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BACKGROUND: Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. METHODS: We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. RESULTS: There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of

Background: Despite significant technological advances in the implantable pulse generator (IPG), complications can still occur. We report a case that unexpected extrusion of the IPG of spinal cord stimulation (SCS) was promptly identified and successfully removed without any complications. Case: After a car accident 4 years ago, a 55-year-old man who was diagnosed with complex local pain syndrome in his right leg. The SCS was inserted with 2 leads, with the IPG being implanted in the right lower abdomen region. Four years later, he developed extrusion of the IPG from his abdominal region. This unexpected extrusion may have been related to pressure necrosis caused by continued compression of pocket site where a belt was frequently tied. The IPG and the leads were successfully removed without infection occurring. Conclusions: To prevent unexpected extrusion of IPG, it is necessary to consider in advance whether the pocket site is pressed against the belt.

Background Nasotracheal intubation is the most commonly used method to secure the field of view when performing surgery on the oral cavity or neck. Like orotracheal intubation, nasotracheal intubation uses a laryngoscope. Hemodynamic change occurs due to the stimulation of the sympathetic nervous system. Recently, video laryngoscope with a camera attached to the end of the direct laryngoscope blade has been used to minimize this change. In this study, we investigated the optimal effect-site concentration (Ce) of remifentanil for minimizing hemodynamic responses during nasotracheal intubation with a video laryngoscope. Methods Twenty-one patients, aged between 19 and 60 years old, scheduled for elective surgery were included in this study. Anesthesia was induced by slowly injecting propofol. At the same time, remifentanil infusion was initiated at 3.0 ng/ml via target-controlled infusion (TCI). When remifentanil attained the preset Ce, nasotracheal intubation was performed using a video laryngoscope. The patient's blood pressure and heart rate were checked pre-induction, right before and after intubation, and 1 min after intubation. Hemodynamic stability was defined as an increase in systolic blood pressure and heart rate by 20% before and after nasotracheal intubation. The response of each patient determined the Ce of remifentanil for the next patient at an interval of 0.3 ng/ml. Results The Ce of remifentanil administered ranged from 2.4 to 3.6 ng/ml for the patients evaluated. The estimated optimal effective effect-site concentrations of remifentanil were 3.22 and 4.25 ng/ml, that were associated with a 50% and 95% probability of maintaining hemodynamic stability, respectively. Conclusion Nasotracheal intubation using a video laryngoscope can be successfully performed in a hemodynamically stable state by using the optimal remifentanil effect-site concentration (Ce50 , 3.22 ng/ml; Ce95 , 4.25 ng/ml).

Background Preterm labor and miscarriage may occur in stressful situations, such as a surgical operation or infection during pregnancy. Pharyngeal and buccal abscess and facial bone fractures are inevitable dental surgeries in pregnant patients. Remifentanil is an opioid analgesic that is commonly used for general anesthesia and sedation. Nonetheless, no study has investigated the effects of remifentanil on amniotic epithelial cells. This study evaluated the effects of remifentanil on the factors related to uterine contraction and its mechanism of action on amniotic epithelial cells. Methods Amniotic epithelial cells were preconditioned at various concentrations of remifentanil for 1 h, followed by 24-h lipopolysaccharide (LPS) exposure. MTT assays were performed to assess the cell viability in each group. The effects of remifentanil on factors related to uterine contractions in amniotic epithelial cells were assessed using a nitric oxide (NO) assay, western blot examinations of the expression of nuclear factor-kappa B (NF-κB), cyclooxygenase 2 (COX2), and prostaglandin E2 (PGE2), and RT-PCR examinations of the expression of the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNF-α). Results Remifentanil did not affect viability and nitric oxide production of amniotic epithelial cells. Western blot analysis revealed that remifentanil preconditioning resulted in decreased expressions of NF-κB and PGE2 in the cells in LPS-induced inflammation, and a tendency of decreased COX2 expression. The results were statistically significant only at high concentration. RT-PCR revealed reduced expressions of IL-1β and TNF-α. Conclusions Preconditioning with remifentanil does not affect the viability of amniotic epithelial cells but reduces the expression of factors related to uterine contractions in situations where cell inflammation is induced by LPS, which is an important inducer of preterm labor. These findings provide evidence that remifentanil may inhibit preterm labor in clinical settings.

Purpose Colon perfusion status is one of the most important factors for the determination of postoperative anastomotic complications. Colonic hypoperfusion can be induced by inferior mesenteric artery (IMA) ligation in some patients. This study aimed to evaluate atherosclerotic risk assessment and vascular parameters of CT angiography as predictors of colonic hypoperfusion. Methods This prospective study was conducted at a tertiary referral hospital and included 46 rectosigmoid colon cancer patients undergoing laparoscopic anterior resection between August 2013 to July 2014. Atherosclerotic risk scores were assessed using the Framingham cardiovascular risk score system. The IMA length, branching pattern, atherosclerotic calcification, and intermesenteric artery and mesenteric vascular diameters were evaluated using CT angiography. Mesenteric marginal artery pressures were measured before and after IMA clamping. The mean arterial pressure (MAP) index was calculated by dividing the mesenteric marginal MAP into the systemic MAP to determine the mesenteric hypoperfusion status after IMA clamping. A critically low MAP index was defined as

Eun-Ji Choi,1,2 Soon Ji Park,1 Yeong-Min Yoo,1 Ji-Uk Yoon,1,2 Sang-Wook Shin,1,2 Gyeong-Jo Byeon1,2 1Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea; 2Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of KoreaCorrespondence: Gyeong-Jo ByeonDepartment of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Geumoro 20, Yangsan, Gyeongnam, 50612, Republic of KoreaTel +82-55-360-2129Fax +82-55-360-2149Email byeongj@pusan.ac.krBackground: Transforaminal epidural steroid injections (TF-ESIs) effectively deliver small amounts of drugs to inflamed sites via the ventral epidural space. However, there is a high risk of nerve damage as the needle narrowly approaches the spinal nerve. Therefore, we devised an oblique interlaminar (OIL) approach as an alternative method. We compared the efficacy of fluoroscopic-guided OIL-ESIs with that of TF-ESIs in the management of lower back and unilateral lumbosacral radicular pain.Materials and Methods: Sixty-six patients were randomized to receive a fluoroscopic-guided ESI either through the OIL (n = 33, group OIL) or TF (n = 33, group TF) approach. They were evaluated for effective pain relief using the visual analogue scale (VAS) and for functional improvement using the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). Other outcome measures were the presence of ventral and contralateral spread of contrast, patients’ satisfaction, and adverse events.Results: There were no significant differences between the groups in the VAS, ODI, and RMDQ scores during the 12-week period. The differences in the ODI and RMDQ scores before and after the treatment were higher in group TF than in group OIL. The contralateral spread of contrast was higher in group OIL than in group TF. There were no significant differences in the other outcomes between the groups.Conclusion: ESIs delivered through the OIL approach are equally effective in pain relief and functional improvement as those delivered via the TF approach in the management of low back and unilateral lumbosacral radicular pain.Keywords: epidural analgesia, fluoroscopy, low back pain, radicular pain, steroid injection

BACKGROUND Liver transplantation (LT) has the incidence of 30-day mortality about 5-10%, Jo et al. reported that 30-day mortality and 1-year mortality for DDLT were 30%, and 39% respectively. It is not easy to create a model for predicting post-transplantation outcomes based on pretransplant variables. MELD does not take into account individual complications such as hepatic encephalopathy (HE), and research has shown that the greater the severity of pretransplant HE, the lower the survival rate after LT; the importance of monitoring for HE is therefore emphasized. METHODS The medical records of adult patients who underwent deceased donor LT (DDLT) were retrospectively reviewed for analysis of the effect of HE on the long-term survival rate of post-transplant for more than 1 year. RESULTS Presence of HE is not statistically associated to patient survival (P=0.062), but the hazard ratio is 1.954 (95% CI, 0.968, 3.943). In addition, the severe HE group significantly decreased survival compared to the non-HE group, and the cumulative 1- and 3-year overall survival rates were 80.9% and 78.7%, respectively, in non HE group, and 65.7% and 56.1%, respectively, in severe HE group (P=0.031). CONCLUSIONS Severe HE is a factor influencing the long-term survival over 3 years in the patients who underwent DDLT. Although prospective validation should be conducted to determine the prognostic value of HE severity, efforts could be made to reduce the severity of HE before DDLT, and consider severity of HE rather than MELD score in DDLT allocation.

Background Perioperative respiratory failure occurs frequently in liver transplantation (LT) recipients. Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been applied in patients with acute and potentially reversible life-threatening respiratory failure that is unresponsive to conventional therapies. VV-ECMO is used as a bridging device for lung transplantation. However, there are few reports on VV-ECMO as bridging therapy in LT patients with respiratory failure. This study assessed patient outcomes of VV-ECMO after LT and investigated its applicability and safety in LT surgery. Methods From January 2017 to May 2019, VV-ECMO was applied in 8 deceased donor LT patients at Pusan National University Yangsan Hospital. Results Patients administered pre- or postoperative VV-ECMO showed a 50% 1-year survival rate and 75% success rate for ECMO weaning. Six patients were administered preoperative VV-ECMO for respiratory failure, of whom 4 patients survived for longer than a year. Two patients who received VV-ECMO for refractory hypoxia during LT died; 1 failed ECMO weaning, and the other was successfully weaned off ECMO but died of other causes. Conclusion VV-ECMO could lower the risk of hypoxemia-related organ failure while awaiting and during LT via better controlled gas exchange without significant acute morbidity. VV-ECMO may expand operability in patients with severe respiratory failure awaiting LT.

Endotracheal intubation is commonly associated with laryngeal injury that often resolves spontaneously without any complication. However, stenosis or granulomatous lesions are generally found on the tracheal wall or vocal process at the tube cuff level, caused by excessive cuff pressure. We present a case of fatal vocal cord granuloma leading to dyspnea following orthognathic surgery and sustained intubation for 14 hours.

An 87-year-old woman was referred for the extraction of residual teeth and removal of tori prior to prosthetic treatment. After surgery under general anesthesia, the surgical tape was removed to detach the bispectral index sensor and the hair cover. After the surgical tape was removed, skin injury occurred on the left side of her face. After epidermis repositioning and ointment application, a dressing was placed over the injury. Her wound was found to have healed completely on follow-up examination. Medical adhesive related skin injury (MARSI) is a complication that can occur after surgery and subjects at the extremes of age with fragile skin are at a higher risk for such injuries. Careful assessment of the risk factors associated with MARSI is an absolute necessity.

Background The structure and function of bone tissue is maintained through a constant remodeling process, which is maintained by the balance between osteoblasts and osteoclasts. The failure of bone remodeling can lead to pathological conditions of bone structure and function. Remifentanil is currently used as a narcotic analgesic agent in general anesthesia and sedation. However, the effect of remifentanil on osteoclasts has not been studied. Therefore, we investigated the effect of remifentanil on pre-osteoclast (pre-OCs) differentiation and the mechanism of osteoclast differentiation in the absence of specific stimulus. Methods Pre-OCs were obtained by culturing bone marrow-derived macrophages (BMMs) in osteoclastogenic medium for 2 days and then treated with various concentration of remifentanil. The mRNA expression of NFATc1 and c-fos was examined by using real-time PCR. We also examined the effect of remifentanil on the osteoclast-specific genes TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. Finally, we examined the influence of remifentanil on the migration of pre-OCs by using the Boyden chamber assay. Results Remifentanil increased pre-OC differentiation and osteoclast size, but did not affect the mRNA expression of NFATc1 and c-fos or significantly affect the expression of TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. However, remifentanil increased the migration of pre-OCs. Conclusions This study suggested that remifentanil promotes the differentiation of pre-OCs and induces maturation, such as increasing osteoclast size. In addition, the increase in osteoclast size was mediated by the enhancement of pre-OC migration and cell fusion.

Background Liver transplantation (LT) is a complicated procedure with a high incidence of postoperative acute kidney injury (AKI). Previous studies indicate that even transient or mild post-LT AKI can result in critical conditions, including prolonged stays in hospitals and intensive care units and increased morbidity and mortality. The aim of this study was to investigate the association between body mass index (BMI) and occurrence of AKI in LT recipients. Methods Medical data from 203 patients who received LT surgery from January 2010 to August 2016 in a single university hospital setting were retrospectively collected and analyzed. Patients were classified as either underweight (BMI

Excess reactive oxygen species are detrimental to wound repair. Remifentanil decreases reactive oxygen species generation and inflammatory response; however, its effects on oxidative cell injury are not completely understood. Therefore, we investigated the effects of remifentanil on human keratinocytes under hydrogen peroxide-induced oxidative stress and the correlation of these effects with autophagy.Human keratinocytes (HaCaT cell line) were randomly assigned to four groups: control, hydrogen peroxide, remifentanil pretreatment + hydrogen peroxide, and 3-methyladenine + remifentanil pretreatment + hydrogen peroxide. The MTT assay was performed to analyze cell viability. Apoptotic cell death was measured by Hoechst staining. A scratch assay was used to measure cell migration. The role of autophagy was ascertained by autophagosome staining and western blot analysis of autophagy-related proteins.Compared with the control group, the hydrogen peroxide group showed decreased cell viability, which was improved by remifentanil pretreatment. Hydrogen peroxide-induced apoptotic cell death and delayed cell migration were also improved by remifentanil pretreatment. Western blot analysis showed that the expression of autophagy-related proteins significantly increased in the remifentanil pretreatment + hydrogen peroxide group compared with that in the hydrogen peroxide group.This study demonstrated that remifentanil pretreatment ameliorates hydrogen peroxide-induced oxidative injury in human keratinocytes. In addition, our results show that the antioxidative effect of remifentanil against hydrogen peroxide-induced oxidative injury was mediated by autophagy.

BACKGROUND The catheter-through-needle (CTN) method involves the insertion of a catheter with an outer diameter smaller than the initial puncture hole. We investigated whether the catheter-over-needle (CON) method is more effective than the CTN method in local anesthetic leakage at the catheter insertion site and catheter dislodgement, and how it affects postoperative pain management. METHODS Seventy patients scheduled to undergo continuous femoral nerve block for pain control following total knee arthroplasty were enrolled and randomized to receive a perineural catheterization with either the CTN method (group CTN) or CON method (group CON). After ultrasound-guided catheterization, the transparent securement dressing was attached. The study compared the CON and CTN methods in terms of leakage at the catheter insertion site, catheter dislodgement, and postoperative analgesic efficacy for 48 hours postoperatively. RESULTS Leakage at the catheter insertion site was significantly lower in the group CON (P

Patients with cleft lip and palate (CLP) must undergo corrective surgeries during infancy and early childhood. Many patients with CLP undergo orthognathic surgery during their childhood for correction of skeletal asymmetries or pharyngoplasty with a pharyngeal flap to improve the quality of speech and velopharyngeal function. During orthognathic surgeries, nasotracheal intubation is performed under general anesthesia. In our case report, the patient had undergone palatoplasty and pharygoplasty previously. During the orthognathic surgery, a flexible fiberoptic bronchoscope-guided nasotracheal tube was inserted through the pharyngeal flap ostium; however, active bleeding occurred in the nasopharynx. Bleeding occurred because the flap was torn. After achieving hemostasis, the surgery was completed successfully. Thus, if a patient may show the potential for velopharyngeal port obstruction, nasotracheal intubation should be performed with utmost care.

Background Reactive oxygen species play critical roles in homeostasis and cell signaling. Dexmedetomidine, a specific agonist of the α2-adrenoceptor, has been commonly used for sedation, and it has been reported to have a protective effect against oxidative stress. In this study, we investigated whether dexmedetomidine has a protective effect against H2O2-induced oxidative stress and the mechanism of H2O2-induced cell death in normal human fetal osteoblast (hFOB) cells. Methods Cells were divided into three groups: control group-cells were incubated in normoxia without dexmedetomidine, hydrogen peroxide (H2O2) group-cells were exposed to H2O2 (200 µM) for 2 h, and Dex/H2O2 group-cells were pretreated with dexmedetomidine (5 µM) for 2 h then exposed to H2O2 (200 µM) for 2 h. Cell viability and apoptosis were evaluated. Osteoblast maturation was determined by assaying bone nodular mineralization. Expression levels of bone-related proteins were determined by western blot. Results Cell viability was significantly decreased in the H2O2 group compared with the control group, and this effect was improved by dexmedetomidine. The Hoechst 33342 and Annexin-V FITC/PI staining revealed that dexmedetomidine effectively decreased H2O2-induced hFOB cell apoptosis. Dexmedetomidine enhanced the mineralization of hFOB cells when compared to the H2O2 group. In western blot analysis, bone-related protein was increased in the Dex/H2O2 group. Conclusions We demonstrated the potential therapeutic value of dexmedetomidine in H2O2-induced oxidative stress by inhibiting apoptosis and enhancing osteoblast activity. Additionally, the current investigation could be evidence to support the antioxidant potential of dexmedetomidine in vitro.

We report cardiac arrest due to obstruction of the right ventricular outflow tract (RVOT) caused by an RVOT mass that was not identified preoperatively. A 62-year-old woman with renal cell carcinoma (RCC) experienced deteriorating hypotension and bradycardia during radical nephrectomy. Hemodynamic stability was maintained on extracorporeal membrane oxygenation, and after surgery, she was transferred to the intensive care unit. On postoperative day 3, transthoracic echocardiography showed an intracardiac mass obstructing the RVOT, which caused severe functional pulmonary stenosis and moderate resting pulmonary hypertension. Despite maintaining extracorporeal membrane oxygenation, the patient died of cardiac arrest. Our findings suggest that it may be necessary to perform additional tests if RCC has invaded the renal vein and inferior vena cava or if a patient with RCC has abnormal cardiovascular symptoms without definite etiology for exclusion of cardiac metastasis or tumor thrombus. In addition, intraoperative transesophageal echocardiography might be the procedure of choice for the evaluation of these conditions because other diagnostic tests are difficult to perform during surgery. In conclusion, for patients with acute hemodynamic instability for whom other possible causes have been excluded, we recommend that anesthesiologists use transesophageal echocardiography to detect outflow tract obstruction or pulmonary thromboembolism and perform anesthetic management.

Background This study investigated the effect of remifentanil pretreatment on Cos-7 cells exposed to oxidative stress, and the influence of remifentanil on intracellular autophagy and apoptotic cell death. Methods Cells were divided into 4 groups: (1) Control: non-pretreated cells were incubated in normoxia (5% CO2, 21% O2, and 74% N2). (2) H2O2: non-pretreated cells were exposed to H2O2 for 24 h. (3) RPC+H2O2: cells pretreated with remifentanil were exposed to H2O2 for 24 h. (4) 3-MA+RPC+H2O2: cells pretreated with 3-Methyladenine (3-MA) and remifentanil were exposed to H2O2 for 24 h. We determined the cell viability of each group using an MTT assay. Hoechst staining and FACS analysis of Cos-7 cells were performed to observe the effect of remifentanil on apoptosis. Autophagy activation was determined by fluorescence microscopy, MDC staining, and AO staining. The expression of autophagy-related proteins was observed using western blotting. Results Remifentanil pretreatment increased the viability of Cos-7 cells exposed to oxidative stress. Hoechst staining and FACS analysis revealed that oxidative stress-dependent apoptosis was suppressed by the pretreatment. Additionally, fluorescence microscopy showed that remifentanil pretreatment led to autophagy-induction in Cos-7 cells, and the expression of autophagy-related proteins was increased in the RPC+H2O2 group. Conclusions The study showed that remifentanil pretreatment stimulated autophagy and increased viability in an oxidative stress model of Cos-7 cells. Therefore, we suggest that apoptosis was activated upon oxidative stress, and remifentanil preconditioning increased the survival rate of the cells by activating autophagy.

SummaryThe overall incidence of cardiac tumor is very low, and malignant cardiac tumors account for only 25% of all cardiac tumors. Angiosarcomas are the most common type of malignant cardiac tumors, characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels and lining irregular blood-filled spaces. We present a 26-year-old man with angiosarcoma involving the right atrium, which was misdiagnosed as aortic intramural hematoma by computed tomography, finally confirmed by transesophageal echocardiography during the operation.

Background Nefopam is a non-opioid non-steroidal centrally acting analgesic. This study was conducted to assess the analgesic efficacy of intravenous patient-controlled analgesia (IV-PCA) using nefopam alone, compared with a combination of morphine and ketorolac, after laparoscopic gynecologic surgery. Methods Sixty patients undergoing laparoscopic gynecologic surgery received IV-PCA. Group A (n = 30) received IV-PCA with a combination of morphine 60 mg and ketorolac 180 mg, while group B (n = 30) received nefopam 200 mg (basal rate 1 ml/h, bolus 1 ml, and lockout time 15 min for both). The primary outcome evaluated was analgesic efficacy using the visual analogue scale (VAS). Other evaluated outcomes included the incidence rate of postoperative nausea and vomiting (PONV), patient satisfaction of pain control, percentage of patients requiring additional opioids, and incidence rate of postoperative adverse effects. Results Group B was not inferior to group A in relation to the VAS in the post-anesthesia care unit, and at 12, 24, and 48 h after surgery (mean difference [95% confidence interval], 0.50 [-0.43 to 1.43], -0.30 [-1.25 to 0.65], -0.05 [-0.65 to 0.55], and 0.10 [-0.55 to 0.75], respectively). The incidence rate of nausea was lower in group B than in group A at 12 and 24 h after surgery (P = 0.004 and P = 0.017, respectively). There were no significant differences in the other outcomes between groups. Conclusions IV-PCA using nefopam alone has a non-inferior analgesic efficacy and produces a lower incidence of PONV in comparison with IV-PCA using a combination of morphine and ketorolac after laparoscopic gynecologic surgery.

Background. Percutaneous radiofrequency ablation (PRFA) is a useful and safe treatment for hepatocellular carcinoma (HCC). Pain management, during and after PRFA, is a critical component of patient care. Objectives. This study reviewed the efficacy of thoracic epidural analgesia, during and after PRFA, for patients with HCC. Study Design. A retrospective, observational chart review. Setting. Tertiary medical center/teaching hospital. Methods. Patients who had undergone PRFA for HCC in the past 5 years were divided into two groups, based on the type of anesthesia administered: thoracic epidural anesthesia group (Group E) and local anesthesia with monitored anesthesia care group (Group C). We retrospectively reviewed changes in the numeric rating scale (NRS) score during and after PRFA, opioid consumption, length of the procedure, length of hospital stay, changes in blood pressure during PRFA, and the incidence of adverse events. Results. The NRS score in Group E was significantly lower than that in Group C (P<0.05). The opioid consumption in Group E was lower than that in Group C after PRFA (P<0.05). The procedure time was shorter in Group E (P<0.05). Neither of the groups showed significant difference with respect to the length of hospital stay and the incidence of respiratory depression, fever, and blood pressure elevation. The incidence of nausea, vomiting, and voiding difficulty was higher in Group E. Limitations. This study is limited by its retrospective design. Conclusions. Thoracic epidural analgesia was associated with shorter procedure times, lower postprocedural pain, and lower opioid consumption during and after PRFA for HCC.

Introduction Thromboelastography (TEG) is gaining increasing acceptance in liver transplantation (LT) with conventional coagulation tests (CCTs) such as prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin III (ATIII), platelet count (PLT), and fibrinogen concentration. The purpose of this study was to evaluate the clinical utility of TEG in LT and investigate the correlation between TEG and CCT values during each phase of LT. Materials and methods Medical records of patients who underwent deceased donor LT at a single, university hospital between October 2010 and July 2015 were retrospectively reviewed. Blood samples were obtained at each phase of LT (pre-anhepatic, anhepatic, and neo-hepatic phase) according to our institutional LT protocol and utilized for analysis of TEG and CCTs. The Spearman correlation coefficient between TEG and CCT values were obtained. Results During the pre-anhepatic phase, the reaction time (R), PT, and aPTT did not correlate with each other, but demonstrated a negative correlation with PLT. Clot formation time (K) demonstrated a similar correlation with R and a negative correlation with fibrinogen. The maximal amplitude (MA) and α-angle (α) were positively correlated with PLT and fibrinogen and inversely correlated with aPTT. During the anhepatic phase, MA was significantly correlated with PLT and inversely correlated with aPTT; other parameters had weak or indistinct correlation. During the neo-hepatic phase, R and K were significantly correlated with aPTT and inversely correlated with PLT and fibrinogen. A correlation of MA and α with PLT, aPTT, and fibrinogen was also observed. Clot lysis at 30 minutes and estimated percent lysis were inversely correlated with levels of ATIII and fibrinogen. Conclusions Conventional coagulation tests and TEG show particularly poor comparability during the anhepatic period of liver transplantation. TEG can be most reliable in the anhepatic phase, during which dynamic hemostatic changes occur.

Remifentanil is commonly used in operating rooms and intensive care units for the purpose of anesthesia and sedation or analgesia. Although remifentanil may significantly affect the bone regeneration process in patients, there have been few studies to date on the effects of remifentanil on bone physiology. The purpose of this study was to investigate the effects of remifentanil on osteoclast differentiation and bone resorption. Bone marrow-derived macrophages (BMMs) were cultured for 4 days in remifentanil concentrations ranging from 0 to 100 ng/ml, macrophage colony-stimulating factor (M-CSF) alone, or in osteoclastogenic medium to induce the production of mature osteoclasts. To determine the degree of osteoclast maturity, tartrate-resistant acid phosphatase (TRAP) staining was performed. RT-PCR and western blotting analyses were used to determine the effect of remifentanil on the signaling pathways involved in osteoclast differentiation and maturation. Bone resorption and migration of BMMs were analyzed to determine the osteoclastic activity. Remifentanil reduced the number and size of osteoclasts and the formation of TRAP-positive multinuclear osteoclasts in a dose-dependent manner. Expression of c-Fos and NFATC1 was most strongly decreased in the presence of RANKL and remifentanil, and the activity of ERK was also inhibited by remifentanil. In the bone resorption assay, remifentanil reduced bone resorption and did not significantly affect cell migration. This study shows that remifentanil inhibits the differentiation and maturation of osteoclasts and reduces bone resorption.

BACKGROUND: Infusion methods during regional analgesia using perineural catheters may influence the quality of postoperative analgesia. This study was conducted to compare the effects of combined or bolus-only infusion of 0.2% ropivacaine on the postoperative analgesia in interscalene brachial plexus block (ISBPB) with perineural catheterization. METHODS: Patients scheduled for arthroscopic rotator cuff repair were divided into two groups, one that would receive a combined infusion (group C, n = 32), and one that would receive intermittent infusion (group I, n = 32). A perineural catheter was inserted into the interscalene brachial plexus (ISBP) using ultrasound (US) and nerve stimulation, and 10 ml of 0.2% ropivacaine was administered. After the operation, group C received a continuous infusion of 4 ml/h, and a 4 ml bolus with a lockout interval of 60 min. Group I received only a 4 ml bolus, and the lockout interval was 30 min. Postoperative pain by the numeric rating scale (NRS) and the forearm muscle tone by the manual muscle test (MMT) were checked and evaluated at the following timepoints: preoperative, and postoperative 1, 4, 12, 24, 36, and 48 h. Supplemental opioid requirements, total consumed dose of local anesthetic, and adverse effects were compared between the two groups. RESULTS: Sixty-four patients completed the study and the postoperative values such as operation time, time to discharge, and operation site were comparable. There were no differences in NRS scores and supplemental opioid requirements between the two groups. The MMT scores of group I at 4 and 12 h after surgery were significantly higher than those of group C (P < 0.05). The total consumed dose of local anesthetic was significantly lower in group I than in group C (P < 0.05). The adverse effects were not different between the groups. CONCLUSIONS: The bolus-only administration of 0.2% ropivacaine provided a similar analgesic effect with a lower total volume of local anesthetic and decreased motor weakness compared to combined infusion. Therefore, bolus-only administration is an effective postoperative analgesic method in ISBPB with perineural catheterization after rotator cuff repair.

Background: Ischemia-reperfusion of bone occurs in a variety of clinical conditions, such as orthopedic arthroplasty, plastic gnathoplasty, spinal surgery, and amputation. Usually, cellular models of hypoxia-reoxygenation reflect in vivo models of ischemia-reperfusion. With respect to hypoxia-reoxygenation conditions, the effects of remifentanil on osteogenesis have received little attention. Therefore, we investigated the effects of remifentanil on the proliferation and differentiation of osteoblasts during hypoxic-reoxygenation. Methods: After remifentanil (0.1, 1 ng/mL) preconditioning for 2 hours, human osteoblasts were cultured under 1% oxygen tension for 24 hours. Thereafter, the cells were reoxygenated for 12 hours at 37 °C. The naloxone groups were treated with naloxone for 30 minutes before remifentanil treatment. We measured cell viability via MTT assay. Osteoblast maturation was determined by assay of bone nodular mineralization. Quantitative PCR and western blot methods were used to determine BMP-2, osteocalcin, Akt, type I collagen, osterix, TGF-β1, HIF-1α, and RUNX2 expression levels. Results: Osteoblast viability and bone nodular mineralization by osteoblasts is recovered by remifentanil preconditioning from hypoxia-reoxygenation insult. During hypoxic-reoxygenation condition, remifentanil preconditioning induced the expression of BMP-2, osteocalcin, Akt, type I collagen, osterix, TGF-β1, HIF-1α, and RUNX2 in osteoblasts. Conclusions: Under hypoxia-reoxygenation conditions, remifentanil preconditioning enhanced the cell viability and maturation of osteoblasts, and stimulated the expression of proteins associated with osteoblast proliferation and differentiation of the osteoblast. Our results suggest that remifentanil may help in the treatment of bone stress injuries.

Human dermal fibroblast is essential in wound healing of the skin through the synthesis of extracellular matrix proteins. With respect to oxidative stress, the effects of remifentanil on human dermal fibroblast have received little attention. Therefore, we investigated the effects of remifentanil on the apoptosis and autophagic reaction of human dermal fibroblasts under oxidative stress. The subjects were divided into the following groups: Control group: cells were incubated at 37°C in a humidified atmosphere with 5% CO2. Hydrogen peroxide (H2O2) group: cells were exposed to H2O2 for 2 h. RPC/H2O2 group: cells were pretreated with remifentanil for 2 h and exposed H2O2 for 2 h. 3-MA/RPC/H2O2 group: cells were pretreated with 3-methyladenine (3-MA) and remifentanil for 1 h and 2 h, respectively. We measured cell viability using MTT assay. Western blot analysis was used to determine the expression levels of proteins associated with apoptosis and autophagy. Quantification of apoptotic cells was performed using flow cytometer analysis, and autophagic vacuoles were observed under a fluorescence microscope. Remifentanil treatment increased the proliferation of human dermal fibroblast and decreased apoptotic cell death, enhancing autophagic activity under oxidative stress. However, 3-MA, the autophagy pathway inhibitor, inhibited the protective effect of remifentanil in oxidative stress. This study demonstrates that remifentanil activated autophagy and decreased apoptotic death of human dermal fibroblasts under oxidative stress. Our results suggest that remifentanil may help in the treatment of oxidative stress.

Background The skin consists of tightly connected keratinocytes, and prevents extensive water loss while simultaneously protecting against the entry of microbial pathogens. Excessive cellular levels of reactive oxygen species can induce cell apoptosis and also damage skin integrity. Propofol (2,6-diisopropylphenol) has antioxidant properties. In this study, we investigated how propofol influences intracellular autophagy and apoptotic cell death induced by oxidative stress in human keratinocytes. Method The following groups were used for experimentation: control, cells were incubated under normoxia (5% CO2, 21% O2, and 74% N2) without propofol; hydrogen peroxide (H2O2), cells were exposed to H2O2 (300 µM) for 2 h; propofol preconditioning (PPC)/H2O2, cells pretreated with propofol (100 µM) for 2 h were exposed to H2O2; and 3-methyladenine (3-MA)/PPC/H2O2, cells pretreated with 3-MA (1 mM) for 1 h and propofol were exposed to H2O2. Cell viability, apoptosis, and migration capability were evaluated. Relation to autophagy was detected by western blot analysis. Results Cell viability decreased significantly in the H2O2 group compared to that in the control group and was improved by propofol preconditioning. Propofol preconditioning effectively decreased H2O2-induced cell apoptosis and increased cell migration. However, pretreatment with 3-MA inhibited the protective effect of propofol on cell apoptosis. Autophagy was activated in the PPC/H2O2 group compared to that in the H2O2 group as demonstrated by western blot analysis and autophagosome staining. Conclusion The results suggest that propofol preconditioning induces an endogenous cellular protective effect in human keratinocytes against oxidative stress through the activation of signaling pathways related to autophagy.

The benefits of an anesthesia pre-operative evaluation clinic (APEC) based on outpatients are well described in previous literatures. In the majority of hospitals in South Korea, preoperative anesthetic evaluation for surgical patients is limited to hospitalized patients on the day before surgery. Thus, we would like to share our institutional experience of implementing an APEC based on outpatients and report on the attitudes and satisfaction of the medical staff (surgeons).A 2-page survey was distributed to all specialists and resident physicians involved in surgery at a single university hospital during a 3-month period. A 5-point Likert scale of agreement and an open-ended question examined perceptions of APEC. A total of 123 questionnaires were distributed and 67 surveys were collected over a 3-month period with a 54.5% collection rate. The surgeons' perceptions of APEC are summarized in . It is difficult to state the tendency of surgeons' perception of the clinic, including workload, patient satisfaction, patient safety, necessity, cost-effectiveness, and efficiency through this survey. However, many surgeons chose to comment on suggestions to improve the quality of the APEC through the open-ended question.The surgeons' attitude and satisfaction to anesthetic services including APEC are an important component of achieving quality improvement. Although it is difficult to state the tendency of surgeons' perception of the clinic, including workload, patient satisfaction, patient safety, necessity, cost-effectiveness, and efficiency through this survey, continuous assessment and feedback may improve efficiency of the APEC and affect patient perception as well.

Ultrasound (US)-guided continuous interscalene brachial plexus block (CBPB) is known to provide effective pain relief for arthroscopic rotator cuff repair. This study was conducted to compare analgesic efficacy and forearm muscle tone of the basal infusion rate and bolus dose of 0.2 % ropivacaine for US-guided CBPB with intravenous patient-controlled analgesia (IV-PCA). In a prospective trial, 99 patients scheduled to undergo arthroscopic rotator cuff repair were divided into three groups. In groups A and B, an US-guided 17-gauge Tuohy needle was inserted into the interscalene brachial plexus. A loading dose of 10 ml 0.2 % ropivacaine was administered via the needle. A 19-gauge perineural catheter was then inserted through the needle and advanced to a depth of 1.5 cm beyond the needle tip between the C5 and C6 nerve trunks. After surgery, groups A and B received a continuous infusion of 0.2 % ropivacaine at 4 or 0 ml/h, a bolus of 0 or 4 ml, and a lockout time of 60 min through the catheter, respectively. Group C received IV-PCA. Pain scores and the forearm muscle tone of patients were compared using a numeric rating scale (NRS), rates of patients taking supplementary opioid analgesics, and manual muscle test (MMT) scoring. The NRS scores and rate of patients taking supplementary opioid analgesics in groups A and B were lower than those in group C after surgery. Groups A and B showed similar clinical efficacy. There were no significant differences in MMT scoring among the three groups. The bolus dose of 0.2 % ropivacaine using US-guided CBPB would provide equivalent analgesic efficacy comparable with the basal infusion and motor weakness comparable with IV-PCA after arthroscopic rotator cuff repair.