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Background: Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) is beneficial for the treatment of profound cardiogenic shock, peripheral VA-ECMO cannulation can increase left ventricular afterload, thus compromising myocardial recovery. We investigated whether early routine left ventricular unloading can reduce 30-day mortality compared with the conventional approach in patients with cardiogenic shock undergoing VA-ECMO., Methods: This randomized clinical trial involved 116 patients with cardiogenic shock undergoing VA-ECMO from March 2021 to September 2022 at Chonnam National University Hospital, Gwangju, South Korea. The patients were randomly assigned to undergo either early routine left ventricular unloading with transseptal left atrial cannulation within 12 hours after randomization (n=58) or the conventional approach, which permitted rescue transseptal left atrial cannulation in case of an increased left ventricular afterload (n=58). The primary outcome was all-cause mortality within 30 days., Results: All 116 randomized patients (mean age, 67.6±13.5 years; 34 [29.3%] women) completed the trial. At 30 days, all-cause death had occurred in 27 (46.6%) patients in the early group and 26 (44.8%) patients in the conventional group (hazard ratio, 1.02 [95% CI, 0.59-1.74]; P =0.942). Crossover to rescue transseptal left atrial cannulation occurred in 29 patients (50%) in the conventional group according to a clear indication. Time to rescue transseptal cannulation in the conventional group was a median of 21.8 (interquartile range, 12.4-52.2) hours after randomization. There were no significant differences in other secondary outcomes between the 2 groups except for a shorter time to disappearance of pulmonary congestion in the early group (median, 3 [interquartile range, 2-6] versus 5 [interquartile range, 3-7] days; P =0.027)., Conclusions: Among patients with cardiogenic shock undergoing VA-ECMO, early routine left ventricular unloading with transseptal left atrial cannulation did not reduce 30-day mortality compared with the conventional strategy, which permitted rescue transseptal left atrial cannulation. These findings should be cautiously interpreted until the results of multicenter trials using other unloading modalities become available., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT04775472., Competing Interests: Disclosures None.

The present study aimed to analyze and compare the prognostic performances of the Japanese Ministry of Health and Welfare (JMHW) score, the Korean Society on Thrombosis and Hemostasis (KSTH) score, the International Society on Thrombosis and Haemostasis (ISTH) score, the Japanese Association for Acute Medicine (JAAM) score, and the revised JAAM (rJAAM) score, for 28-day mortality in severe trauma.This retrospective observational study included patients admitted for severe trauma between 2012 and 2015. Receiver operating characteristics analysis was performed to examine the prognostic performance of the 5 different DIC score systems. The primary outcome was 28-day mortality following an injury.Of the 1266 patients included in the study, 28-day mortality rate was 19.7% (n = 249). The area under the curves (AUCs) of JMHW, KSTH, ISTH, JAAM, and rJAAM scores for 28-day mortality were 0.751 [95% confidence interval (95% CI), 0.726-0.775], 0.726 (95% CI, 0.701-0.750), 0.700 (95% CI, 0.674-0.725), 0.673 (95% CI, 0.646-0.699), and 0.676 (95% CI, 0.649-0.701), respectively. The AUC of JMHW score was significantly different from those of the other score systems. Fibrinogen levels ≤1.0 g/L [odds ratio (OR), 1.824; 95% CI, 1.029-3.232] and 1.0 to 1.5 g/L (OR, 1.697; 95% CI, 1.058-2.724) were independently associated with 28-day mortality compared with fibrinogen level above 1.5 g/L.JMHW score has the highest prognostic performance for 28-day mortality among DIC score systems in severe trauma. Fibrinogen level seemed to have a role in greater discrimination of JMHW scores than the other DIC score systems.

Rationale: Myoclonic movement is a rare side effect after general anesthesia. Since we use various intravenous agents during general anesthesia recently, it is troublesome to find out the exact cause of this neurologic complication., Patient Concerns: A 31-year-old female patient without any past medical history underwent hip arthroscopic surgery under general anesthesia., Diagnoses: Although there was no specific event during the operation, she showed a sudden myoclonic movement confined to left upper extremity in recovery room., Interventions: We administered anticonvulsant agents intrvenously, the myoclonus was stopped shortly but recurred over again. As we stopped the patient-controlled analgesia due to nausea, the symptom halted., Outcomes: There was no significant abnormality in electroencephalography or brain diffusion magnetic resonance imaging, which was taken after the event., Lessons: Clinicians should carefully consider the pharmacologic characteristics and neurologic adverse effects of all administered agents when myoclonus occurs after general anesthesia.

Background: Alzheimer disease (AD) entails a long-term progressive decline in the cognitive ability to think and remember, and it has become a major concern for patients receiving surgery and anesthesia. However, studies investigating the relationship between general anesthesia and AD have yielded inconsistent results. Therefore, we plan to perform a systematic review and meta-analysis to determine the relationship between general anesthesia and AD, and to verify whether general anesthesia is an independent risk factor for AD., Methods: A systematic and comprehensive search will be performed using MEDLINE, EMBASE, and Google scholar from their inception to August 2017. Peer-reviewed cohort and case-control studies including nested case-control studies reporting the relationship between general anesthesia and AD will be eligible for inclusion. The quality of included studies will be assessed using the Newcastle-Ottawa scale. Heterogeneity of estimates across studies as well as publication bias will be assessed. This systematic review and meta-analysis will be performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. All statistical analyses will be conducted using the Stata SE version 15.0., Results: The results of this systematic review and meta-analysis will be published in a peer-reviewed journal., Conclusion: Our study will provide the evidence for the relationship between general anesthesia and dementia. The review will benefit patients and anesthesiologists, surgeons, and policymakers., Ethics and Dissemination: Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care., Trial Registration: The protocol for this review has been registered in the PROSPERO network (registration number: CRD42017073790)., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pain and adhesion are problematic issues after surgery. Lidocaine has analgesics and anti-inflammatory properties, and poloxamer/alginate/CaCl2 (PACM) is a known antiadhesive agent. We hypothesized that the novel combination of lidocaine as chemical barrier and PACM as physical barrier would be beneficial for both postoperative pain and adhesion. The purpose of this study was to investigate the effects of lidocaine-loaded PACM in a rat model of incisional pain. Primary outcome was to evaluate between-group differences for the mechanical withdrawal threshold (MWT) measured by von Frey filament in various concentrations of lidocaine-loaded PACM applied, PACM applied, and sham-operated groups., Methods: Male Sprague-Dawley rats were used for the postoperative pain model. After plantar incision and adhesion formation, 0.5%, 1%, 2%, and 4% lidocaine-loaded PACM, PACM only, nothing, and 4% lidocaine only were applied at the incision site in groups PL0.5, PL1, PL2, PL4, P, S, and L4, respectively. MWT using a von Frey filament and serum levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-6, and high-sensitivity C-reactive protein were measured. Rats were euthanized 2 weeks after surgery, and inflammation and fibrosis were assessed with microscopy. Data were analyzed using the Kruskal-Wallis test, multivariate analysis of variance, and linear mixed-effect model. To compare MWT at each time point, analysis of variance with Bonferroni correction was used., Results: Multivariate analysis of variance showed that 4% lidocaine-loaded PACM significantly raised the MWT up to 6 and 8 hours after surgery compared with lidocaine-unloaded groups S and P, respectively; 2% lidocaine-loaded PACM significantly increased the MWT at 4 hours after surgery compared with groups S and C. Linear mixed-effect model showed that the MWT (estimated difference in means [95% confidence interval]) was significantly increased in groups PL2 and PL4 (6.58 [2.52-10.63], P = .002; 11.46 [7.40-15.51], P < .001, respectively) compared with group P. Inflammation and fibrosis seen on microscopic evaluation were significantly decreased in groups PL2 and PL4 compared with group S. Four percent of lidocaine only showed a significant reduction in inflammation. Serum levels of tumor necrosis factor-α, IL-1β, IL-6, and high-sensitivity C-reactive protein were decreased in lidocaine-loaded groups compared with group S or P at 1, 2, and 48 hours, and 2 weeks after surgery, respectively., Conclusions: Lidocaine-loaded PACM reduced postoperative pain, and lidocaine strengthened the antiadhesive effect of PACM.

In this study, we aimed to compare the effect of desflurane and sevoflurane on postoperative nausea and vomiting and pain in patients receiving opioid-based intravenous patient-controlled analgesia (IV-PCA) after thyroidectomy.We reviewed the electronic medical records of 1042 patients administered opioid-based IV-PCA after a thyroidectomy at Chung-Ang University Hospital between January 1, 2010 and June 30, 2016. We classified the patients into 2 groups according to the inhalation anesthetic used for anesthesia: desflurane versus sevoflurane (groups D and S, n = 587 and 455, respectively). Then, propensity scoring was used to select 234 matched subjects between both groups based on their confounding factors. A propensity score matching method was used to match patients from the 2 groups in a 1:1 ratio.Before the propensity score analysis, there was no significant difference between the 2 groups. However, after the propensity score matching, the frequency of complete remission (CR, defined as no nausea and vomiting) was significantly higher in group S than it was in group D. The number of patients administered rescue antiemetics on day 0 in group S was lower than that in group D, although it was not statistically significant.In patients receiving opioid-based IV-PCA after thyroidectomy, sevoflurane seems to be more beneficial in achieving CR than desflurane was. However, further randomized controlled studies are needed to confirm this conclusion.

Background: Intravenous oxycodone has been used as an adjunct to anesthetic agents. This study aimed to assess the optimal dose of intravenous oxycodone for the attenuation of the hemodynamic responses to laryngoscopy and endotracheal intubation., Methods: A prospective, randomized, double-blind study was conducted. Ninety-five patients were randomly divided into 5 groups based on the oxycodone dose: 0, 0.05, 0.1, 0.15, 0.2 mg/kg. After administering the assigned dose of intravenous oxycodone, anesthesia was induced with thiopental. Heart rate (HR) and blood pressure (BP) were measured at baseline, before intubation, and 1, 2, and 3 minutes after intubation. The percentage increase of BP was calculated as (highest BP after intubation - baseline BP)/baseline BP × 100 (%). The percentage increase of HR was calculated in same formula as above. Hypertension was defined as a 15% increase of systolic BP from baseline, and probit analysis was conducted., Results: Hemodynamic data from 86 patients were analyzed. The percentage increase of mean arterial pressure after intubation in groups 0.05, 0.1, 0.15, and 0.2 was significantly different from that in the control (P < 0.001). For HR, the percentage increase was lower than control group when oxycodone was same or more than 0.1 mg/kg (P < 0.05). Using probit analysis, the 95% effective dose (ED95) for preventing hypertension was 0.159 mg/kg (95% confidence interval [CI], 0.122-0.243). In addition, ED50 was 0.020 mg/kg (95% CI, -0.037 to 0.049). However, oxycodone was not effective for maintaining the HR in our study dosage. There were no significant differences in the incidence of hypotension during induction between groups., Conclusions: Using 0.1 mg/kg of intravenous oxycodone is sufficient to attenuate the increase of BP and HR during induction period in healthy patients. The ED95, which was 0.159 mg/kg, can be useful to adjust the dosage of IV oxycodone for maintain stable BP during induction of general anesthesia.

Background: Previous randomized controlled trials regarding the effectiveness of perioperative midazolam in preventing postoperative nausea and vomiting (PONV) have produced conflicting results. Consequently, the present systematic review was performed to assess the effect of perioperative administration of midazolam on PONV., Methods: The MEDLINE®, Embase, and Cochrane Central Register of Controlled Trials databases were searched to identify all randomized controlled trials that investigated the effectiveness of midazolam under general anesthesia. The primary end points were defined as postoperative nausea (PON), postoperative vomiting (POV), and PONV., Results: From 16 studies, 1433 patients were included in the final analysis. Compared with the control group, patients who received midazolam showed a lower overall incidence of PON (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.40-0.65; I = 35%; number needed to treat [NNT] = 6; number of included studies [n] = 11), POV (RR, 0.46; 95% CI, 0.33-0.65; I = 0%; NNT = 8; n = 10), and PONV (RR, 0.45; 95% CI, 0.36-0.57; I = 31%; NNT = 3; n = 7)., Conclusions: Perioperative administration of midazolam was effective in preventing PON, POV, and PONV.