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Virtual reality (VR), which offers an immersive experience, has been implemented into the education of pediatric patients to reduce peri-procedural anxiety. This randomized clinical trial evaluated the effect of VR, compared with standard video, on reducing anxiety and distress in pediatric patients undergoing chest radiography. A total of 120 children aged 4 to 8 years with scheduled chest radiography appointments were randomized into either the tablet or the VR group. Children in the tablet group experienced chest radiography indirectly with a 3 min tablet video, whereas those in the VR group received the same content via a VR experience. The distress of children was measured using the Observational Scale of Behavioral Distress (OSBD) scale. Parental presence and procedural outcomes were also recorded. The number of less distressed children (OSBD score < 5) was significantly higher in the VR group than in the tablet group (49 [81.7%]) vs. 32 [53.3%]) (p = 0.001). The OSBD scores, the need for parental presence, the procedure time, and the number of repeated procedures were all lower in the VR group. The immersive VR experience appears to decrease the degree of anxiety in children and increase the efficiency of the procedures compared with the tablet video with the same content.

Although thiopental improved neurological outcomes in several animal studies, there are still insufficient clinical data examining the efficacy of thiopental for patients undergoing surgical clipping of unruptured intracranial aneurysm (UIA). This study validated the effect of thiopental and investigated risk factors associated with postoperative neurological complications in patients undergoing surgical clipping of UIA. In total, 491 patients who underwent aneurysm clipping were included in this retrospective cohort study. Data regarding demographics, aneurysm characteristics, and use of thiopental were collected from electronic medical records. Propensity score matching and logistic regression analysis were used. After propensity score matching, the thiopental group showed a lower incidence of the postoperative neurological complications than non-thiopental group (5.5% vs. 17.1%, p = 0.001). In multivariate analysis, thiopental reduced the risk of postoperative neurological complications (odds ratio (OR) 0.26, 95% confidence interval (CI) 0.13 to 0.51, p &lt, 0.001) while aneurysm size ≥ 10 mm (OR 4.48, 95% CI 1.69 to 11.87, p = 0.003), and hyperlipidemia (OR 2.24, 95% CI 1.16 to 4.32, p = 0.02) increased the risk of postoperative neurological complications. This study showed that thiopental was associated with the lower risk of neurological complications after clipping of UIA.

Neurotoxic effects of local anesthetics (LAs) on developing motor neurons have not been documented. We investigated the neurotoxic effects of LAs on developing motor neurons in terms of cell viability, cytotoxicity, reactive oxygen species (ROS), and apoptosis. Embryonic spinal cord motor neurons were isolated from Sprague-Dawley rat fetuses and exposed to one of the three LAs—lidocaine, bupivacaine, or ropivacaine—at concentrations of 1, 10, 100, or 1000 µM. The exposure duration was set to 1 or 24 h. The neurotoxic effects of LAs were determined by evaluating the following: cell viability, cytotoxicity, ROS production, and apoptosis. In the 1-h exposure group, the motor neurons exposed to lidocaine and bupivacaine had reduced cell viability and increased cytotoxicity, ROS, and apoptosis in a concentration-dependent manner. Lidocaine showed the highest toxicity, followed by bupivacaine. In the 24-h exposure group, all three LAs showed significant effects (decreased cell viability and increased cytotoxicity, ROS, and apoptosis) on the motor neurons in a concentration-dependent manner. The neurotoxic effects of lidocaine were greater than those of bupivacaine and ropivacaine. Ropivacaine appeared to have the least effect on motor neurons. This study identified the neurotoxic effects of lidocaine and bupivacaine on developing spinal cord motor neurons.

Spinal cord ischemia is one of the most serious complications of aortic repair in patients with acute aortic syndrome. However, the effect of hypotension before aortic clamping on spinal cord injury has not been documented. A total of 48 male Sprague-Dawley rats were randomly divided into four groups: the sham group, control group (mean arterial pressure (MAP) &lt, 90% of baseline value before aortic clamping), mild hypotension group (MAP &lt, 80%), and profound hypotension group (MAP &lt, 60%). Spinal cord ischemia was induced using a balloon-tipped catheter placed in the descending thoracic aorta. Neurological function of the hind limbs was evaluated for seven days after reperfusion and recorded using a motor deficit index (MDI). The spinal cord was then harvested for histopathological examination and evaluation of oxidative stress and inflammation. The profound hypotension group demonstrated a significantly higher MDI 48 h post-reperfusion and lower number of normal motor neurons than the other groups (p &lt, 0.001). The levels of tissue malondialdehyde and tumor necrosis factor-&alpha, (TNF-&alpha, ) were also significantly increased in the profound hypotension group compared with other groups. Profound hypotension before aortic clamping can aggravate neurologic outcomes after aortic surgery by exacerbating neurologic injury and reducing the number of normal motor neurons.

Ultrasound-guided erector spinae plane block (ESPB), a recent regional analgesic technique, has been used to manage acute pain after surgery. The aim of this meta-analysis is to identify the benefits of ESPB in patients undergoing laparoscopic cholecystectomy (LC). The authors searched PubMed, EMBASE, CENTRAL, CINAHL, and Web of Science to identify all randomized controlled trials (RCTs) evaluating the effects of ESPB on postoperative pain after LC. Primary outcome was defined as 24 h cumulative opioid consumption. Secondary outcomes were pain scores and the incidence of postoperative nausea and vomiting (PONV). We estimated mean differences (MD) and odds ratio (OR) using a random-effects model. A total of 8 RCTs, including 442 patients, were included in the final analysis. Postoperative opioid consumption was significantly lower in the ESPB group than in the control group (MD &minus, 4.72, 95% CI &minus, 6.00 to &minus, 3.44, p &lt, 0.001). Compared with the control group, the ESPB group also showed significantly lower pain scores and incidence of PONV. A separate analysis of RCTs comparing ESPB with oblique subcostal transversus abdominis plane (OSTAP) block showed that the analgesic efficacy of ESPB was similar to that of OSTAP block. The results of this meta-analysis demonstrated that ESPB may provide effective postoperative analgesia in patients undergoing LC.

Sugammadex reverses the rocuronium-induced neuromuscular block by trapping the cyclopentanoperhydrophenanthrene ring of rocuronium. Dexamethasone shares the same steroidal structure with rocuronium. The purpose of this study was to evaluate the influence of dexamethasone on neuromuscular reversal of sugammadex after general anesthesia. Electronic databases were searched to identify all trials investigating the effect of dexamethasone on neuromuscular reversal of sugammadex after general anesthesia. The primary outcome was time for neuromuscular reversal, defined as the time to reach a Train-of-Four (TOF) ratio of 0.9 after sugammadex administration. The secondary outcome was the time to extubation after sugammadex administration. The mean difference (MD) and 95% CI were used for these continuous variables. Six trials were identified, a total of 329 patients were included. The analyses indicated that dexamethasone did not influence the time for neuromuscular reversal of sugammadex (MD &ndash, 3.28, 95% CI &ndash, 36.56 to 29.99, p = 0.847) and time to extubation (MD 25.99, 95% CI &ndash, 4.32 to 56.31, p = 0.093) after general anesthesia. The results indicate that dexamethasone did not influence the neuromuscular reversal of sugammadex in patients after general anesthesia. Therefore, the dexamethasone does not appear to interfere with reversal of neuromuscular blockade with sugammadex in patients undergoing general anesthesia for elective surgery.

The use of sugammadex can reduce post-operative residual neuromuscular blockade, which is known to increase the risk of post-operative respiratory events. However, its effect on post-operative pulmonary complications is not obvious. This study was performed to evaluate the effects of sugammadex on post-operative pulmonary complications in patients undergoing laparoscopic gastrectomy between 2013 and 2017. We performed propensity score matching to correct for selection bias. Post-operative pulmonary complications (i.e., pneumonia, respiratory failure, pleural effusion, atelectasis, pneumothorax, and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. We also evaluated admission to the intensive care unit after surgery, re-admission or an emergency room visit within 30 days after discharge, length of hospital stay, re-operation, and mortality within 90 days post-operatively as secondary outcomes. In the initial cohort of 3802 patients, 541 patients were excluded, and 1232 patients were analyzed after propensity score matching. In the matched cohort, pleural effusion was significantly reduced in the sugammadex group compared to the neostigmine group (neostigmine 23.4% vs. sugammadex 18%, p = 0.02). Other pulmonary complications and secondary outcomes were not significantly different between the groups. In comparison to neostigmine, the use of sugammadex was associated with a lower incidence of post-operative pleural effusion in laparoscopic gastrectomy.

Background and aims An immersive virtual reality tour of the operating theater could reduce preoperative anxiety. This study was designed to determine whether a preoperative immersive virtual reality tour demonstrates a reduction in emergence delirium through reducing the preoperative anxiety in children undergoing general anesthesia. Methods Eighty-six children were randomly allocated into either the control or virtual reality group. The control group received conventional education regarding the perioperative process. The virtual reality group watched a 4-minute virtual reality video showing the operating theater and explaining the perioperative process. Incidence and severity of emergence delirium were the main outcomes. Secondary outcomes included preoperative anxiety using modified Yale Preoperative Anxiety Scale and postoperative behavioral disturbance. Results Eighty children completed the final analysis (control group = 39, virtual reality group = 41). The incidence (risk ratio [95% CI]: 1.1 [0.5-2.8], P = 0.773) and severity of emergence delirium (mean difference [95% CI]: -0.2 [-2.7 to 2.2], P = 0.791) were similar in the two groups. After the intervention, children in the virtual reality group had a significantly lower modified Yale Preoperative Anxiety score than those in the control group (mean difference [95% CI]: 9.2 [0.3-18.2], P = 0.022). No difference was observed regarding postoperative behavioral disturbance between the two groups at postoperative 1 day (mean difference [95% CI]: -0.1 [-0.3 to 0.1], P = 0.671) and 14 day (mean difference [95% CI]: -0.0 [-0.1 to 0.0], P = 0.329). Conclusion Preoperative immersive virtual reality tour of the operating theater did not reduce the incidence and severity of emergence delirium, although it was effective in alleviating preoperative anxiety in children.

The relationship between preoperative hyperglycemia and postoperative acute kidney injury (AKI) occurrence in non-cardiac surgery including laparoscopic surgery remains unclear. This study aimed to assess the relationship between preoperative chronic hyperglycemia and postoperative AKI occurrence after a major laparoscopic abdominal surgery.We retrospectively reviewed medical records of diabetic patients (≥ 20 years old) who underwent elective major laparoscopic abdominal surgery procedures between 2010 and 2016. Patients were divided into two groups based on a cut-off value of hemoglobin A1c (HbA1c) at 6%. Serum creatinine value was used for the diagnosis of AKI, and all assessments and diagnoses of postoperative AKI were performed on 0-3 postoperative days (POD) using the criteria of Kidney Disease: Improving Global Outcomes.In all, 1885 patients were included in the final analysis, and patients were divided into the following groups: 6.0% group with 1257 patients (66.7%), and ≥ 6.0% group with 628 patients (33.3%). Sixty-nine patients (3.7%) were diagnosed with postoperative AKI within 3 POD. Multivariable logistic regression analysis showed no significant difference in the incidence rate of postoperative AKI between the HbA1c ≥ 6.0% group and the 6.0% group (odds ratio 1.10, 95% confidence interval 0.57-2.15; P = 0.770). In addition, there was no significant interaction between preoperative HbA1c group and exposure to acute hyperglycemia (serum glucose 200 mg/dL) for incidence of AKI on POD 0-3 (P = 0.181).In diabetic patients, preoperative chronic hyperglycemia is not associated with postoperative AKI occurrence within 3 POD after a major laparoscopic abdominal surgery.

To compare between deep neuromuscular blockade (NMB) and moderate NMB with respect to endoscopic surgical conditions and recovery profiles in patients with general anesthesia for transurethral resection of bladder (TURB). 108 patients undergoing elective TURB were randomized into two groups: the moderate NMB (n = 54) or deep NMB (n = 54) group. After the operation, NMB was reversed with 2 mg/kg sugammadex at a train-of-four (TOF) count of 1 or 2 (moderate NMB group) or with 4 mg/kg sugammadex at post-tetanic count (PTC) of 2 (deep NMB group). Surgeons, who were blinded to the study design, rated the endoscopic surgical condition on a 5-point scale (1 = extremely poor, 2 = poor, 3 = acceptable, 4 = good, 5 = optimal) immediately following the operation. Recovery profiles, including postoperative residual curarization (PORC), respiratory complication, and recovery time, were recorded. No difference was observed between the two groups regarding patients and anesthesia characteristics. There were statistically significant differences in endoscopic surgical conditions between the two groups (P

OBJECTIVE: To investigate the effects of morphine on microglial phagocytosis during neuroinflammation. METHODS: C8-B4 mouse microglial cells were exposed to various concentrations of morphine after the stimulation with lipopolysaccharide and interferon-γ and then fluorescent immunostaining was performed to assess the percentage of microglia that engulfed fluorescent microspheres in total microglia. Naloxone, β funaltrexamine, or naltrindole was used with 1 μM morphine to assess the involvement of specific opioid receptor. P38 and phosphorylated p38 were determined by Western blotting. A p38 mitogen-activated protein kinase (MAPK) activator (anisomycin 0.1 μM) or inhibitor (SB 203580, 20 μM) was used to determine the involvement of p38 MAPK pathway. RESULTS: Morphine decreased lipopolysaccharide and interferon-γ induced microglial engulfment except the highest concentration (10 μM) and both naloxone and naltrindole (a selective δ opioid receptor antagonist) attenuated morphine effect (P < 0.001). The phosphorylated p38 was up-regulated in lipopolysaccharide and interferon-γ group compared with control group (P < 0.001). This up-regulation was decreased by 1 μM morphine (P < 0.001). However, naltrindole abolished this morphine effect (P = 0.015). SB203580 blocked the increased microglial engulfment induced by lipopolysaccharide and interferon-γ (P < 0.001); whereas anisomycin enhanced the morphine-induced decrease of engulfment (P < 0.001). CONCLUSION: Morphine reduced mouse microglial engulfment induced by lipopolysaccharide and interferon-γ. This morphine effect seems to be mediated by δ opioid receptor and via p38 MAPK inhibition.

Study objective This study aimed to identify the benefits of quadratus lumborum block (QLB) in terms of postoperative analgesic effects in adult participants undergoing hip surgery. Design Meta-analysis of randomized controlled trials. Setting Previous randomized controlled trials that evaluated the analgesic effect of QLB compared to that of no block. Patients Nine studies including 616 participants. Interventions Participants in the treatment group received QLB, whereas those in the control group received no block. Measurements Outcomes were postoperative 24-h opioid consumption (primary), 12-h/24-h visual analog scale (VAS) or numeric rating scale (NRS) pain scores, postoperative nausea and vomiting (PONV), and satisfaction. The effect size was estimated using the standardized mean difference (SMD), mean difference (MD), or risk ratio (RR) with a 95% confidence interval (CI). We used the risk of bias tool (RoB 2) to assess the risk of bias of the included studies and the GRADE approach to determine the level of certainty of the evidence. Main results Compared to no block, the QLB group has less opioid consumption (SMD -1.69, 95% CI -2.54 to -0.84; low level of certainty of the evidence). Estimated MD for morphine consumption was 24 mg. The QLB group had a lower 12-h VAS/NRS pain score (MD -1.16, 95% CI -1.82 to -0.51; moderate level of certainty of the evidence) and 24-h VAS/NRS pain score (MD -0.92, 95% CI -1.42 to -0.43; moderate level of certainty of the evidence). QLB decreased the incidence of PONV (RR 0.43, 95% CI 0.24 to 0.79; moderate level of certainty of the evidence) and increased participants' satisfaction (SMD 1.15, 95% CI 0.63 to 1.67; moderate level of certainty of the evidence). Estimated MD for satisfaction was 1.74 points of Likert scale. There were no significant adverse events associated with the QLB in any of the included trials. Conclusion Our meta-analysis showed that QLB when compared to no block clinically decreased opioid requirements, reduced PONV, and improved participants' satisfaction. QLB also seems to be significantly superior to no block in terms of pain score, but its clinical importance remains unclear.

To compare GlideScope and lighted stylet for double-lumen endobronchial tube (DLT) intubation in terms of intubation time, success rate of first attempt at intubation, difficulty in DLT advancement toward the glottis, and postoperative sore throat and hoarseness.A prospective, randomized study.Medical center governed by a university hostpial.Sixty-two adult patients undergoing thoracic surgery using DLT intubation.After the induction of anesthesia, DLT intubation was performed using GlideScope (n = 32) or lighted stylet (n = 32).Number of intubation attempts, difficulty of DLT advancement toward the glottis, time taken for DLT intubation, and the incidence and severity of postoperative sore throat and hoarseness at 1 and 24 hours after surgery were evaluated. Time taken for DLT intubation was shorter in the lighted stylet group compared with the GlideScope group (30 [28-32] s v 45 [38-53] s, median [interquartile range], respectively; p0.001). DLT advancement toward the glottis was easier in the lighted stylet group than in the GlideScope group (p = 0.016). The success rate of DLT intubation in the first attempt (96.9% v 90.6% for lighted stylet and GlideScope, respectively), and the incidence and severity of postoperative sore throat and hoarseness were not different between the two groups.The use of lighted stylet allowed easier advancement of the DLT toward the glottis in the oropharyngeal space and reduced time for achieving DLT intubation compared with GlideScope.

Background A virtual reality (VR) tour of the operating theatre before anaesthesia could provide a realistic experience for children. This study was designed to determine whether a preoperative VR tour could reduce preoperative anxiety in children. Methods Children scheduled for elective surgery under general anaesthesia were randomized into a control or VR group. The control group received conventional information regarding anaesthesia and surgery. The VR group watched a 4-min video showing Pororo, the famous little penguin, visiting the operating theatre and explaining what is in it. The main outcome was preoperative anxiety, assessed using the modified Yale Preoperative Anxiety Scale (m-YPAS) before entering the operating theatre. Secondary outcomes included induction compliance checklist (ICC) and procedural behaviour rating scale (PBRS) scores during anaesthesia. Results A total of 69 children were included in the analysis, 35 in the control group and 34 in the VR group. Demographic data and induction time were similar in the two groups. Children in the VR group had a significantly lower m-YPAS score than those in the control group (median 31·7 (i.q.r. 23·3–37·9) and 51·7 (28·3–63·3) respectively; P < 0·001). During anaesthesia, the VR group had lower ICC and PBRS scores than the control group. Conclusion This preoperative VR tour of the operating theatre was effective in alleviating preoperative anxiety and increasing compliance during induction of anaesthesia in children undergoing elective surgery. Registration number: UMIN000025232 (http://www.umin.ac.jp/ctr).

Scarless remote access endoscopic and robotic thyroidectomy has been recently performed as a safe and feasible method. However, little is known about the laryngo-pharyngeal complications after surgery and the effect of adjusting the endotracheal tube cuff pressure during surgery on laryngo-pharyngeal complications. Patients were randomized into two groups: the control group (n = 52) and adjusted group (n = 52). The initial cuff pressure was set to 25 mmHg and then monitored without adjustment (control group) or with adjustment at approximately 25 mmHg (adjusted group) throughout surgery. The incidences and severity of postoperative sore throat (POST), hoarseness, dysphagia, and cough were recorded at 1, 6, 24, and 48 h after surgery. Cuff pressures of the control group changed significantly over time and were higher than those of the adjusted group. The incidence of POST was lower in the adjusted group at 24 h postoperatively (p = 0.035), and there was a significant difference in the severity of POST at 6 and 24 h postoperatively between the two groups. There were no differences in the incidence of hoarseness, dysphagia, and cough between the two groups, except dysphagia and cough at 6 h postoperatively. Therefore, intraoperative monitoring and adjustment of the cuff pressure can reduce the incidence of laryngo-pharyngeal complications.

IMPORTANCE: Pediatric patients often encounter anxiety and distress in hospital settings, and virtual reality education, providing a vivid, immersive, and realistic experience, has been introduced to mitigate these anxiety responses. OBJECTIVE: To evaluate whether virtual reality education for pediatric patients before chest radiography could reduce anxiety and distress in children and improve the radiographic process. DESIGN, SETTING, AND PARTICIPANTS: This prospective randomized clinical trial was conducted in a tertiary academic hospital in Seongnam, Republic of Korea. Participants (n = 112) were children aged 4 to 8 years who underwent chest radiography between July 20, 2018, and September 11, 2018. Analysis was performed from October 2, 2018, to April 23, 2019. INTERVENTIONS: Children were randomized to simple verbal instruction (control group) or 3-minute virtual reality education explaining the process of chest radiography in detail and leading to appropriate cooperation (virtual reality group). MAIN OUTCOMES AND MEASURES: The primary outcome was anxiety and distress among pediatric patients based on behavioral observations using the amended version of the Observational Scale of Behavioral Distress scale for radiology procedures (total score of 30, with a score

Maintaining deep neuromuscular block during surgery improves surgical space conditions. However, its effects on patient outcomes have not been well documented. We examined whether maintaining deep neuromuscular blockade during surgery could decrease the stress response compared to moderate neuromuscular blockade. Patients undergoing laparoscopic gastrectomy were randomly allocated to either the moderate (train-of-four counts of 1–2) or deep (post-tetanic counts of 1–2) neuromuscular blockade group. The primary outcome variable was the postoperative blood level of interleukin-6, and the secondary outcome variables were intraoperative or postoperative blood levels of tumor necrosis factor-α, interleukin-1β, interleukin-8, and C-reactive protein. A total of 96 patients were recruited and 88 (44 in each group) were included in the analyses. The levels of tumor necrosis factor-α and interleukin-1β measured at the end of surgery, interleukin-6 and interleukin-8 measured at 2 h postoperatively, and C-reactive protein measured at 48 h postoperatively were all significantly increased compared to the preoperative values, but there were no differences between the moderate and deep neuromuscular block groups. We found no differences in surgical stress response measured using determining levels of interleukin-6 and other mediators released between the moderate and deep neuromuscular blockade groups in patients undergoing laparoscopic gastrectomy.

The aim of this study was to identify factors that are independently associated with the 30-day unplanned readmission rate of patients who underwent elective spine surgery.This study was a retrospective cohort study conducted in a single tertiary academic hospital. The study analyzed the electronic health records of adult patients aged 18 years or older who underwent inpatient elective spine surgery under general anesthesia between January 2010 and March 2018. The primary endpoint was an unplanned readmission within 30 days. The study used uni- and multivariable logistic regression analyses.A total of 7,025 patients were included in the analysis. Among the patients included in the analysis, 215 patients (3.1%) had unplanned readmission within 30 days after being discharged following elective spine surgery. In the complete-case analysis in the multivariable model, the factors associated with a 30-day unplanned readmission were found to be preoperative ASA physical status of ≥ 3 (vs 1) (OR: 2.21, 95% CI: 1.27, 3.84; P = 0.005), cancer (OR: 4.60, 95% CI: 2.72, 7.77; P 0.001), and pRBC transfusion (OR: 1.81, 95% CI: 1.20, 2.71; P = 0.004).The present study showed that preoperative ASA physical status of ≥ 3, diagnosis of cancer, and transfusion of pRBC were associated with an increased 30-day unplanned readmission rate after elective spine surgery.

Annual precipitation in the largely agricultural South-Central United States is characterized by a primary wet season in May and June, a mid-summer dry period in July and August, and a second precipitation peak in September and October. Of the 22 CMIP5 global climate models with sufficient output available, 16 are able to reproduce this bimodal distribution (we refer to these as “BM” models), while 6 have trouble simulating the mid-summer dry period, instead producing an extended wet season (“EW” models). In BM models, the timing and amplitude of the mid-summer westward extension of the North Atlantic Subtropical High (NASH) are realistic, while the magnitude of the Great Plains Lower Level Jet (GPLLJ) tends to be overestimated, particularly in July. In EW models, temporal variations and geophysical locations of the NASH and GPLLJ appear reasonable compared to reanalysis but their magnitudes are too weak to suppress mid-summer precipitation. During warm-season droughts, however, both groups of models reproduce the observed tendency towards a stronger NASH that remains over the region through September, and an intensification and northward extension of the GPLLJ. Similarly, future simulations from both model groups under a +1 to +3 °C transient increase in global mean temperature show decreases in summer precipitation concurrent with an enhanced NASH and an intensified GPLLJ, though models differ regarding the months in which these decreases are projected to occur: early summer in the BM models, and late summer in the EW models. Overall, these results suggest that projected future decreases in summer precipitation over the South-Central region appear to be closely related to anomalous patterns of large-scale circulation already observed and modeled during historical dry years, patterns that are consistently reproduced by CMIP5 models.

Study objective To determine the concentration of desflurane necessary to blunt changes in spectral entropy during surgical incision when two different target-controlled effect-site concentrations of remifentanil (1 and 3ng/ml) were infused. Design Prospective, randomized controlled study. Setting Operating room of a university hospital. Interventions Forty-two patients undergoing general anesthesia for elective surgery were enrolled and randomly allocated to the R1 (1ng/ml of remifentanil, n =21) or R3 (3ng/ml of remifentanil, n =21) group. After at least a 10-min administration of target-controlled remifentanil concentration and predetermined end-tidal desflurane following endotracheal intubation, changes in spectral entropy in response to surgical incision were evaluated. Measurements Concentration of desflurane necessary to blunt changes in spectral entropy during surgical incision for each group was determined using Dixon's up-and-down method. Hemodynamic variables including mean arterial pressure (MAP) and heart rate (HR) were measured. Main results Concentration of desflurane necessary to blunt changes in spectral entropy during surgical incision in 50% of patients (EC 50 ) was 4.1% (95% CI: 3.5–4.7%) for the R1 group and 3.4% (95% CI: 3.0–3.8%) for the R3 group ( P =0.033). Additionally, the calculated EC 95 values using the logistic regression analysis for the R1 and R3 groups were 5.8% (95% CI: 5.0–10.8%) and 5.1% (95% CI: 4.3–10.6%), respectively. MAPs and HRs were significantly higher in the R1 than in the R3 group after surgical incision. Conclusions Desflurane 4.1% with remifentanil 1ng/ml and desflurane 3.4% with remifentanil 3ng/ml significantly blunt the change in spectral entropy after surgical incision in 50% of patients.

Microglial engulfment is a basic function to clean up dead and injured cells and invaders, such as bacteria. This study was designed to assess the effects of isoflurane on the microglial engulfment induced by lipopolysaccharide (LPS) plus interferon-γ (IFN-γ) and the involvement of p38 mitogen-activated protein kinase (MAPK) in these effects. C8-B4 microglial cells were exposed to 1, 2, and 3% isoflurane at 2 h after the initiation of LPS (100 ng/ml) and IFN-γ (1 ng/ml) stimulation. Fluorescent immunostaining was performed to assess the percentage of cells with engulfment of fluorescent microspheres after stimulation for 24 h. P38 and phosphorylated p38 were determined by Western blotting. Isoflurane concentration dependently decreased microglial engulfment stimulated by LPS and IFN-γ. LPS and IFN-γ increased the phosphorylated p38 in microglial cells. This upregulation was decreased by isoflurane. SB203580, a p38 MAPK inhibitor, abolished the LPS-induced and IFN-γ-induced increase of engulfment activity, whereas anisomycin, a p38 MAPK activator, partly reversed the isoflurane-decreased microglial engulfment activity. These results suggest that isoflurane reduces LPS-induced and IFN-γ-induced microglial engulfment and that these effects may be mediated by inhibiting p38 MAPK.

Monitored anesthesia care (MAC) is an anesthesia technique combining local anesthesia with parenteral drugs for sedation and analgesia. The use of MAC is increasing for a variety of diagnostic and therapeutic procedures in and outside of the operating room due to the rapid postoperative recovery with the use of relatively small amounts of sedatives and analgesics compared to general anesthesia. The purposes of MAC are providing patients with safe sedation, comfort, pain control and satisfaction. Preoperative evaluation for patients with MAC is similar to those of general or regional anesthesia in that patients should be comprehensively assessed. Additionally, patient cooperation with comprehension of the procedure is an essential component during MAC. In addition to local anesthesia by operators or anesthesiologists, systemic sedatives and analgesics are administered to provide patients with comfort during procedures performed with MAC. The discretion and judgment of an experienced anesthesiologist are required for the safety and efficacy profiles because the airway of the patients is not secured. The infusion of sedatives and analgesics should be individualized during MAC. Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.

We investigate the response of moist convection to the spatial variation of surface sensible heat flux (SHF) in a mesoscale domain during the evolution of the afternoon convective boundary layer (CBL), using large-eddy simulation. The surface SHF heterogeneity in the domain is analytically created as a function of the spectral slope in the wavelength range from a few tens of kilometres to a few hundreds of metres in the SHF spectrum on a log–log scale. Assuming surface energy balance and spatially uniform available energy, the prescribed SHF has a phase lag of 180° with respect to the latent heat flux (LHF) in the domain. Two sets of three simulations are forced by heterogeneous surface SHF fields, which are characterized by similar statistics. One set, however, is created with a spectral slope of k−3 (where k is wave number) and the other with a slope of k−2. All of the simulations are integrated with the same observation-based initial sounding favourable for moist convection. In all of the k−3-slope cases, early non-precipitating shallow clouds further develop into deep thunderstorms. But in all of the k−2-slope cases, only shallow clouds develop. A key process in the transition to deep convection is the formation of a mesoscale pool of cool and moist air just above the top of the CBL. This high relative humidity (RH) pool is formed by repeated deep penetrations of turbulent plumes into the free atmosphere over a mesoscale surface of high SHF. These cross-scale fluxes, the vertical transports of mesoscale moisture and heat fluctuations by turbulent updraughts, are critical for the formation of the mesoscale pool of high RH. However, these cross-scale fluxes are cancelled out in the process of averaging, and thus appear negligible in the vertical profiles of domain-averaged moisture and heat fluxes.

The degree of neuromuscular blockade is one of the important factors that determine the condition of surgical space during laparoscopic surgery. Magnesium sulfate potentiates the actions of neuromuscular blocking agent, and we hypothesized that intraoperative magnesium sulfate infusion may improve surgical space condition during laparoscopic surgery. Eighty-four patients undergoing elective laparoscopic gastrectomy were randomized to receive isotonic saline (group C) or magnesium sulfate (group M, loading dose with 50 mg/kg over 10 min and then 15 mg/kg/h by continuous infusion) to maintain the moderate neuromuscular blockade using rocuronium. Two experienced surgeons scored the quality of surgical space condition using a 5-point surgical rating scale (SRS). The secondary outcomes included recovery profiles, postoperative pain and adverse events. The SRS in group M was higher than that of group C. The proportion of patients with a SRS of 5 (optimal) was 2.7 % in the group C and 40.5 % in the group M (P

Background Although dexmedetomidine has been used as either the anesthetic agent for light sedation or as an adjunct to other sedatives, no study has investigated the usefulness of dexmedetomidine as the main sedative agent for invasive and painful procedures. The purpose of this study was to compare the safety of dexmedetomidine-remifentanil and propofol-remifentanil during monitored anesthesia care (MAC) for hysteroscopy. Methods Female patients undergoing hysteroscopy were randomly assigned to either the dexmedetomidine (group D) or the propofol group (group P). The study drug (0.6 ml/kg; dexmedetomidine 2 μg/ml or propofol 4 mg/ml) was loaded for 10 minutes followed by 0.1 to 0.5 ml/kg/hour to maintain a bispectral index of 60 to 80 during the procedure. In both groups, remifentanil was infused using a target-controlled-infusion system with a target concentration of 2 ng/ml and titrated during the procedure. The incidence rates of intraoperative respiratory depression in both groups were compared. Postoperative pain and patients satisfaction were also compared. Results A total of 69 female patients were included in this study. Dexmedetomidine significantly decrease the incidence of respiratory depression compared with propofol (15/34 [44.1%] vs 5/35 [14.3%], P = .006, group P and D, respectively). Postoperative pain and patients satisfaction score did not differ between the groups. Conclusion The combination of dexmedetomidine-remifentanil can reduce the incidence of respiratory depression without increasing hemodynamic complications compared with propofol-remifentanil for MAC during hysteroscopy.

Virtual reality (VR), a technology that provides a stimulated sensory experience, has recently been implemented in various fields of medicine. Several studies have investigated the efficacy of VR on preoperative anxiety. The purpose of this meta-analysis was to validate whether VR could relieve preoperative anxiety in patients undergoing surgery. Electronic databases were searched to identify all randomized controlled trials (RCTs) investigating the effect of VR on preoperative anxiety. The primary outcome was defined as the preoperative anxiety scores. We estimated the effect size using the standard mean difference (SMD) with a 95% confidence interval (CI) using a random effect model. Ultimately, 10 RCTs, with a total of 813 patients, were included in the final analysis. Preoperative anxiety was significantly lower in the VR group than in the control group (SMD &minus, 0.64, 95% CI &minus, 1.08 to &minus, 0.20, p = 0.004). In a subgroup analysis, the preoperative anxiety scores were lower in the VR group than in the control group in pediatric patients (SMD &minus, 0.71, 95% CI &minus, 1.14 to &minus, 0.27, p = 0.002), whereas a significant difference was not observed between the two groups in adult patients (p = 0.226). The results of this meta-analysis indicated that VR could decrease preoperative anxiety, especially in pediatric patients.

Non-steroidal anti-inflammatory drugs (NSAIDs) can be used as opioid alternatives for patient-controlled analgesia (PCA). However, their use after nephrectomy has raised concerns regarding possible nephrotoxicity. This study compared postoperative renal function and postoperative outcomes between patients using NSAID and patients using opioids for PCA in nephrectomy. In this retrospective observational study, records were reviewed for 913 patients who underwent laparoscopic or robot-assisted laparoscopic nephrectomy from 2015 to 2017. After propensity score matching, 247 patients per group were analyzed. Glomerular filtration rate (GFR) percentages (postoperative value divided by preoperative value), blood urea nitrogen (BUN)/creatinine ratios, and serum creatinine percentages were compared at 2 weeks, 6 months, and 1 year after surgery between users of NSAID and users of opioids for PCA. Additionally, postoperative complication rates, postoperative acute kidney injury (AKI) incidences, postoperative pain scores, and lengths of hospital stay were compared between groups. Postoperative GFR percentages, BUN/creatinine ratios, and serum creatinine percentages were similar between the two groups. There were no significant differences in the rates of postoperative complications, incidences of AKI, and pain scores at 30 min, 6 h, 48 h, or 7 days postoperatively. The length of hospital stay was significantly shorter in the NSAID group than in the opioid group. This study showed no association between the use of NSAID for PCA after laparoscopic nephrectomy and the incidence of postoperative renal dysfunction.

Skull-pin head-holder application during neurosurgery is a highly noxious stimulus that may lead to abrupt hemodynamic change, which is an unfavorable response to maintain hemodynamics stability. The aim of this meta-analysis was to evaluate the effects of intravenous dexmedetomidine on hemodynamic response (blood pressure and heart rate) resulting from the application of skull-pin head-holder in neurosurgery.A systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The protocol was registered with the International Prospective Register of Systematic Reviews (CRD 420119127876). Electronic databases were searched, without discrimination of publication year, language, and region, to identify all randomized controlled trials investigating the effects of dexmedetomidine on hemodynamic response resulting from skull-pin head-holder application during general anesthesia for neurosurgery. The mean arterial pressure and heart rate were analyzed using random-effect model, and the mean difference (MD) was calculated.Seventeen trials were identified; a total of 878 patients were enrolled. The analysis indicated that dexmedetomidine infusion reduced the mean arterial pressure (MD -11.70, 95% confidence interval [CI] -16.33 to -7.07, p 0.00001) and heart rate (MD -14.48, 95% CI -23.10 to -5.86, p = 0.001) during skull-pin head-holder application. Subgroup analysis showed that dexmedetomidine was superior to fentanyl for the attenuation of hemodynamic response. Dexmedetomidine infusion also reduced the incidence of hypertension, tachycardia and brain relaxation score.The result of this analysis indicates that intraoperative dexmedetomidine administration could decrease the hemodynamic response and provide hemodynamic stability during skull-pin head-holder application in neurosurgery.

Thyroid storm (TS) is a life-threatening emergency endocrine condition. Thyroid hormones should be normalized before thyroidectomy is performed in patients with Graves&rsquo, disease. However, thyroid hormone levels are inevitably high in patients undergoing surgery. This study analyzed differences in vital sign changes during thyroidectomy between patients with controlled and uncontrolled Graves&rsquo, disease and assessed thyroid hormone cutoffs for TS. Preoperative levels of the thyroid hormones free T4 (FT4), T3, and thyroid stimulating hormone (TSH) were retrospectively analyzed in patients who underwent total thyroidectomy for Graves&rsquo, disease. Patients were divided into those with uncontrolled Graves&rsquo, (UG) disease, defined as preoperative TSH &lt, 0.3 &micro, IU/mL and FT4 &gt, 1.7 ng/dL, those with controlled Graves&rsquo, (CG) disease, those with extremely uncontrolled Graves&rsquo, (EUG) disease, defined as TSH &lt, 3.4 ng/dL, and finally, those without EUG (non-EUG). The 29 patients with Graves&rsquo, disease included 12 with CG group and 17 with UG. FT4 and T3 concentrations were significantly higher in the UG group. There were no differences in vital sign and anesthetic agent. These 29 patients could also be divided into those with (n = 4) and without EUG (n = 25). The mean age was lower (21.5 vs. 40.9 years, p &lt, 0.001) and the mean operation time was shorter (121.4 vs. 208.8 min, p = 0.003) in the EUG group. Requirements for anesthetic agents were greater in the EUG group. Mean FT4 concentration in the EUG group was 3.8 ng/dL, and there were no changes in vital signs during surgery. Vital sign change during thyroid surgery was not observed in patients with uncontrolled Graves&rsquo, disease up to the twice upper normal limit of T4 level.

The purpose of this study was to compare the incidence of airway complications between extubation under deep anesthesia (deep extubation) and extubation when fully awake (awake extubation) in pediatric patients after general anesthesia. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement standards. The review protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD 42018090172). Electronic databases were searched, without discrimination of publication year and language, to identify all randomized controlled trials investigating airway complications following deep or awake extubation after general anesthesia. The Cochrane tool was used to assess the risk of bias of trials. Randomized trials investigating airway complications of deep extubation compared with awake extubation after general anesthesia with an endotracheal tube and laryngeal mask airway (LMA) were sought. Overall airway complications, airway obstruction, cough, desaturation, laryngospasm and breath holding were analyzed using random-effect modelling. The odds ratio was used for these incidence variables. Seventeen randomized trials were identified, and a total of 1881 pediatric patients were enrolled. The analyses indicated deep extubation reduces the risk of overall airway complications (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33&ndash, 0.96, p = 0.04), cough (OR 0.30, 95% CI 0.12&ndash, 0.72, p = 0.007) and desaturation (OR 0.49, 95% CI 0.25&ndash, 0.95, p = 0.04) in children after general anesthesia. However, deep extubation increased the risk of airway obstruction compared with awake extubation (OR 3.38 CI 1.69&ndash, 6.73, p = 0.0005). No difference was observed in the incidence of laryngospasm and breath-holding between the two groups regardless of airway device. The result of this analysis indicates that deep extubation may decrease the risk of overall airway complications including cough and desaturation but may increase airway obstruction compared with awake extubation in pediatric patients after general anesthesia. Therefore, deep extubation may be recommended in pediatric patients to minimize overall airway complications except airway obstruction and the clinicians may choose the method of extubation according to the risk of airway complications of pediatric patients.

The use of gamification in healthcare has been gaining popularity. This prospective, randomized, clinical trial was designed to evaluate whether gamification of the preoperative process&mdash, via virtual reality (VR) gaming that provides a vivid, immersive and realistic experience&mdash, could reduce preoperative anxiety in children. Seventy children scheduled for elective surgery under general anesthesia were randomly divided into either the control or gamification group. Children in the control group received conventional education regarding the preoperative process, whereas those in the gamification group played a 5 min VR game experiencing the preoperative experience. Preoperative anxiety, induction compliance checklist (ICC), and procedural behavior rating scale (PBRS) were measured. Sixty-nine children were included in the final analysis (control group = 35, gamification = 34). Preoperative anxiety (28.3 [23.3&ndash, 36.7] vs. 46.7 [31.7&ndash, 51.7], p &lt, 0.001) and intraoperative compliance measured using ICC (p = 0.038) were lower in the gamification group than in the control group. However, PBRS (p = 0.092) and parent/guardian satisfaction (p = 0.268) were comparable between the two groups. VR experience of the preoperative process could reduce preoperative anxiety and improve compliance during anesthetic induction in children undergoing elective surgery and general anesthesia.

Elevated high-sensitivity C-reactive protein (hsCRP) levels are known to be associated with a poor prognosis for cancer patients, but inadequate data exist regarding whether pre- or postoperative hsCRP levels have better predictive value after oncologic surgery. This study evaluated the associations between pre- and postoperative hsCRP levels and 90-day postoperative mortality among patients who underwent surgery for abdominal or thoracic cancers.This retrospective cohort study included 7933 patients who underwent elective surgery between January 2010 and December 2016. Cox regression analysis and receiver operative characteristic curve analyses were used to evaluate the prognostic values of preoperative hsCRP ( 1 month before surgery) and postoperative hsCRP ( 3 days after surgery).For predicting 90-day mortality, the area under the receiver operating characteristic curve was significantly larger for preoperative hsCRP than for postoperative hsCRP [0.76; 95% confidence interval (CI) 0.71-0.81 vs 0.65 95% CI 0.57-0.72; P 0.001]. The optimal cutoff values were 0.5 mg/dL for preoperative hsCRP and 9.7 mg/dL for postoperative hsCRP. Based on these cutoff values, increased risks of 90-day mortality were significantly associated with preoperative hsCRP levels higher than 0.5 mg/dL [hazard ratio (HR) 7.60; 95% CI 4.43-13.03; P 0.001] and postoperative hsCRP levels higher than 9.7 mg/dL (HR 1.83; 95% CI 1.12-2.98; P = 0.016).Both elevated pre- and postoperative hsCRP levels were associated with increased risks of 90-day mortality after surgery for thoracic and abdominal cancer. However, preoperative hsCRP had better prognostic value than postoperative hsCRP.

We examined the use of neostigmine for reversing shallow (defined as train-of-four ratio of 0.5), cisatracurium- and rocuronium-induced neuromuscular block in 112 patients, by use of 0 μg.kg(-1) , 10 μg.kg(-1) , 20 μg.kg(-1) or 40 μg.kg(-1) dose of neostigmine for reversal. The times from neostigmine administration to train-of-four ratios of 0.7, 0.9 and 1.0 were evaluated. Analysis of variance showed that the duration of action was significantly longer after cisatracurium compared with rocuronium. The time to reach a train-of-four ratio of 1.0 was significantly shorter with neostigmine 40 μg.kg(-1) compared with lower neostigmine doses, and at this dose the time did not differ between cisatracurium and rocuronium. The recovery time from a train-of-four ratio of 0.5-1.0 did not differ between cisatracurium and rocuronium, and was significantly shortened by the administration of neostigmine. We conclude that a neostigmine dose of 40 μg.kg(-1) was the most effective at reducing recovery time after neuromuscular blockade.

OBJECTIVE: The abacus, first used in Asian countries more than 800 years ago, enables efficient arithmetic calculation via visuospatial configuration. We investigated whether abacus-trained children performed better on cognitive tasks and demonstrated higher levels of arithmetic abilities compared to those without such training. METHODS: We recruited 75 elementary school children (43 abacus-trained and 32 not so trained). Attention, memory, and arithmetic abilities were measured, and we compared the abacus with the control group. RESULTS: Children who had learned to use an abacus committed fewer commission errors and showed better arithmetic ability than did controls. We found no significant differences between children with and without abacus training in other areas of attention. CONCLUSION: We speculate that abacus training improves response inhibition via neuroanatomical alterations of the areas that regulate such functions. Further studies are needed to confirm the association between abacus training and better response inhibition.

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.

Acute postoperative pain and chronic discomfort are reported after robotic or endoscopic thyroidectomy. The purpose of this prospective, randomized, and double-blinded clinical trial was to investigate whether intraoperative infusion of nefopam decreases acute postoperative pain and chronic discomfort following either a robotic or endoscopic thyroidectomy via the bilateral axillo-breast approach (BABA). Patients were randomized into two groups: The control group (n = 29) or the nefopam group (n = 29). Patients in each group were infused with the same volume of saline or nefopam (0.2 mg/kg bolus, 120 μg/kg/h continuous infusion) during surgery. Acute postoperative pain, the need for rescue analgesics, and other postoperative adverse effects were assessed at 1, 6, 24, and 48 h postoperatively. Chronic pain and discomfort was recorded at 3 months after surgery. Patients in the nefopam group reported lower pain scores in the neck, as well as the axilla and anterior chest areas at 1, 6, 24, and 48 h postoperatively, when compared with the control group (P

Fluoroscopy (FL)-guided lumbar sympathetic ganglion block (LSGB) is widely performed to diagnose and manage various diseases associated with sympathetically maintained pain. Recently, numerous ultrasound (US)-assisted procedures in pain medicine have been attempted, showing an advantage of low radiation exposure. This randomized, prospective trial compared the procedural outcomes and complications between FL-guided and US-assisted LSGBs.Fifty LSGBs were randomly divided into 2 groups: FL-guided (FL group) or US-assisted (US group) LSGB group. Both groups received FL-guided or US-assisted LSGB with 10 mL of 0.25% levobupivacaine. The primary end point was the total procedure time. Secondary outcomes were success rate, imaging time, onset time (based on temperature rise), dosage of radiation exposure, other procedure-related outcomes, and complications.Total procedure time and success rate were not statistically different between the 2 groups, whereas imaging time of the US group was longer than that of the FL group (P = .012). The onset time was faster in the US group (P = .019), and bone touching during the procedure was less frequent in the US group (P = .001). Moreover, radiation exposure was significantly lower in the US group than in the FL group (P.001). No serious complications were reported in all patients.US-assisted LSGB appears to be a feasible method with the added benefit of lower radiation exposure. In our study, we did not find an advantage of US-assisted LSGB over FL-guided LSGB in terms of performance time.

In 41 healthy volunteers, we investigated the cross-sectional area (CSA) of the subclavian vein (SCV) in the following head positions: neutral and 30° head rotation toward the contralateral or ipsilateral sides. Significant differences were observed in the CSA of the SCV at 3 different head positions: contralateral 30° versus neutral, -0.05 cm (95% confidence interval, -0.08 to -0.03); contralateral 30° versus ipsilateral 30°, -0.15 cm (-0.19 to -0.12); neutral versus ipsilateral 30°, -0.10 cm (-0.13 to -0.07); all Pcorrected< .001). For SCV catheterization, 30° head rotation to the ipsilateral side provided significant improvements in the CSA compared with the other head positions.

Background Spinal cord ischemic injury remains a serious complication of open surgical and endovascular aortic procedures. Simvastatin has been reported to be associated with neuroprotective effect after spinal cord ischemia-reperfusion (IR) injury. The aim of this study was to determine the therapeutic efficacy of starting simvastatin after spinal cord IR injury in a rat model. Methods In adult Sprague-Dawley rats, spinal cord ischemia was induced using a balloon-tipped catheter placed in the descending thoracic aorta. The animals were then randomly divided into 4 groups: group A (control); group B (0.5 mg/kg simvastatin); group C (1 mg/kg simvastatin); and group D (10 mg/kg simvastatin). Simvastatin was administered orally upon reperfusion for 5 days. Neurological function of the hind limbs was evaluated for 7 days after reperfusion and recorded using a motor deficit score (MDS) (0: normal, 5: complete paraplegia). The number of normal motor neurons within the anterior horns of the spinal cord was counted after final MDS evaluation. Then, the spinal cord was harvested for histopathological examination. Results Group D showed a significantly lower MDS than the other groups at post-reperfusion day 1 and this trend was sustained throughout the study period. Additionally, a greater number of normal motor neurons was observed in group D than in other groups (group D 21.2 [3.2] vs. group A: 15.8 [4.2]; group B 15.4 [3.4]; and group C 15.5 [3.7]; P = 0.002). Conclusions The results of the current study suggest that 10 mg/kg can significantly improve neurologic outcome by attenuating neurologic injury and restoring normal motor neurons after spinal cord IR injury.

We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy. The 60 enrolled patients were randomly assigned to the control (n = 32) or nefopam (n = 28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption. The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08 ± 0.05 μg/kg/min) than in the control group (0.13 ± 0.06 μg/kg/min) (P

The use of lidocaine in spinal anesthesia may increase the risk of transient neurological symptoms (TNS) according to previous meta-analyses. However, the previous meta-analyses lacked data on some other local anesthetics and thus, more evaluations are still needed to compare the effect of lidocaine on the development of TNS. The objective of this study was to compare the risk of TNS according to lidocaine versus other local anesthetics in patients undergoing spinal anesthesia. A total of 39 randomized controlled trials with 4733 patients were analyzed. The incidence of TNS was 10.8% in the lidocaine group and was 2.2% in the control groups (risk ratio (RR) 4.12, 95% confidence interval (CI) 3.13 to 5.43, p &lt, 0.001). In subgroup analysis, lidocaine increased the incidence of TNS compared with other local anesthetics except mepivacaine, ropivacaine or sameridine. The risk of TNS was higher in the hyperbaric (p &lt, 0.001) or isobaric lidocaine (p &lt, 0.001) group compared with the control group, but there were no differences found between the two groups when hypobaric lidocaine was administered (p = 1.00). This study confirmed that lidocaine for spinal anesthesia still causes TNS more frequently than most other local anesthetics, especially when hyperbaric or isobaric lidocaine was used.

We evaluate the ability of global climate models participating in phase 5 of the Coupled Model Intercomparison Project (CMIP5) to reproduce observed seasonality and interannual variability of temperature over the Caribbean, and compare these with simulations from atmosphere-only (AMIP5) and previous-generation CMIP3 models. Compared to station and gridded observations, nearly every CMIP5, CMIP3 and AMIP5 simulation tends to reproduce the primary inter-regional features of the Caribbean annual temperature cycle. In most coupled model simulations, however, boreal summer temperature lags observations by about 1 month, with a similar lag in the simulated annual cycle of sea surface temperature (SST), and a systematic cold bias in both climatological annual mean air temperature and SST. There is some improvement from CMIP3 to CMIP5 but the bias is still marked compared to AMIP5 and observations, implying that biases in the annual temperature cycle may originate in the ocean component of the coupled models. This also suggests a tendency for models to over-emphasize the influence of SSTs on near-surface temperature, a bias that may be exacerbated by model tendency to over-estimate ocean mixed layer depth as well. In contrast, we find that both coupled and atmosphere-only models tend to reasonably simulate the response of observed temperature to global temperature, to regional and large-scale variability across the Caribbean region and the Gulf of Mexico, and even to more remote Atlantic and Pacific influences. These findings contribute to building confidence in the ability of coupled models to simulate the effect of global-scale change on the Caribbean.

Robotic thyroidectomy (RoT) is frequently performed due to its excellent cosmesis and recovery features. However, postoperative pain in the operating field after RoT remains a concern due to extensive tissue dissection and tension during the operation. The aim of this study was to evaluate the anterior chest pain and the effect of levobupivacaine spraying on postoperative pain control after bilateral axillo-breast approach (BABA) RoT. We randomized 55 adult patients scheduled for BABA RoT into the control group (group C, n = 27) or the levobupivacaine group (group L, n = 28). At the end of surgery, patients in groups C and L were sprayed with the same volume (30 ml) of normal saline and 0.25 % levobupivacaine, respectively, on the flap dissection area. Pain scores, the consumption of patient-controlled analgesia (PCA), and other adverse effects were assessed at 1, 6, 24, and 48 h postoperatively. Patients in group L showed lower pain scores than those of group C at 1 h (50 [0–100] vs. 80 [20–100]; p = 0.004), 6 h (30 [0–90] vs. 70 [30–90]; p

We performed a multicenter, randomized, double-blind trial to assess the efficacy and safety of a single, fixed, intravenous dose of palonosetron (0.075 mg) in the treatment of established postoperative nausea and vomiting (PONV).Three hundred and eighty-four patients who had at least one risk factors of PONV and underwent surgery under general anesthesia were screened. Those who developed PONV were randomized to receive either 0.075 mg intravenous palonosetron or a placebo. The incidence of nausea and vomiting, severity of nausea, requirements for rescue anti-emetics, and adverse effects at 2, 24, and 72 h after drug administration were evaluated. Complete response (CR) and complete control (CC) rate were compared for 24 and 72 h.Among the 384 patients, 152 (39.6 %) developed PONV and were randomized to either the palonosetron (n = 75) or placebo (n = 77) group. The number of patients with CR at 24 and 72 h was higher in the palonosetron group than the placebo group [0-24 h: n = 49 (68.1 %) vs. n = 30 (40.5 %), p0.001; 0-72 h: n = 47 (65.3 %) vs. n = 28 (37.8 %), p0.001]. The incidence of PONV at 2, 24, and 72 h periods was lower in the palonosetron group than the placebo group (29.2, 45.8, and 50.0 % in the palonosetron group vs. 50.0, 62.2, and 66.2 % in the placebo group, p = 0.010, 0.048, 0.047, respectively). The incidence of adverse events was not different between the groups.A single 0.075 mg IV dose of palonosetron effectively increased the CR rates at 24 and 72 h in these moderate-risk patients with established PONV.

Objective This study evaluated whether adding a preoperative single thoracic paravertebral block (TPVB) to intravenous patient-controlled analgesia (IV PCA) would improve postoperative analgesia compared with using IV PCA alone in patients undergoing nephrectomy. Design Prospective, randomized, controlled, observer-blinded trial. Setting University hospital. Subjects Thirty-four adult patients undergoing elective open nephrectomy. Methods The patients were randomized to receive a TPVB plus IV PCA (group T) or IV PCA alone (group C). A single 18-mL injection of 0.75% ropivacaine was administered preoperatively under ultrasound guidance; fentanyl was used for IV PCA. Each patient's postoperative pain score based on a verbal numerical rating scale, postoperative fentanyl consumption, inspiratory volume by incentive spirometry, and complications were evaluated at 1, 3, 6, 12, and 24 hours after surgery. Changes in heart rate (HR), systolic arterial pressure (SAP), and mean arterial pressure (MAP) were evaluated following skin incision. Results The postoperative pain score and fentanyl consumption were significantly lower in group T than in group C at all time points up to 24 hours after surgery. The postoperative inspiratory volumes were not significantly different. The changes in HR were similar, while the increases in SAP and MAP after skin incision were lower in group T than in group C. Conclusions A preoperative single TPVB improved postoperative analgesia by reducing the postoperative pain score and fentanyl consumption in patients undergoing nephrectomy.

Background This study determined the dose of remifentanil to use during insertion of a Classic™ laryngeal mask airway (LMA, The Laryngeal Mask Co., Nicosia, Cyprus) in elderly patients during emergency airway management when combined with a single dose of propofol. Methods Patients aged 65-80 years were enrolled. Anesthesia was induced with propofol 1 mg/kg, and then a blinded dose of remifentanil was infused over 30 s after confirming the patient's loss of consciousness. The dose of remifentanil was determined using Dixon's up-and-down method, starting at 0.5 µg/kg (a step size of 0.1 µg/kg). Insertion of the LMA was attempted 60 s after loss of consciousness. Results In total, 23 patients were recruited and the mean age ± standard deviation was 72 ± 3 years. The effective dose for successful LMA insertion in 50% of the patients (ED50) was 0.20 ± 0.05 µg/kg. No patient needed more than 0.3 µg/kg. Conclusions Remifentanil 0.20 ± 0.05 µg/kg with propofol 1 mg/kg resulted in excellent LMA insertion in 50% of elderly patients without significant hemodynamic changes during emergency airway management.