scale (NRS) and postoperative intravenous fentanyl were evaluated for the first 24 postoperative hours. Median values (interquartile range) of NRS scores when the patients were transferred to post-anesthesia care unit (PACU) were 5 (2-7) in Ropivacaine group and 6 (4-8) in Control group at rest (P = 0.03), 5 (2-8) in Ropivacaine group and 7 (5-8) in Control group during movement (P < 0.01). These significant differences disappeared at the time of discharging PACU. Fentanyl doses for the first 24 postoperative hours were 210 mu g (120-360) in Ropivacaine group and 200 mu g (120-370) in Control group (P = 0.79). These results indicated that subcostal TAP block by anesthesiologists of varied level of training reduced postoperative pain immediate after RALP. TAP block had fundamental analgesic effect, but this benefit was too small to reduce postoperative 24-hour fentanyl consumption

Intraoperative Hypothermia Is Not Associated with Surgical Site Infections after Total Hip or Knee Arthroplasty

Maintaining perioperative normothermia decreases the post-surgery surgical site infection (SSI) rate. We investigated whether SSI is associated with intraoperative hypothermia in total hip (THA) and total knee (TKA) arthroplasties by retrospectively analyzing 297 THA and TKA cases. The patients’ intraoperative core body temperature (BT) was measured by bladder catheter or forehead sensor. We evaluated the associations between SSI and intraoperative BT and other variables and patient characteristics. Fifty-six patients (18.8%) had hypothermia (BT 36.0°C (OR 3.6, 95%CI: 1.367-9.475, p=0.009). Intraoperative hypothermia was not associated with SSI in adults who underwent THA or TKA. These results suggest that hypothermia might not be the problem for SSI

Association between the Remifentanil Dose during Anesthesia and Postoperative pain

Remifentanil is an ultra-short-acting opioid that sometimes causes opioid-induced hyperalgesia, which has led to controversy regarding the association between intraoperative remifentanil administration and postoperative pain. This study aimed to assess the effects of the intraoperative remifentanil dose on postoperative pain. Patients undergoing esophageal, gastric/hepatobiliary, or intestinal/colon surgery and using postoperative patient-controlled epidural analgesia were analyzed. The patients were divided into two groups based on the average intraoperative remifentanil dose (high-dose remifentanil [HR] group: ≥0.1 μg/kg/min; low-dose remifentanil [LR] group: 3/10) was also similar between the groups (HR: 14%; LR: 16%; p=0.57). Older age (> 60 years) and type of surgery (esophageal surgery) were associated with worse postoperative NRS scores. No significant association was seen between the intraoperative remifentanil dose and postoperative NRS scores following thoracoabdominal surgery with postoperative epidural pain management

Postoperative Course of Serum Albumin Levels and Organ Dysfunction After Liver Transplantation

Background and aims: Postoperative hypoalbuminemia, especially following liver transplantation, can lead to adverse multisystem effects and even death. We investigated the relationship between postoperative albumin levels and organ failure (assessed using Sequential Organ Failure Assessment [SOFA] scores). Methods: Sixty liver transplant recipients admitted to the intensive care unit (ICU) from 2012 to 2015 were retrospectively divided into 2 groups: lower albumin (LA) (n=28) and higher albumin (HA) (n=32), using whether serum albumin level fell below 3.0 g/dL during the first postoperative week as the stratifying factor. The SOFA scores (primary endpoint) and associated complications (ascites amount, rejection, re-intubation, abdominal re-operation, thrombosis), additional treatment (dialysis, pleural effusion drainage), and duration of ICU stay (secondary endpoints) of the 2 groups were compared. Results: Average serum albumin levels were significantly different between HA and LA groups (3.6 [3.4-3.8] vs 3.1 [2.9-3.3], respectively, P Conclusions: Serum albumin level might not influence cumulative organ function, but it decreases the amount of hemodynamic support required in liver transplant recipients

Observational Study to Assess and Predict Serious Adverse Events after Major Surgery

Many patients suffer from postoperative serious adverse events (SAEs). Here we sought to determine the incidence of SAEs, assess the accuracy of currently used scoring systems in predicting postoperative SAEs, and determine whether a combination of scoring systems would better predict postoperative SAEs. We prospectively evaluated patients who underwent major surgery. We calculated 4 scores: American Society of Anesthesiologists physical status (ASA-PS) score, the Charlson Score, the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) score, and the Surgical Apgar Score (SAS). We assessed the occurrence of SAEs. We assessed the association between each score and SAEs. We combined these scoring systems to find the best combination to predict the occurrence of SAEs. Among 284 patients, 43 suffered SAEs. All scoring systems could predict SAEs. However, their predictive power was not high (the area under the receiver operating characteristic curves [AUROC] 0.6-0.7). A combination of the ASA-PS score and the SAS was the most predictive of postoperative SAEs (AUROC 0.714). The incidence of postoperative SAEs was 15.1 . The combination of the ASA-PS score and the SAS may be a useful tool for predicting postoperative serious adverse events after major surgery

Pediatric Living Donor Liver Transplantation for Congenital Absence of the Portal Vein With Pulmonary Hypertension: A Case Report

Few reports of liver transplantation exist in patients with congenital absence of the portal vein and pulmonary hypertension. Living donor liver transplantation is usually performed before exacerbation of pulmonary hypertension. A 7-year-old girl (height: 131.5 cm; weight: 27.4 kg) with congenital absence of the portal vein was diagnosed with pulmonary hypertension (mean pulmonary artery pressure 35 mm Hg), and liver transplantation was planned before exacerbation of pulmonary hypertension. We successfully managed her hemodynamic parameters using low-dose dopamine and noradrenaline under monitoring of arterial blood pressure, central venous pressure, cardiac output, and stroke volume variation. Anesthesia was maintained using air-oxygen-sevoflurane and remifentanil 0.1 to 0.6 μg∙kg-1∙min-1. It is necessary to understand the potential perioperative complications in such cases and to adopt a multidisciplinary team approach in terms of the timing of transplantation and readiness to deal with exacerbation of pulmonary hypertension

Heme breakdown and ischemia/reperfusion injury in grafted liver during living donor liver transplantation

Living donor liver transplantation (LDLT) requires ischemia/reperfusion (I/R), which can cause early graft injury. However, the detailed mechanism of I/R injury remains unknown. Heme oxygenase-1 (HO-1) is a rate-limiting enzyme in heme catabolism and results in the production of iron, carbon monoxide (CO), and biliverdin IXα. Furthermore, in animals, HO-1 has a protective effect against oxidative stress associated with I/R injury. However, in humans, the molecular mechanism and clinical significance of HO-1 remain unclear. We previously demonstrated that exhaled CO levels increase during LDLT, and postulated that this may indicate I/R injury. In this study, we elucidate the origin of increased exhaled CO levels and the role of HO-1 in I/R injury during LDLT. We studied 29 LDLT donors and recipients each. For investigation of HO-1 gene expression by polymerase chain reaction and HO-1 localization by immunohistological staining, liver biopsies from the grafted liver were conducted twice, once before and once after I/R. Exhaled CO levels and HO-1 gene expression levels significantly increased after I/R. In addition, HO-1 levels significantly increased after I/R in Kupffer cells. Furthermore, we found a significant positive correlation between exhaled CO levels and HO-1 gene expression levels. These results indicated that increased heme breakdown in the grafted liver is the source of increased exhaled CO levels. We also found a significant relationship between HO-1 gene expression levels and alanine aminotransferase (ALT) levels; i.e., the higher the HO-1 gene expression levels, the higher the ALT levels. These results suggest that HO-1-mediated heme breakdown is caused by I/R during LDLT, since it is associated with increased exhaled CO levels and liver damage