Dose-Ranging Study of Ramosetron for the Prevention of Nausea and Vomiting after Laparoscopic Gynecological Surgery: A Prospective Randomized Study

Patients undergoing laparoscopic gynecologic surgery and receiving postoperative analgesia with opioids have a high risk of postoperative nausea and vomiting (PONV). We compared the antiemetic efficacy of three doses of ramosetron in this high-risk population. In this prospective, double-blind trial, 174 patients randomly received ramosetron 0.3 mg (R0.3 group; n = 58), 0.45 mg (R0.45 group; n = 58), or 0.6 mg (R0.6 group; n = 58) at the end of surgery. The primary outcome was the incidence of PONV during the first postoperative 48 h. Nausea severity, pain scores, adverse events, and patient satisfaction (1-4; 4, excellent) were assessed. The incidence of PONV was not different between groups (35%, 38%, and 35% in R0.3, R0.45, and R0.6 groups; p = 0.905). Nausea severity, pain scores, and incidence of adverse events (dizziness, headache, or sedation) were similar between groups. Compared to the R0.3 group, the R0.45 and R0.6 groups had lower incidence of premature discontinuation of fentanyl-based patient-controlled analgesia primarily because of intractable PONV (9% and 5% vs. 24%; p = 0.038), and higher satisfaction scores (3.4 ± 0.8 and 3.3 ± 0.7 vs. 2.4 ± 0.9; p = 0.005). Compared to ramosetron 0.3 mg, ramosetron 0.45 and 0.6 mg did not reduce PONV, but reduced premature discontinuation of patient-controlled analgesia and increased patient satisfaction, without increasing adverse events.ope

Endoscopic Sedation: Risk Assessment and Monitoring

Sedation for endoscopic procedures is done to increase patient comfort and endoscopic performance. Drugs used for sedation suppress respiratory and cardiovascular function, and while the degree of suppression may vary, it may be fatal in certain patients. The aim of this article is to provide an overview and brief summary of presedation risk assessment and monitoring during and after sedation in order to maintain patient safety.ope

Administration of Low-Dose Dexmedetomidine Did Not Affect Acute Inflammatory Response after Cytoreductive Surgery Combined with Hyperthermic Intraperitoneal Chemotherapy: A Double-Blind Randomized Controlled Trial

During cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), attenuation of inflammatory responses that increase susceptibility to postoperative complications, morbidity, and mortality is important. We aimed to evaluate whether intraoperative dexmedetomidine infusion impacted inflammatory response in patients undergoing CRS with HIPEC. Fifty-six patients scheduled for CRS with HIPEC were randomly assigned to the control (n = 28) and dexmedetomidine (n = 28) groups. The primary endpoint was the effect of dexmedetomidine on the interleukin-6 (IL-6) level measured at pre-operation (Pre-OP), before HIPEC initiation (Pre-HIPEC), immediately after HIPEC; after the end of the operation; and on postoperative day (POD) 1. In both groups, the IL-6 levels from Pre-HIPEC until POD 1 and the C-reactive protein (CRP) levels on PODs 1, 2, and 3 were significantly higher than the Pre-OP values (all Bonferroni corrected, p < 0.001). However, total differences in IL-6 and CRP levels, based on the mean area under the curve, were not detected between the two groups. The continuous intraoperative infusion of dexmedetomidine (0.4 μg/kg/h) in patients undergoing CRS with HIPEC did not significantly lower the inflammatory indices. Further dose investigative studies are needed to find the dexmedetomidine dose that provides anti-inflammatory and sympatholytic effects during HIPEC.ope

Comparison of Biochemical Recurrence After Robot-assisted Laparoscopic Radical Prostatectomy with Volatile and Total Intravenous Anesthesia

Aims: Recurrence after cancer surgery is a major concern in patients with cancer. Growing evidence from preclinical studies has revealed that various anesthetics can influence the immune system in different ways. The current study compared the long-term biochemical recurrence of prostate cancer after robot-assisted laparoscopic radical prostatectomy (RALP) in terms of selection of anesthetic agent between total intravenous anesthesia (TIVA) with propofol/remifentanil and volatile anesthetics (VA) with sevoflurane or desflurane/remifentanil. Methods: We followed up oncologic outcomes of patients who underwent RALP from two previous prospective randomized controlled trials, and the outcomes of those who received TIVA (n = 64) were compared with those who received VA (n = 64). The follow-up period lasted from November 2010 to March 2019. Results: Both TIVA and VA groups showed identical biochemical recurrence-free survivals at all-time points after RALP. The following predictive factors of prostate cancer recurrence were determined by Cox regression: colloid input [hazard ratio (HR)=1.002, 95% confidence interval (CI): 1.000-1.003; P = 0.011], initial prostate-specific antigen level (HR=1.025, 95% CI: 1.007-1.044; P = 0.006), and pathological tumor stage 3b (HR=4.217, 95% CI:1.207-14.735; P = 0.024), but not the anesthetic agent. Conclusions: Our findings demonstrate that both TIVA with propofol/remifentanil and VA with sevoflurane or desflurane/remifentanil have comparable effects on oncologic outcomes in patients undergoing RALP.ope

Issues in procedural sedation outside the operating theater: characteristics and safety of commonly used sedatives and analgesics

With increasing interest towards the proper management of the patient's anxiety and pain during diagnostic and therapeutic procedures, adequate sedation has become an essential part of a successful procedure. Due to recent advancements in modern medicine, many surgical procedures that were once done under general anesthesia are being increasingly replaced by minimally invasive procedures that are performed under sedation. However, the duration or degrees of pain that are caused by different types of procedures vary extensively. Some procedures are easily done under only light sedation, while others require extensive pain control and deeper sedation. Comfort and safety are essential components of 'successful sedation', and full understanding of the degree of pain and the physiologic changes that the procedure may cause is needed in order to offer this to the patient. The depth of sedation should be controlled with proper sedatives while adequate analgesia should be offered according to type of procedure. Choice and doses of drugs should always be tailored to the patient's general condition, and additional administrations should be done after the effect of the previous dose is observed in order to avoid overdosing. When combining sedatives and/or analgesics, the possible synergistic effects between different drugs should always be kept in mind. In order to choose the adequate type and dose of drug, knowledge regarding the pharmacodynamic and pharmacokinetic properties of commonly used drugs for procedures is needed for safe and effective sedation.ope

Anesthetic considerations for lung transplantation

Since the first lung transplantation, developments in surgical techniques, immunosuppressants, preservation solutions, monitoring devices, anesthetic agents, and drugs and devices for hemodynamic support have resulted in improved survival rates after lung transplantation. Lung transplantation is a high-risk procedure and end-stage lung disease is frequently accompanied by compromised cardiopulmonary function. Therefore, a highly trained cardiothoracic anesthesiologist is required during the procedure. As various factors related to anesthesia may have important effects on the prognosis of the patient after the lung transplantation, an anesthesiologist must not only be familiar with the use of various medications and monitoring devices, but also understand the patient’s pathophysiology and the surgical procedure.ope

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation.

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.ope

Room for Quality Improvement in Endoscopist-Directed Sedation: Results from the First Nationwide Survey in Korea

BACKGROUND/AIMS: This study sought to characterize the current sedation practices of Korean endoscopists in real-world settings. METHODS: All active members of the Korean Society of Gastrointestinal Endoscopy were invited to complete an anonymous 35-item questionnaire. RESULTS: The overall response rate was 22.7% (1,332/5,860). Propofol-based sedation was the dominant method used in both elective esophagogastroduodenoscopy (55.6%) and colonoscopy (52.6%). The mean satisfaction score for propofol-based sedation was significantly higher than that for standard sedation in both examinations (all p<0.001). The use of propofol was supervised exclusively by endoscopists (98.6%). Endoscopists practicing in nonacademic settings, gastroenterologists, or endoscopists with. CONCLUSIONS: Endoscopist-directed propofol administration is the predominant sedation method used in Korea. This survey strongly suggests that there is much room for quality improvement regarding sedation training and patient vigilance in endoscopist-directed sedation.ope

Single dose of dexamethasone is not associated with postoperative recurrence and mortality in breast cancer patients: a propensity-matched cohort study

BACKGROUND: Dexamethasone is widely used in cancer patients despite the concern that perioperative glucocorticoids may potentially cause immunosuppression. However, studies on the influence of dexamethasone on cancer recurrence after curative surgery have produced conflicting results. The goal of our study was to compare postoperative recurrence-free survival and overall survival between patients with breast cancer who received perioperative dexamethasone and those who did not. METHODS: The medical records of 2729 patients who underwent breast cancer surgery between November 2005 and December 2010 were reviewed. These patients were followed up until December 2015. The patients were categorised according whether they received a single dose of intravenous dexamethasone perioperatively or not. Cox regression analyses were conducted to evaluate any associations between dexamethasone usage with postoperative recurrence and mortality. Additionally, we performed a sensitivity test with propensity score matching to adjust for selection bias. RESULTS: Among the 2628 patients, 236 (8.5%) received perioperative dexamethasone. No increasing risk for recurrence (hazard ratio [HR], 1.442; 95% confidence interval [CI], 0.969-2.145; P = 0.071) or mortality (HR, 1.256; 95% CI, 0.770-2.047; P = 0.361) after breast cancer surgery were identified in patients who received dexamethasone. Similarly, propensity score matching did not show significant associations in postoperative recurrence (HR, 1.389; 95% CI, 0.904-2.132; P = 0.133) or mortality (HR, 1.506; 95% CI, 0.886-2.561; P = 0.130) in patients who received dexamethasone. CONCLUSIONS: We found that a perioperative single dose of dexamethasone is not associated with increased recurrence or mortality after curative surgery in breast cancer patients.ope

Total intravenous anesthesia with propofol reduces postoperative nausea and vomiting in patients undergoing robot-assisted laparoscopic radical prostatectomy: a prospective randomized trial

PURPOSE: We investigated the effect of total intravenous anesthesia (TIVA) with propofol on postoperative nausea and vomiting (PONV) after robot-assisted laparoscopic radical prostatectomy (RLRP) in patients at low risk of developing PONV, in comparison to balanced anesthesia with desflurane. MATERIALS AND METHODS: Sixty two patients were randomly assigned to the Des or TIVA group. Propofol and remifentanil were used for induction of anesthesia in both groups and for maintenance of the anesthesia in the TIVA group. In the Des group, anesthesia was maintained with desflurane and remifentanil. In both groups, postoperative pain was controlled using fentanyl-based intravenous patient controlled analgesia, and ramosetron 0.3 mg was administered at the end of surgery. The incidence of PONV, severity of nausea and pain, and requirements of rescue antiemetics and analgesics were recorded. RESULTS: The incidence of nausea in the post-anesthetic care unit was 22.6% in the Des group and 6.5% in the TIVA (p=0.001) group. The incidence of nausea at postoperative 1-6 hours was 54.8% in the Des group and 16.1% in the TIVA group (p=0.001). At postoperative 6-48 hours, there were no significant differences in the incidence of nausea between groups. CONCLUSION: In order to prevent PONV after RLRP in the early postoperative period, anesthesia using TIVA with propofol is required regardless of patient-related risk factors.ope