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Background: When an imbalance occurs between the demand and capacity for protein folding, unfolded proteins accumulate in the endoplasmic reticulum (ER) lumen and activate the unfolded protein response (UPR). In addition, unfolded proteins are cleared from the ER lumen for ubiquitination and subsequent cytosolic proteasomal degradation, which is termed as the ER-associated degradation (ERAD) pathway. This study focused on changes in the UPR and ERAD pathways induced by the repeated inhalation anesthetic exposure in Caenorhabditis elegans. Methods: Depending on repeated isoflurane exposure, C. elegans was classified into the control or isoflurane group. To evaluate the expression of a specific gene, RNA was extracted from adult worms in each group and real-time polymerase chain reaction was performed. Ubiquitinated protein levels were measured using western blotting, and behavioral changes were evaluated by chemotaxis assay using various mutant strains. Results: Isoflurane upregulated the expression of ire-1 and pek-1 whereas the expression of atf-6 was unaffected. The expression of both sel-1 and sel-11 was decreased by isoflurane exposure, possibly indicating the inhibition of retro-translocation. The expression of cdc-48.1 and cdc-48.2 was decreased and higher ubiquitinated protein levels were observed in the isoflurane group than in the control, suggesting that deubiquitination and degradation of misfolded proteins were interrupted. The chemotaxis indices of ire-1, pek-1, sel-1, and sel-11 mutants decreased significantly compared to N2, and they were not suppressed further even after the repeated isoflurane exposure. Conclusion: Repeated isoflurane exposure caused significant ER stress in C. elegans. Following the increase in UPR, the ERAD pathway was disrupted by repeated isoflurane exposure and ubiquitinated proteins was accumulated subsequently. UPR and ERAD pathways are potential modifiable neuroprotection targets against anesthesia-induced neurotoxicity.

Background Serine synthetic pathway plays an essential role in the development and function of the nervous system. This study investigated whether the serine synthetic pathway was affected by repeated volatile anesthetic exposure using C. elegans and its relationship with anesthesia-induced neurotoxicity. Methods Synchronized worms were divided into two groups: the control and isoflurane groups. Worms in the isoflurane group were exposed to isoflurane for 1 h at each larval stage. The chemotaxis index was evaluated when they reached the young adult-stage in both groups. Also, RNA was extracted from the young adult-worms, and the expressions of C31C9.2, F26H9.5, and Y62E10 A.13 were evaluated using real-time polymerase chain reaction in both groups. At the same time, the l -serine level was measured. After phosphoserine phosphatase inhibitor – glycerophosphorylcholine (GPC) – and l -serine were treated, the change of chemotaxis index was determined. Results In young adult worms exposed to isoflurane, the genetic expressions of C31C9.2, F26H9.5, and Y62E10 A.13 were decreased, and a significant decrease was shown in Y62E10 A.13. The serine level in worms was also lower in the isoflurane group than in the control group (5.13 ± 1.44 vs. 7.65 ± 0.81 pM, n = 5 in each group, p = 0.009). Exposure to GPC reduced the chemotaxis index to a similar degree as repeated isoflurane exposure (52.9% in GPC group vs 58.7% in the isoflurane group). The chemotaxis index (61.1%) was not decreased by repeated isoflurane anesthesia in GPC-treated worms. In this condition, the l -serine level was low similarly in both groups (5.22 ± 1.19 vs. 4.90 ± 1.36 pM, n = 5 in each group, p = 0.702). When l -serine was supplied to C. elegans, the deteriorated chemotaxis index by isoflurane exposure recovered (78.1% in the control group vs. 75.5% in the isoflurane group, p = 0.465). Conclusion Serine synthetic pathway was negatively affected in C. elegans by repeated isoflurane exposure. Y62E10 A.13, which corresponds to phosphoserine phosphatase, was mostly influenced, followed by low l -serine level. Supplementation with l -serine could restore the chemotaxis index.

Tak Kyu Oh,1 Sung-Bum Kang,2 In-Ae Song,1 Jung-Won Hwang,1 Sang-Hwan Do,1 Jin Hee Kim,1 Ah-Young Oh1 1Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 2Department of Surgery, Seoul National University Bundang Hospital, Seoul, South Korea Purpose: This study aimed to identify the effect of preoperative serum total cholesterol on postoperative pain outcome in patients who had undergone laparoscopic colorectal cancer surgery. Methods: We retrospectively reviewed the medical records of patients diagnosed with colorectal cancer who had undergone laparoscopic colorectal surgery from January 1, 2011, to June 30, 2017, to identify the relationship of total cholesterol levels within a month prior to surgery with the numeric rating scale (NRS) scores and total opioid consumption on postoperative days (PODs) 0–2. Results: We included 1,944 patients. No significant correlations were observed between total cholesterol and the NRS (POD 0), NRS (POD 1), and oral morphine equivalents (PODs 0–2) (P>0.05). There was no significant difference between the low (0.05). Furthermore, there was no significant association in multivariate linear regression analysis for postoperative opioid consumption according to preoperative serum total cholesterol level (coefficient 0.08, 95% CI –0.01 to 0.18, P=0.81). Conclusion: This study showed that there was no meaningful association between preoperative total cholesterol level and postoperative pain outcome after laparoscopic colorectal cancer surgery. Keywords: cholesterol, analgesia, colon, rectum, laparoscopy

Serum albumin and conventional BMI (cBMI) are commonly used indices of malnutrition status. Because cBMI does not reflect fluid accumulation, modified body mass index (mBMI, serum albumin × cBMI) is a more accurate measure of malnutrition status. This study investigated the association between preoperative mBMI and postoperative 1-year mortality, in comparison with serum albumin and cBMI. Medical records of 80,969 adult patients who underwent surgical procedures in a tertiary care hospital between 1 January, 2011 and 31 December, 2015 were retrospectively reviewed. Postoperative 1-year mortality increased with reduction in cBMI, mBMI, and albumin separately (P P P > 0.05). Adjusted area under the curve (AUC) was highest (0.885) in the overall model (cBMI + albumin + cBMI * albumin); adjusted AUC between mBMI and albumin did not differ significantly (P = 0.558). Low albumin is the strongest independent predictor of postoperative 1-year mortality among the three variables (albumin, cBMI, mBMI). Adding cBMI to albumin does not increase the validity of the AUC of albumin.

Controversy exists as to whether the physician turnover affects patient outcome in academic hospitals. In-hospital cardiopulmonary resuscitation (CPR) is an important indicator of in-hospital mortality. This study aimed to investigate whether the physician turnover is associated with the in-hospital CPR rate. This retrospective cohort study was conducted at a single center; all in-hospital CPR cases among in-patients from 1 January 2007 to 31 December 2016 were analyzed. The turnover period was defined as the changeover of the trainee workforce in March, May, and November. The primary outcome was any variation in the monthly in-hospital CPR events (per 1000 admissions). The secondary outcomes were return of spontaneous circulation (ROSC), CPR in intensive care unit (ICU), monthly in-hospital deaths per 1000 admissions, and average length of hospital stay. A total of 2182 in-hospital CPR cases were included in the analysis. Monthly in-hospital CPR rates were greater during the turnover period when compared to the non-turnover period (4.66 ± 1.02 vs. 4.18 ± 1.56, P = 0.027). There was no significant difference in ROSC rate, CPR in ICU rate, monthly in-hospital deaths per 1000 admissions, or average length of hospital stay between the two periods. Our findings indicate that physician turnover may be associated with in-hospital CPR rate. However, physician turnover was not associated with ROSC rate, rate of CPR in the ICU, in-hospital death, or length of hospital stay.

Background Opioid usage is reportedly increased in patients with advanced cancer and low total cholesterol (TC). The aim of this study was to determine the effects of preoperative serum TC levels on postoperative opioid usage in patients undergoing laparoscopic gastric cancer surgery. Methods We retrospectively analyzed the medical records of patients with gastric cancer who underwent laparoscopic gastrectomy at our institution between January 1, 2011 and July 31, 2017. We investigated the correlation between TC levels in the month before surgery and numeric rating scale (NRS) scores and opioid consumption on postoperative days (PODs) 0 to 3. The patients were stratified according to preoperative TC level (< 160 mg/dL, low; 160 to 199 mg/dL, medium; ≥ 200 mg/dL, high). Results TC and NRS scores (PODs 0, 1) for 1,919 eligible patients showed weak but significant positive coefficients (0.074 and 0.098 on POD 0 and POD 1, respectively, P < 0.01). After adjusting for confounders, there were no significant differences in postoperative NRS scores on PODs 0, 1, 2, or 3 or in oral morphine equivalents on PODs 0 to 3 according to TC level. Conclusion Preoperative serum TC levels have no effect on pain outcomes in the 3 days following laparoscopic gastric surgery.

Background The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS. Methods Both groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups. Results The failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups. Conclusions SA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.

OBJECTIVE We assessed and compared two landmarks (conventional vs. high approach) used in internal jugular vein (IJV) cannulation with respect to the degree of overlap with the carotid artery (CA) and the cross-sectional area (CSA) of the IJV using ultrasonography. PATIENTS AND METHODS Forty-eight adult patients were included. Using ultrasonography, the percentage overlaps with the CA and the CSA of both IJVs were measured in the supine and Trendelenburg positions using conventional and high approaches. With the conventional approach, the IJV is penetrated at the apex of Sedillot's triangle, formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid muscle. The high approach involves the midpoint between the sternal notch and the mastoid process. RESULTS The degree of overlap with the CA was 30.5 (7.5-69.4)% [median (interquartile range)] and 0.0 (0.0-25.4)% with the conventional and high approaches, respectively, for the right IJV (P

This retrospective study evaluated the association between maximum clot firmness of FIBTEM (MCFFIB) and blood loss, and determined a cutoff value of MCFFIB that may predict massive bleeding in total hip replacement arthroplasty (THRA). Seventy-two adult patients undergoing THRA for avascular necrosis of the femoral head or degenerative arthritis of the hip were included. Patients' medical records were reviewed to collect pre and postoperative laboratory data, as well as the amount of intra and postoperative blood loss (IBL and PBL). Each pre and postoperative fibrinogen level had a significant correlation with the pre and postoperative MCFFIB, respectively (ρ = 0.289, P = 0.014 and ρ = 0.286, P = 0.015). IBL had significant correlations with pre and postoperative MCFFIB (ρ = -0.305, P = 0.010 and ρ = -0.297, P = 0.013, respectively), and PBL also showed significant correlations with the pre and postoperative MCFFIB (ρ = -0.471, P < 0.001 and ρ = -0.475, P < 0.001, respectively). A respective pre or postoperative MCFFI cutoff value of 16 mm or less or 10 mm or less showed the highest sensitivity and specificity for predicting IBL 1000 ml or above or PBL 400 ml or above. Postoperative transfusion was performed more frequently in patients showing postoperative MCFFIB 10 mm or less (31 vs. 3.3%, P = 0.005). MCFFIB correlated well with the amount of IBL or PBL. In addition, a particular value of pre or postoperative MCFFIB could offer the predictive standard for massive bleeding in THRA.

The current study aimed to measure the effects of Plasma-Lyte 148 solution on the blood coagulation profile according to the hemodilution level using rotational thromboelastometry (ROTEM) tests. Venous blood was collected from 12 healthy volunteers and divided into four specimen bottles, which were diluted at different levels with Plasma-Lyte 148 (0, 20, 40, and 60%). Following this, ROTEM tests were performed on the study samples. We found that as the hemodilution level increased, the ROTEM values showed a hypocoagulable pattern. The change rate of the maximum clot firmness (MCF) of INTEM was greater in the 40 (P = 0.015) and 60% (P

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462–0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359–0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746–0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476–0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery.

This study was conducted to evaluate the effect of scalp blocks using levobupivacaine on recovery profiles including postoperative pain, patient-controlled analgesia (PCA) consumption, postoperative nausea and vomiting (PONV), and other adverse events in patients undergoing frontoparietal craniotomy for aneurysm clipping.Fifty-two patients scheduled for elective frontoparietal craniotomy for unruptured aneurysm clipping were enrolled. After surgery, scalp blocks were performed using normal saline (group C, n = 26) or 0.75% levobupivacaine (group L, n = 26). Postoperative pain scores and PCA consumption were recorded for 72 hours after recovery of consciousness. The time from patient recovery to the first use of PCA drug and rescue analgesics, the requirement for vasoactive agents, and adverse effects related to PCA and local anesthetics also were recorded.Postoperative pain scores and PCA consumption in group L were lower than in group C (P.05). The time intervals from patient recovery to the first use of PCA drug (P.001) and rescue analgesics (P = .038) was longer in group L than in group C. Additionally, less antihypertensive agent was required (P = .017), and PONV occurred less frequently (P = .039) in group L than in group C.Scalp blocks with 0.75% levobupivacaine improved recovery profiles in that it effectively lowered postoperative pain and PCA consumption without severe adverse events and also reduced the requirement for a postoperative antihypertensive agent and the incidence of PONV in patients who underwent frontoparietal craniotomy for aneurysm clipping.

Catheter-related bladder discomfort (CRBD) secondary to intraoperative catheterization of urinary bladder is one of the most distressing symptoms during recovery from anaesthesia. Butylscopolamine, a peripheral antimuscarinic agent, is effective for relieving the pain, which is because of smooth muscle contraction. The aim of this study was to assess the efficacy and safety profiles of butylscopolamine in treating CRBD after urological surgeries.Adult male patients undergoing urological surgery requiring urinary bladder catheterization intraoperatively were enrolled. Induction and maintenance of anaesthesia were standardized. Patients were randomized into two groups after complaining of CRBD in the post-anaesthesia care unit. The control group (n=29) received normal saline and the butylscopolamine group (n=28) was administered butylscopolamine 20 mg i.v. The severity of CRBD, postoperative pain, and adverse effects were assessed at baseline, 20 min, 1, 2, and 6 h after administration of the study drug.The severity of CRBD observed in the butylscopolamine group was significantly lower than that of the control group at 1, 2, and 6 h after administration of the study drug [59 (12), 50 (16), 40 (21) in the control group vs 41 (22), 32 (25), 23 (18) in the butylscopolamine group, P0.01]. Rescue analgesics were required less in the butylscopolamine group than in the control group (P=0.001). Adverse events were comparable between the two groups.Butylscopolamine 20 mg administered i.v. after complaining CRBD during recovery reduced both the severity of CRBD and the need for rescue analgesics without adverse effects in patients undergoing urologic surgeries.

Progesterone is an important sex hormone for pregnancy and also has neuroprotective and anticonvulsant effects. It is well-known that full-term parturients become more susceptible to volatile anesthetics. Glutamate transporters are important for preventing neurotoxicity and anesthetic action in the central nervous system. We investigated the effects of progesterone on the activity of glutamate transporter type 3 (EAAT3), the major neuronal EAAT. EAAT3 was expressed in Xenopus laevis oocytes by injecting its mRNA. Oocytes were incubated with diluted progesterone for 72 h. Two-electrode voltage clamping was used to measure membrane currents before, during, and after applying 30 μM L-glutamate. Progesterone (1–100 nM) significantly increased EAAT3 activity in a dose-dependent manner. Our kinetic study showed that the V max was increased in the progesterone group compared with that in the control group (2.7±0.2 vs. 3.6±0.2 μC for control group vs. progesterone group; n =18–23; P K m was unaltered (46.7±10.2 μM vs. 55.9±10.5 μM for control group vs. progesterone group; n =18–23; P >0.05). P horbol-12-myristate-13-acetate, a protein kinase C (PKC) activator, did not change progesterone-enhanced EAAT3 activity. Inhibitors of PKC or phosphatidylinositol 3-kinase (PI3K) abolished the progesterone-induced increases in EAAT3 activity. Our results suggest that progesterone enhances EAAT3 activity and that PKC and PI3K are involved in mediating these effects. These effects of progesterone may contribute to its anticonvulsant and anesthesia-related properties.

This study aimed to evaluate the effect of riluzole on the activity of excitatory amino acid transporter type 3 (EAAT3), a neuronal glutamate transporter, and to investigate the role of protein kinase C (PKC) in this effect. EAAT3 expression was induced in Xenopus oocytes by injecting EAAT3 mRNA. Using the two-electrode voltage clamping method, membrane currents were recorded before, during, and after applying l-glutamate (30 μM) in the absence and presence of prior incubation with riluzole (0.3-100 μM). To study the effect of PKC on the riluzole-induced change in EAAT3 activity, oocytes were preincubated with 100 μM phorbol-12-myristate-13-acetate (PMA), a PKC activator, or PKC inhibitors (2 µM staurosporine and 100 µM chelerythrine) before the recording. Responses were quantified by integrating current traces and are reported in microCoulombs (μC). Riluzole reduced EAAT3 activity in a concentration-dependent manner (0.3-100 μM). Treatment of oocytes with PMA significantly increased the baseline and riluzole-reduced EAAT activity (P0.05). In addition, treatment of oocytes with PKC inhibitors reduced basal transporter currents, but did not show a further significant decrease in the riluzole-reduced EAAT3 activity. These results suggest that riluzole reduces EAAT3 activity through PKC inhibition.

Magnesium sulfate has been used in preeclampsia patients in order to prevent seizure. It is also used for the treatment of arrhythmia and asthma and as an anesthetic adjunct in patients undergoing surgery for pheochromocytoma. However, its potentiating effects on perioperative analgesia and muscle relaxation have drawn attention recently. These characteristics of magnesium (anesthetic- and analgesic-sparing effect) enable anesthesiologists to reduce the use of anesthetics during surgery and the use of analgesics after surgery. Magnesium sulfate has a high therapeutic index and cost-effectiveness. Considering these diverse characteristics useful for anesthesia, appropriate use of magnesium sulfate would improve surgical outcome and patients' satisfaction.

In patients with cervical spine injuries, respiratory function requires careful attention. Voluntary respiratory control is usually possible with lesions below C4 level although paralysis of the abdominal musculature results in a decreased ability to cough and to clear secretions, which may later lead to respiratory insufficiency. Therefore, injuries above C5 usually necessitate long term mechanical ventilation. Even though weaning criteria are not definitive for the quadriplegic patient, M-mode ultrasonography of the diaphragm may be useful in identifying patients at high risk of difficulty weaning. Diaphragmatic dysfunction (vertical excursion < 10 mm or paradoxical movements) results in frequent early and delayed weaning failures. We present our clinical experience with successful weaning by using M-mode ultrasonography and a cough-assist device for secretion clearance after extubation in a quadriplegic patient undergoing C2-4 spine laminoplasty.

Caffeine has been known to trigger seizures, however, the precise mechanism about the proconvulsive effect of caffeine remains unclear. Glutamate transporters play an important role to maintain the homeostasis of glutamate concentration in the brain tissue. Especially, dysfunction of excitatory amino acid transporter type 3 (EAAT3) can lead to seizures. We investigated the effects of caffeine on the activity of EAAT3 and the involvement of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K). Rat EAAT3 was expressed in Xenopus oocytes by injecting EAAT3 mRNA. l- Glutamate (30 μM)-induced inward currents were recorded via the two-electrode voltage clamp method. Caffeine decreased EAAT3 activity in a dose-dependent manner. Caffeine (30 μM for 3 min) significantly reduced V max , but did not alter K m value of EAAT3 for glutamate. When preincubated oocytes with phorbol-12-myristate-13-acetate (PMA, a PKC activator) were exposed to caffeine, PMA-induced increase in EAAT3 activity was abolished. Two PKC inhibitors (chelerythrine and staurosporine) significantly reduced basal EAAT3 activity. Whereas, there were no significant differences among the PKC inhibitors, caffeine, and PKC inhibitors + caffeine groups. In similarly fashion, wortmannin (a PI3K inhibitor) significantly decreased EAAT3 activity, however no statistical differences were observed among the wortmannin, caffeine, and wortmannin + caffeine groups. Our results demonstrate that caffeine attenuates EAAT3 activity and this reducing effect of caffeine seems to be mediated by PKC and PI3K.

Postoperative sore throat (POST) is a common complaint after general anesthesia, especially following thyroidectomy.We examined the effect of adjusting the endotracheal tube cuff pressure during thyroidectomy on the incidence of airway complications. Ninety patients scheduled for elective thyroidectomy were randomized into two groups: control (group A, n = 45) and experimental (group B, n = 45). All patients underwent total intravenous anesthesia with propofol and remifentanil. In group A, the cuff pressure was set to 25 cm H2O initially and then monitored continuously without adjustment during thyroidectomy. In group B, the cuff pressure was maintained at approximately 25 cm H2O throughout the operation. The incidences and the severity of POST, hoarseness, dysphagia, and cough were recorded at 2 and 24 h postoperatively.Cuff pressures in group A changed significantly over time (P 0.05) and were higher than those of group B during thyroidectomy (P 0.05). The incidences of POST were lower in group B than in group A at 2 and 24 h postoperatively (P 0.05), and there was a significant difference in the severity of POST at 2 h postoperatively between the two groups. There were no differences in the incidences of hoarseness, dysphagia, and cough between the two study groups (P 0.05). Adjusting the endotracheal cuff pressure during thyroidectomy decreased the incidence and degree of POST.Intraoperative monitoring and adjustment of the cuff pressure can reduce POST in patients undergoing thyroidectomy.

Background Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA. Methods Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2–3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit. Results The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25–10.25) vs. 11 (7.75–14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025]. Conclusion The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Laryngoscopy and tracheal intubation (LTI) after induction of general anesthesia often cause hypertension and tachycardia. Labetalol and nicardipine have been used to prevent and treat acute cardiovascular responses to LTI.The goal of this study was to compare the preventive and therapeutic effects of labetalol 0.4 mg/kg IV and nicardipine 20 μg/kg IV on hypertensive responses to LTI during induction of general anesthesia.Patients undergoing general anesthesia were randomly allocated to 4 groups. In part I (prevention), 80 patients were randomized to receive either 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) 4 minutes before LTI. In part II (treatment), patients were randomized to receive 0.4 mg/kg of labetalol (n = 40) or 20 μg/kg of nicardipine (n = 40) after LTI if hypertension occurred. The number of additional study drug doses required by patients with hypertension (parts I and II) and time to return to normotension (part II) were recorded. Mean arterial pressure and heart rate were monitored, and rate-pressure product was calculated. Adverse events were also monitored.A total of 130 patients (72 patients in part I and 58 patients in part II) were included in the analysis. In parts I and II, the number of patients who required additional doses of the study drug because of persistent hypertension was lower in the nicardipine groups than in the labetalol groups (P0.05). Mean arterial pressure was lower and heart rate was significantly higher over time in the nicardipine groups compared with the labetalol groups (P0.05) in parts I and II. In part II, time to return to normotension was shorter in the nicardipine treatment group than in the labetalol treatment group (61 [21] vs 130 [46] seconds; P = 0.01). No statistical differences were observed in the incidence of adverse events except for tachycardia in part I (2 cases in the labetalol prevention group vs 18 cases in the nicardipine prevention group; P = 0.01).Patients who received nicardipine were less likely to require additional doses for either the prevention or treatment of hypertensive responses to LTI and responded to the study drug more rapidly than patients who received labetalol for the treatment of hypertensive responses to LTI. However, labetalol was associated with a lower incidence of tachycardia and less of an increase in rate-pressure product when used for the prevention of hypertension during LTI.

Background Remifentanil is known to cause bradycardia and hypotension, as well as the decreases of cardiac output (CO). We hypothesized that hemodynamic suppression by remifentanil would affect the onset time of rocuronium. This study investigated whether the onset of rocuronium was influenced by the drug-administration sequence during induction of anesthesia with target-controlled infusion of propofol and remifentanil. Methods Healthy adult patients (n = 126) undergoing elective surgery under general anesthesia were randomized into two groups according to drug-administration sequence. In Remi-Pro-Rocu group (n = 62), remifentanil was infused first, followed by propofol. Then, rocuronium was administered lastly. In Pro-Rocu-Remi group (n = 64), propofol, rocuronium, and remifentanil were given in that order. As a primary outcome, the onset time of rocuronium was measured. Mean arterial pressure (MAP), heart rate (HR), CO, and stroke volume were recorded before anesthesia (T1), at injection of rocuronium (T2), immediately before and after intubation (T3 and T4). Results In Remi-Pro-Roc group, the onset of rocuronium was delayed significantly compared with Pro-Rocu-Remi group [median (interquartile range); 130 (105–150) vs. 90 (71–100) s, P

Background Patients undergoing general anesthesia for laparoscopic cholecystectomy have a high risk of postoperative nausea and vomiting (PONV) with incidences up to 75%. Ramosetron, a serotonin subtype 3 (5-HT 3 ) antagonist, has been shown to be effective as an antiemetic after chemotherapy and surgery. Consensus guidelines recommend a combination of antiemetic therapies in high-risk groups. Until now, no published data have been available on the use of combination oral plus intravenous ramosetron. Objective The goal of this prospective, randomized, double-blind study was to compare the efficacy and tolerability of intravenous, oral, and the combination of oral and intravenous ramosetron for PONV prophylaxis in patients undergoing laparoscopic cholecystectomy. Methods Patients scheduled for laparoscopic cholecystectomy were double-randomly allocated to 1 of 3 groups. Patients were randomly allocated to receive either 0.3 mg of intravenous ramosetron (group A), 0.1 mg of oral ramosetron (group B), or the combination of 0.1 mg of oral ramosetron and 0.3 mg of intravenous ramosetron (group C). All patients received standardized balanced anesthesia with desflurane and remifentanil. Postoperative nausea, retching, vomiting, pain, and adverse effects were assessed at 0 to 2, 2 to 24, and 24 to 48 hours after surgery. Results A total of 124 Korean patients (67 women, 57 men; age range, 25–65 years) were randomized to 1 of 3 study groups (42 in group A [mean age, 49.8 years], 41 in group B [mean age, 47.4 years], and 41 in group C [mean age, 48.9 years]). No statistical differences were observed among the 3 groups with regard to patient characteristics and information on surgery and anesthesia. During postoperative period 0 to 2 hours, complete response occurred in 31 (74%) patients in group A, 27 (66%) in group B, and 37 (90%) in group C. During the postoperative period of 2 to 24 hours, complete response was observed in 36 (86%), 33 (80%), and 40 (98%) patients in groups A, B, and C, respectively; there was a statistically significant difference in group C compared with group A or group B. During the postoperative period of 0 to 48 hours, incidences of rescue antiemetic use were 13 (31%), 14 (34%), and 3 (7%) in groups A, B and C, respectively. Common adverse effects (headache, dizziness, and drowsiness) were observed, but there was no significant difference in the incidences of adverse effects among the 3 groups ( P > 0.05). Conclusions The combination of 0.1-mg oral and 0.3-mg intravenous ramosetron was more effective than either 0.3-mg intravenous ramosetron or 0.1-mg oral ramosetron alone for the prophylaxis of nausea and vomiting after laparoscopic cholecystectomy during the first 24 hours after surgery. In addition, differences did not reach the level of statistical significance between 0.1 mg of oral ramosetron and 0.3 mg of intravenous ramosetron for the prevention of PONV in this patient population. Oral, intravenous, and combined oral and intravenous ramosetron appears well tolerated in the population studied. ClinicalTrials.gov identifier: NCT 01041183.

BACKGROUND: The authors examined the impact of parenteral iron and recombinant human erythropoietin-β (rHuEPO-β) administered in the bilateral total knee replacement arthroplasty (TKRA), on postoperative anemia and transfusion requirements in iron-deficient patients. STUDY DESIGN AND METHODS: A total of 108 iron-deficient patients were randomly assigned to two groups: Group C (control) or Group IE (200 mg of iron sucrose intravenously over 1 hr and 3000 IU of rHuEPO-β subcutaneously during the operation and during the postoperative period if the hemoglobin [Hb] level was 70-80 g/L). One or 2 units of blood were transfused to patients in both groups according to postoperative Hb level (between 60 and 70 g/L or betweeen 50 and 60 g/L, respectively). Perioperative laboratory and clinical outcomes (Hb, iron variables, postoperative bleeding amount, and number of units of RBCs transfused and incidences) were documented. RESULTS: Although preoperative Hb and the amount of postoperative bleeding were comparable in the two groups, Hb levels at 1, 2, and 3 days and at 2 and 6 weeks postoperation were significantly higher in Group IE. Furthermore, the transfusion rate was significantly lower in Group IE (20.4% vs. 53.7%, p = 0.011) and the mean number of red blood cell units transfused was markedly lower in Group IE (0.2 ± 0.5 vs. 0.8 ± 0.8, p = 0.005). Postoperative iron, ferritin, and transferrin saturation levels were significantly higher in Group IE. CONCLUSIONS: Treatment with parenteral iron and low-dose rHuEPO-β in bilateral TKRA effectively attenuated anemia and decreased transfusion requirements in iron-deficient patients.

Glucocorticoids can increase the extracellular concentrations of glutamate, the major excitatory neurotransmitter. We investigated the effects of corticosterone on the activity of a glutamate transporter, excitatory amino acid carrier 1 (EAAC1; also called excitatory amino acid transporter type 3 [EAAT3]), and the roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in regulating these effects. Rat EAAC1 was expressed in Xenopus oocytes by injecting mRNA. L-Glutamate (30 μM)-induced membrane currents were measured using the two-electrode voltage clamp technique. Exposure of these oocytes to corticosterone (0.01-1 μM) for 72 h decreased EAAC1 activity in a dose-dependent fashion, and this inhibition was incubation time-dependent. Corticosterone (0.01 μM for 72 h) significantly decreased the V(max), but not the K(m), of EAAC1 for glutamate. Furthermore, pretreatment of oocytes with staurosporine, a PKC inhibitor, significantly decreased EAAC1 activity (1.00±0.06 to 0.70±0.05 μC; P

To determine the effect-site target concentration (C(et)) of remifentanil that provides optimal conditions for patients and operators during cataract surgery during monitored anesthesia care using a target controlled infusion (TCI) of propofol and remifentanil.Prospective, randomized, double-blinded study.Operating room and postoperative recovery area of a university-affiliated hospital.66 adult, ASA physical status I, II, and III patients undergoing cataract surgery.Group I received C(et) of remifentanil 0.5 ng/mL; Group 2 received C(et) of remifentanil one ng/mL; and Group 3 received C(et) of remifentanil 1.5 ng/mL. After giving TCI propofol (C(et); one μg/mL)-remifentanil, an ophthalmologist administered topical anesthesia.Intraoperative hemodynamics, pain scores, sedation scores, patient satisfaction scores, and operators' satisfaction scores regarding surgical conditions were recorded. No statistical differences in heart rate or mean blood pressure were detected among the three groups during surgery. Pain scores (Group 1: 31.9 ± 17.9 vs. Group 2: 11.8 ± 7.7 and Group 3: 11.8 ± 7.7; P0.05) were higher and patient satisfaction scores (Group 1: 4.7 ± 0.8 vs. Group 2: 5.4 ± 0.4 and Group 3: 5.5 ± 0.4; P0.05) were lower in Group 1 than Groups 2 and 3. On the other hand, surgeon satisfaction was lowest in Group 3 (Group 3: 2.9 ± 1.3 vs. Group 1: 4.7 ± 0.4 and Group 2: 4.6 ± 0.7; P0.05) due to ocular movement.C(et) values of remifentanil and propofol of one ng/mL and one μg/mL, respectively, appear to provide optimal conditions for patients and operators during cataract surgery using monitored anesthesia care with TCI.

BACKGROUND: The extracellular glutamate concentration is tightly controlled by excitatory amino acid transporters (EAATs). EAAT4 is the predominant EAAT in the cerebellar Purkinje cells. Purkinje cells play a critical role in motor coordination and may be an important target for ethanol to cause motor impairments. We designed this study to determine the effects of chronic ethanol exposure on the activity of EAAT4 and evaluate the involvement of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in these effects. METHODS: EAAT4 was expressed in Xenopus oocytes following injection of EAAT4 mRNA. Oocytes were incubated with ethanol-containing solution for 24 to 96 hours. Membrane currents induced by l-aspartate were recorded using 2-electrode voltage clamps. Responses were quantified by integration of the current trace and reported in microCoulombs (microC). RESULTS: Ethanol dose- and time-dependently reduced EAAT4 activity. EAAT4 activity after a 96-hour exposure was significantly decreased compared to the control values at all concentrations tested (10 to 100 mM). Ethanol (50 mM) significantly decreased the Vmax (2.2 +/- 0.2 microC for control vs. 1.6 +/- 0.2 microC for ethanol, n = 18, p < 0.05) of EAAT4 for L-aspartate. Preincubation of ethanol-treated (50 mM for 96 hours) oocytes with phorbol-12-myrisate-13-acetate (100 nM for 10 minutes) abolished the ethanol-induced decrease in EAAT4 activity. While staurosporine (2 microM for 1 hour) or chelerythrine (100 microM for 1 hour) significantly decreased EAAT4 activity, no difference was observed in EAAT4 activity among the staurosporine, ethanol, or ethanol plus staurosporine groups. Similarly, EAAT4 activity did not differ among the chelerythrine, ethanol, or ethanol plus chelerythrine groups. Pretreatment of the oocytes with wortmannin (1 microM for 1 hour) also significantly decreased EAAT4 activity. However, no difference was observed in the wortmannin, ethanol, or ethanol plus wortmannin groups. CONCLUSIONS: The results of this study suggest that chronic ethanol exposure decreases EAAT4 activity and that PKC and PI3K may be involved in these effects. These effects of ethanol on EAAT4 may cause an increase in peri-Purkinje cellular glutamate concentration, and may be involved in cerebellar dysfunction and motor impairment after chronic ethanol ingestion.

Glutamate transporters (excitatory amino acid transporters, EAAT) regulate extracellular concentrations of glutamate, a major excitatory neurotransmitter. We reported that acute ethanol exposure increases the activity of a major neuronal EAAT, EAAT3. This effect is consistent with the general inhibitory effect of acute alcohol toxicity in the central nervous system (CNS). However, chronic ethanol exposure has CNS presentations different from acute alcohol toxicity. We hypothesize that chronic ethanol exposure will affect the EAAT3 activity differently from acute ethanol exposure.EAAT3 was expressed in Xenopus oocytes by injection of EAAT3 mRNA. Oocytes were incubated with diluted ethanol for 24-96 hr. Using two-electrode voltage clamp, membrane currents were recorded after the application of L-glutamate. Responses were quantified by integration of the current trace and reported as microCoulombs (microC).Ethanol (10-100 mM) reduced EAAT3 activity in a time-dependent and reversible manner. After a 96 hr-incubation, the activity was significantly decreased compared to the control values at any concentrations tested in this study. Kinetic study demonstrated that a 96 hr-exposure to 50 mM ethanol significantly decreased Vmax (3.6 +/- 0.3 for control versus 2.6 +/- 0.3 microC for ethanol, n = 20, p0.05) but had no effect on Km (57.6 +/- 12.8 for control versus 51.8 +/- 16.3 microM for ethanol, n = 20, p0.05) of EAAT3 for glutamate. When ethanol (50 mM for 96 hr)-treated oocytes were incubated with phorbol-12-myrisate-13-acetate (50 or 100 nM for 10 min), ethanol-induced decrease in EAAT3 activity was abolished. Preincubation of the oocytes with 100 microM chelerythrine significantly decreased EAAT3 activity (1.00 +/- 0.08 for control versus 0.51 +/- 0.09 microC for chelerythrine group, n = 18-20, p0.05). However, there was no statistical difference among the chelerythrine, ethanol, or chelerythrine plus ethanol groups. Likewise, staurosporine (2 microM for 1 hr) significantly decreased EAAT3 activity and there was no statistical difference among the staurosporine, ethanol, or staurosporine plus ethanol groups.Our results show that chronic ethanol exposure decreases EAAT3 activity at clinically relevant concentrations and that this effect may be protein kinase C-dependent. Such an effect could be a neuroadaptive mechanism to overcome the inhibitory effect of ethanol on the excitatory neurotransmission.

C-reactive protein and albumin are associated with poor outcomes in critically ill patients. This study aimed to investigate the significance of the C-reactive protein/albumin (CRP/ALB) ratio as a novel prognostic factor for 30-day or 1-year mortality after admission to the postoperative intensive care unit (ICU). This retrospective study was conducted by examining the medical records of postoperative patients aged 19 years or older admitted to the ICU at a tertiary care hospital from January 2007 to July 2016. This study included data on 11,832 postoperative patients in the analysis. The cut-off value of the CRP/ALB ratio was set at 1.75 and 1.58 for 30-day and 1-year mortality after ICU admission, respectively. In postoperative patients with a high CRP/ALB ratio (>1.75 or >1.58), the probability of death within 30 days or 1 year after ICU admission were 30% or 43% higher than that in the group with the least CRP/ALB ratio, respectively (≤1.75 or ≤1.58)(p < 0.05). This study found the CRP/ALB ratio measured immediately after ICU admission to be an independent risk factor for 30-day and 1-year mortality in postoperative patients admitted to the ICU.

Background: This study compared two insertion techniques of ProSeal™ laryngeal mask airway. Methods: A total of 160 female patients (American Society of Anesthesiologists physical status I or II; age 18-80 yrs) undergoing gynecologic surgery were randomly allocated to the standard or rotational technique groups. In the standard technique group (n = 80), ProSeal™ laryngeal mask airway insertion was performed by a single experienced user using digital manipulation. In the rotational technique group (n = 80), the ProSeal™ laryngeal mask airway was rotated counter clockwise through 90 degrees in the mouth and advanced until the resistance of the hypopharynx was felt, and then straightened out in the hypopharynx (n = 80). The ease of insertion was assessed by the success rate at the first attempt. Heart rate and mean blood pressure were recorded 1 min before and 1 min after insertion. Postoperative complications were noted. Results: The success rate of insertion at the first attempt was higher for the rotational technique (100% vs. 85%, P < 0.001). The overall success rate, i.e., successful insertion within three attempts, was 94% for the standard technique versus 100% for the rotational technique. There was no significant change in heart rate, but mean blood pressure increased significantly with the standard technique (P = 0.001). The incidence of blood staining (9% vs. 36%, P < 0.001) and sore throat (8% vs. 25%, P = 0.005) was lower with the rotational technique. Conclusion: The rotational technique is more successful than the standard technique and is associated with less pharyngeal mucosal trauma, as evidenced by a lower incidence of sore throat and mucosal bleeding.

The adverse effects of spinal anesthesia (SA) include arterial hypotension and bradycardia. The aim of this study was to compare the effects of 2 type 3 serotonin receptor antagonists in SA-induced adverse effects. Specifically, we assessed whether ramosetron was more effective than ondansetron in reducing SA-induced decreases in blood pressure (BP) and heart rate (HR).A total of 117 patients undergoing orthopedic surgery and receiving SA were intravenously administered 0.3 mg of ramosetron (n = 39, group R), 4 mg of ondansetron (n = 39, group O4), or 8 mg of ondansetron (n = 39, group O8). Systolic BP (SBP), diastolic BP (DBP), mean BP (MBP), HR, and the lowest SBP, DBP, MBP, and HR values were measured preoperatively (baseline) and intraoperatively. The incidence of postoperative nausea and vomiting, the need for rescue antiemetics, the amount of patient-controlled analgesia consumption, and pain score in the first 48 hours after surgery were determined.Baseline values did not significantly differ among the 3 groups. After SA, SBP, DBP, MBP, and HR were lower than their baseline values in all 3 groups. The differences between the baseline and the lowest values were significantly less in group R than in groups O4 and O8 with respect to SBP (P0.001), DBP (P = 0.001), and MBP (P0.001) less in group R than in group O4 with respect to HR (P = 0.032). Intergroup differences were not significant for postoperative nausea and vomiting, the need for rescue antiemetics, patient-controlled analgesia consumption, or pain score.The administration of ramosetron (0.3 mg) significantly attenuated the SA-induced decrease in BP compared with 4 or 8 mg of ondansetron and HR compared with 4 mg of ondansetron.

Many anti-epileptics cause resistance to non-depolarizing neuromuscular blocking agents, but this has not been reported for valproic acid (VPA). We hypothesized that VPA would increase the rocuronium requirement and that magnesium sulphate (MgSO(4)) may reduce this increase.Fifty-five patients undergoing cerebrovascular surgeries were studied. Subjects were allocated into three groups at a 1:1:1 ratio: Groups VM, VC, and C. Groups VM and VC were given VPA premedication; Group C was not. A rocuronium injection (0.6 mg kg(-1) i.v.) was administered to Group VM, followed by MgSO(4) as a 50 mg kg(-1) i.v. bolus and 15 mg kg(-1) h(-1) infusion. The same volume of 0.9% saline was administered to the other groups. Supplementary rocuronium (0.15 mg kg(-1)) was given whenever the train-of-four count reached 2. Rocuronium requirements (primary outcome), mean arterial pressure (MAP), heart rate (HR), nausea, vomiting, shivering, and use of anti-emetics and nicardipine were compared.Group VC showed the highest rocuronium requirement [mg kg(-1) h(-1): 0.47 (0.08) vs 0.33 (0.12) (Group C), 0.31 (0.07) (Group VM); P0.001]. MAP, intraoperative HR, nausea, vomiting, shivering, and use of anti-emetics and nicardipine were not significantly different among the groups. Postoperative HR was lower in Group VM than in Group VC.VPA increased the rocuronium requirement, and MgSO(4) infusion attenuated this increase.

Glutamate is the major excitatory neurotransmitter in the central nervous system and is critical for essentially all physiological processes, such as learning, memory, central pain transduction, and control of motor function. Excitatory amino acid transporters (EAATs) play a key role in regulating glutamate neurotransmission by uptake of glutamate into cells. EAAT4 is the major EAAT in the cerebellar Purkinje cells. The authors investigated the effects of ethanol on EAAT4 and the mediatory effects of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in this context.Excitatory amino acid transporter 4 was expressed in Xenopus oocytes by injecting EAAT4 mRNA. l-aspartate-induced membrane currents were measured using a two-electrode voltage clamp. Responses were quantified by integrating current traces and are represented in microCoulombs (microC).Ethanol increased EAAT4 activity in a dose-dependent manner. At ethanol concentrations of 25, 50, 100, and 200 mM, the responses were significantly higher than untreated control values. Ethanol (25 mM) significantly increased the V(max) (1.5 +/- 0.1 microC for control vs. 2.0 +/- 0.1 microC for ethanol, p0.05), but did not affect K(m) (2.3 +/- 0.6 microM for control vs. 1.7 +/- 0.7 microM for ethanol, p0.05) of EAAT4 for l-aspartate. Preincubation of oocytes with phorbol-12-myristate-13-acetate (PMA, a PKC activator) significantly increased EAAT4 activity. However, combinations of PMA and ethanol versus PMA or ethanol alone did not increase responses further. Two PKC inhibitors, chelerythrine and staurosporine did not reduce basal EAAT4 activity but abolished ethanol-enhanced EAAT4 activity. Pretreatment with wortmannin (a PI3K inhibitor) also abolished ethanol-enhanced EAAT4 activity.These results demonstrate that acute ethanol exposure increases EAAT4 activity at clinically relevant concentrations and that PKC and PI3K may mediate this. The effects of ethanol on EAAT4 may play a role in the cerebellar dysfunction caused by ethanol intoxication.

Glutamate is a major excitatory neurotransmitter in the central nervous system. Glutamate transporters play a critical role in maintaining extracellular glutamate concentrations. We investigated the effects of ethanol on a neuronal glutamate transporter, excitatory amino acid transporter type 3 (EAAT3), and the role of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3 K) in mediating these effects.EAAT3 was expressed in Xenopus oocytes by injection of EAAT3 messenger RNA. By using a two-electrode voltage clamp, membrane currents were recorded after the application of l-glutamate. Responses were quantified by integration of the current trace and reported as microcoulombs. Data are mean +/- SEM.Ethanol enhanced EAAT3 activity in a concentration-dependent manner. At 25, 50, 100, and 200 mM of ethanol, the responses were significantly increased compared with control values. Kinetic study demonstrated that ethanol (50 mM) significantly increased Vmax (3.48 +/- 0.2 microC for control versus 4.16 +/- 0.24 microC for ethanol; n = 19; p0.05) without a significant change in the Km (65.6 +/- 11.1 microM for control versus 55.8 +/- 9.6 microM for ethanol; n = 19; p0.05) of EAAT3 for glutamate. Preincubation of the oocytes with phorbol-12-myristate-13-acetate (PMA) significantly increased EAAT3 activity (0.98 +/- 0.08 muC for control versus 1.28 +/- 0.09 microC for ethanol; n = 19; p0.05). However, there was no statistical difference among the responses of EAAT3 to PMA, ethanol, or PMA plus ethanol. Although the PKC inhibitors chelerythrine and staurosporine did not decrease the basal EAAT3 activity, they abolished the enhancement of EAAT3 activity by ethanol. Pretreatment with wortmannin, a PI3 K inhibitor, also abolished the ethanol-enhanced EAAT3 activity.These results suggest that acute ethanol exposure increases EAAT3 activity at clinically relevant concentrations and that PKC and PI3 K may be involved in mediating these ethanol effects.

Electroconvulsive therapy (ECT) had been used for psychiatric diseases such as depression. Recently, modified ECT is preferred, where the patient is in a state of muscle relaxation induced by muscle relaxant before the influx of electrical current. Although muscle relaxant is used, forceful jaw clenching is inevitable during ECT, since masticatory muscles, particularly the temporalis and the masseter, are directly stimulated by the electrical current. Although biting pressure in a conscious individual is usually controlled by a feedback mechanism to avoid excessive strain, this feedback mechanism does not come into action in an anesthetized patient [1]. Therefore, the teeth or other intraoral structures can be injured from biting or invagination during modified ECT. Psychiatric patients are especially vulnerable to intraoral injuries during modified ECT, because they are more likely to have drug-related dry mouth, smoking, and/or alcohol addiction. In xerostomia patients, the change in the pH and the immune function secondary to reduced salivary flow may also lead to an increased risk of intraoral infection [2]. In order to prevent intraoral injury during modified ECT, mouthguards rather than oral airways are used. Various types of gags and mouthguards have been used such as rubber bite blocks, braided guaze gags, gauze wrapped tongue blades and mouthguards. McClure devised a gag made of dental plastic, and also described about molded mouthguards [1]. But individually molded mouthguards like hard rubber bite blocks are so firm that care should be given to prevent soft tissue injuries such as tongue bites which can occur between the teeth and the mouthguard. We would like to describe a tongue laceration case which occurred during modified ECT despite using a mouthguard. A 71-year-old female patient was admitted for modified ECT under the diagnosis of depression. The mouthguard was made of silicone, immersed in hot water before use and transformed to fit the denture of the patient (Fig. 1A). After modified ECT was given, tongue laceration was found, which seemed to have occurred from biting between the mouthguard and the teeth. Tongue laceration was 1.5 cm long and 0.5 cm deep. Neither active bleeding nor hematoma was observed. After physical examination by an otolaryngologist, it was sutured simply with Vicryl 4-0 under local anesthesia (Fig. 1B). The wound recovered well without complication. Fig. 1 The mouthguard in proper position (A). Tongue laceration repaired with a simple continuous suture. The tongue has an irregular and dry fissured surface, which is a typical characteristic of dry mouth (B). Intraoral soft tissue injuries, especially tongue injuries generally recover well after simple treatment because of the abundant blood supply. Most tongue lacerations do not require sutures. Lacerations that should be repaired with suture include bisecting wounds, lateral border wounds, wounds with active hemorrhage, wounds larger than 2 cm, gaping wounds and amputation injuries [3,4]. If the patient cooperates well, tongue laceration can be sutured under local anesthesia using absorbable material such as Vicryl 4-0 [3]. Some lacerations may cause airway complications including intraoral structure swelling and difficult breathing. In the case of hematoma, blood fills the submandibular space, the floor of the mouth becomes full, and then the tongue is forced upwards and backwards, causing an elevation of the tongue and airway obstruction. If swelling and difficult breathing became severe, early nasotracheal intubation or tracheostomy should be considered for airway protection. Extubation should be performed after the swelling subsides. While active arterial bleeding requires intervention, subsequent treatments are usually conservative, such as steroids, antibiotics and reversal of any coagulopathy [5]. Before all else, one should examine the patient's dental and oral condition carefully and check whether the mouthguard fits well to the patient before performing ECT. If necessary, the patient should get dental treatment in advance to ensure his or her safety during ECT.

Background We investigated the effects of a magnesium sulfate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI) in this double-blind randomized study. Methods Adult patients (n = 154) were randomly allocated to a rocuronium-0.6, rocuronium-0.9, or magnesium group. The magnesium group was pretreated with 50 mg/kg MgSO4, and the other two groups received the same volume of isotonic saline. Anesthesia was induced with alfentanil, propofol, and either 0.6 mg/kg (rocuronium-0.6 and magnesium groups) or 0.9 mg/kg (rocuronium-0.9 group) rocuronium. An anesthesiologist, blinded to the group assignments, performed RSI and assessed the intubating conditions. Systolic arterial pressure (SAP) and heart rate (HR) were recorded before the magnesium sulfate or normal saline was administered, before anesthesia induction, before intubation, and every minute after intubation for 5 min. Results Airway features were similar among the three groups. The intubating conditions were improved significantly in the magnesium group (P < 0.001) compared with the other two groups. Significant increases in SAP at 1 min after intubation were observed in the rocuronium-0.6 and -0.9 groups when compared with the magnesium group (P < 0.05). HR was comparable among the three groups (P > 0.05). No hypertensive episode occurred during the immediate post-intubation period in the magnesium group (P = 0.001), and tachycardia occurred most frequently in the rocuronium-0.6 group (P < 0.05). Conclusions MgSO4 administered prior to RSI using alfentanil, propofol, and rocuronium may improve intubating conditions and prevent post-intubation hypertension.

Background Prophylactic fluid preloading before spinal anesthesia has been a routine procedure to prevent maternal hypotension during cesarean delivery. Unlike colloid, timing of infusion of crystalloid may be important because of its short stay in intravascular space. We hypothesized that crystalloid loading just after intrathecal injection compared to preload would be more effective in preventing maternal hypotension. Methods In this prospective controlled study, sixty parturients were randomized to receive 15 ml/kg of crystalloid before (preload group) or after (coload group) intrathecal drug injection for spinal anesthesia. Hypotension was defined if systolic arterial pressure decreased below 80% of baseline and ephedrine was administered to treat hypotension. The incidence of hypotension and the total dose of ephedrine were checked. Blood pressure, heart rate and nausea before childbirth were assessed. Neonatal outcomes were evaluated with Apgar scores and umbilical blood gas analysis. Results The incidence of hypotension was lower in the coload group compared to the preload group (53% vs. 83%, P = 0.026). The blood pressure showed the bigger drop during spinal anesthesia in the preload group (34 ± 13 vs. 25 ± 10 mmHg, P = 0.002) and smaller dose of ephedrine was required in the coload group (7.5 [0–30] vs. 15 [0–40] mg, P = 0.015). The incidence of nausea was also lower in the coload group (27% vs. 60%, P = 0.019). Neonatal outcome measures were comparable between two groups. Conclusions In case of using crystalloids for cesarean delivery, coload is more effective than preload for the prevention of maternal hypotension after spinal anesthesia. Trial registration Clinical Research Information Service KCT0000324 (Jan 12th, 2012)