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OBJECTIVES We investigated the safety and efficacy of continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic lobectomy for left lung cancer in preventing recurrent laryngeal nerve injury. METHODS From August 2015 to March 2020, 22 patients with left lung cancer without CIONM (unmonitored) and 20 patients with left lung cancer with CIONM underwent thoracoscopic lobectomy with complete mediastinal lymph node dissection including 4L dissection. Clinical outcomes from these 2 groups were compared. RESULTS The incidence of 4L metastasis was 7.14% (3 patients). There was no significant difference in the total number of dissected 4L lymph nodes between the 2 groups (3.23 ± 2.2 in the unmonitored group, 3.95 ± 2.0 in the CIONM group). CIONM was successful in all of the cases. There was no significant difference in the incidence of postoperative vocal cord palsy (22.7% in the unmonitored group, 20% in the CIONM group, P = 1.000). All of the 5 patients (100%) had permanent vocal cord palsy in the unmonitored group. Although statistically insignificant, 75% (3 patients) had total recovery of the vocal cord function, with only 1 patient remaining in permanent vocal cord palsy in the CIONM group. CONCLUSIONS CIONM was safe and efficient. CIONM might be helpful to avoid permanent vocal cord palsy by immediately warning the surgeon about impending nerve injury, so the surgeon can stop delivering further injury to the recurrent laryngeal nerve.

We hypothesized that when a right-handed operator catheterizes the left internal jugular vein (IJV), the tip of the needle might be positioned closer to the center of the vessel after puncture if the operator is standing in the patient's left axillary line, rather than standing cephalad to the patient.The study randomly allocated 44 patients undergoing elective surgery under general anesthesia with planned left central venous catheterization to either conventional (operator stood cephalad to the patient) or intervention (operator stood in the patient's axillary line) groups. The left IJV was catheterized by 18 anesthesiologists. The distance between the center of the vessel and the needle tip, first-attempt success rate, and procedure time were compared.The distance from the needle tip to the center of the IJV after needle puncture was 3.5 (1.9-5.5) and 3.2 (1.7-4.9) cm in the conventional and intervention groups, respectively (P = .47). The first-attempt success rate was significantly higher in the intervention group (100% vs 68.2%, P = .01). Overall time to successful guidewire insertion was faster in the intervention group (P = .007).There was no significant difference in needle tip position when the right-handed operator was standing in the patient's left axillary line compared to standing cephalad to the patient during left IJV catheterization. However, it increased the first-attempt success rate and reduced the overall time for guidewire insertion.

Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine‐glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle‐twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine‐glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine‐glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 μV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 μV and 1177.2 ± 572.7 μV, respectively. Neostigmine‐glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine‐glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.

BACKGROUND Accurate identification of the cricothyroid membrane is crucial for successful cricothyroidotomy. The aim of this study was to compare the conventional downward and modified upward laryngeal handshake techniques in terms of accuracy to identify the cricothyroid membrane in nonobese female patients. METHODS In 198 anesthetized female patients, the cricothyroid membrane was identified by either the conventional downward laryngeal handshake technique (n = 99) or the modified upward laryngeal handshake technique (n = 99). According to the conventional downward laryngeal handshake technique, the cricothyroid membrane was identified by palpating the neck downward from the greater cornu of the hyoid bone, thyroid laminae, and cricoid cartilage. According to the modified upward laryngeal handshake technique, the cricothyroid membrane was located by moving up from the sternal notch. The primary outcome was the accuracy of identifying the cricothyroid membrane. Secondary outcomes included the accuracy of midline identification and time taken to locate what participants believed to be the cricothyroid membrane. The primary and secondary outcomes according to the technique were analyzed using generalized estimating equations. RESULTS The cricothyroid membrane could be identified more accurately by the modified upward laryngeal handshake technique than by the conventional downward technique (84% vs 56%, respectively; odds ratio [OR], 4.36; 95% confidence interval [CI], 2.13-8.93; P < .001). Identification of the midline was also more accurate by the modified laryngeal handshake than by the conventional technique (96% vs 83%, respectively; OR, 4.98; 95% CI, 1.65-15.01; P = .004). The time taken to identify the cricothyroid membrane was not different between the conventional and modified techniques (20.2 [16.2-26.6] seconds vs 19.0 [14.5-26.4] seconds, respectively; P = .83). CONCLUSIONS The modified upward laryngeal handshake technique that involved tracing the trachea and laryngeal structures upward from the sternal notch was more accurate in identifying the cricothyroid membrane than the conventional downward technique in anesthetized female patients.

BACKGROUND: Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve (RLN) injury by providing the surgeon with real-time feedback on nerve stimulation during dissection. We applied a disposable adhesive patch electrode to a dissecting instrument to transfer electrical stimulation to the dissecting instrument for IONM during thyroid surgery. This study aimed to evaluate the feasibility of using the patch stimulator approach for IONM during thyroid surgery. METHODS: We reviewed the medical records of patients who underwent thyroidectomy using both conventional stimulator and adhesive patch stimulator for IONM. The electromyography (EMG) amplitudes of the vagal and the RLNs before (V1, R1) and after thyroid resection (V2, R2) were alternatively checked with each type of stimulator at the same location of each nerve. RESULTS: Fifteen consecutive patients (4 males, 11 females) were included in this analysis, and a total of 38 nerves (19 vagus nerves and 19 RLNs) were evaluated. No statistically significant differences were seen in the mean amplitudes evoked by the patch stimulator and the conventional probe stimulator for the V1 signal (825.5±394.6 vs. 821.8±360.9 µV, P=0.954), R1 signal (1,044.8±471.2 vs. 1,039.2±507.4 µV, P=0.898), R2 signal (1,037.8±495.0 vs. 938.2±415.8 µV, P=0.948), or V2 signal (812.5±391.9 vs. 787.3±355.7 µV, P=0.975). CONCLUSIONS: The patch stimulator was safely and effectively used for IONM during thyroid surgery and provided similar nerve monitoring responses as the conventional stimulator. This approach may be used to enhance the surgeon’s convenience during thyroid surgery.

This prospective observational study investigated the optimal insertion depth of the central venous catheter through the right internal jugular vein using transesophageal echocardiography. After tracheal intubation, the anesthesiologist inserted a probe for esophageal echocardiography into the patient’s esophagus. The investigators placed the catheter tip 2 cm above the crista terminalis with echocardiography, which was defined as the optimal point. We measured the inserted length of the catheter. Pearson correlation tests were performed with the measured optimal depth and some patient parameters. We made a new formula for placing the catheter at the optimal position. A total of 89 subjects were enrolled in this trial. The correlation coefficient between the measured optimal depth and the patient’s parameters was highest for patient height (0.703, p

Maneuvers for preventing passive regurgitation of gastric contents are applied to effectively occlude the esophagus throughout rapid sequence induction and intubation. The aim of this randomized, crossover study was to investigate the effectiveness of cricoid and paratracheal pressures in occluding the esophagus through induction of anesthesia and videolaryngoscopy.After the induction of anesthesia in 40 adult patients, the location of the esophageal entrance relative to the glottis and location of the upper esophagus relative to the trachea at the low paratracheal region were assessed using an ultrasonography, and the outer diameter of the esophagus was measured on ultrasound before and during application of cricoid and paratracheal pressures of 30 N. Then, videolaryngoscopy was performed with the application of each pressure. During videolaryngoscopy, location of the esophageal entrance relative to the glottis under cricoid pressure was examined on the screen of videolaryngoscope, and the upper esophagus under paratracheal pressure was evaluated using ultrasound. The occlusion rate of the esophagus, and the best laryngeal view using the percentage of glottic opening scoring system were also assessed during videolaryngsocopy. Esophageal occlusion under each pressure was determined by inserting an esophageal stethoscope into the esophagus. If the esophageal stethoscope could not be advanced into the esophagus under the application of each pressure, the esophagus was regarded to be occluded.During videolaryngoscopy, esophagus was occluded in 40 of 40 (100%) patients with cricoid pressure and 23 of 40 (58%) patients with paratracheal pressure (difference, 42%; 95% confidence interval, 26-58; P.001). Both cricoid and paratracheal pressures significantly decreased the diameter of the esophagus compared to no intervention in the anesthetized paralyzed state ( P.001, respectively). Ultrasound revealed that the compressed esophagus by paratracheal pressure in the anesthetized paralyzed state was partially released during videolaryngoscopy in 17 of 40 patients, in whom esophageal occlusion was unsuccessful. The best laryngeal view was not significantly different among the no intervention, cricoid pressure, and paratracheal pressure (77 [29] % vs 79 [30] % vs 76 [31] %, respectively; P = .064).The occlusion of the upper esophagus defined by inability to pass an esophageal stethoscope was more effective with cricoid pressure than with paratracheal pressure during videolaryngoscopy, although both cricoid and paratracheal pressures reduced the diameter of the esophagus on ultrasound in an anesthetized paralyzed state.

Surgical outcomes of patients with thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus transoral robotic thyroidectomy (TORT) were compared.Patients who underwent TOETVA or TORT between July 2016 and February 2022 were retrospectively analyzed. TOETVA and TORT groups were propensity score-matched (1:1) based on age, sex, body mass index, surgical extent, tumor size, and presence of thyroiditis.A total of 185 patients underwent transoral thyroidectomy (142 TOETVA and 43 TORT). Final diagnoses consisted of 135 papillary and seven follicular thyroid carcinomas in the TOETVA group and 43 papillary thyroid carcinomas in the TORT group (p = 0.138). Mean operative time was shorter for the TOETVA group than the TORT group (106.3 vs. 158.9 min, p 0.001), whereas mean hospital stay was longer for the TOETVA group than the TORT group (2.2 vs. 1.9 days, p = 0.031). After 1:1 propensity score matching, each group included 43 patients. Mean operative time was shorter in the TOETVA group than the TORT group (106.2 vs. 158.9 min, p 0.001), whereas mean hospital stay was longer in the TOETVA group (2.3 vs. 1.9 days, p = 0.031). There was no significant difference in vocal cord palsy incidences between the groups (one transient, one permanent in the TOETVA group vs. none in the TORT group, p = 0.359). The learning curve was 71 cases for TOETVA and 25 cases for TORT.TOETVA had shorter mean operative time, and TORT had shorter learning curve and shorter mean hospital stay. Surgeons should be familiar with the advantages and disadvantages of each procedure.

Background For successful lighted stylet intubation, bending the lighted stylet with an appropriate angle is a prerequisite. The purpose of this study was to compare three different bend angles of 70, 80, and 90 degrees for lighted stylet intubation. Methods The patient trachea was intubated with a lighted stylet bent at 70, 80, or 90 degrees according to the randomly allocated groups (group I, II, and III, respectively). A lighted stylet combined with a tracheal tube was prepared with a bend angle of 70, 80, or 90 degrees according to the assigned group. We checked the success rate at the first attempt and overall success rate for the two attempts. Additionally, we measured search time, which was time from insertion of the bent union into the patient mouth to the start of advancing the tracheal tube while separating it from the lighted stylet, and evaluated postoperative sore throat (POST) at 2, 4, and 24 h after the recovery from anesthesia. Results There was no statistically significant difference between group I, II, and III for success rate at first attempt (73.9 %, 88.2 %, and 94.7 %, respectively, p = 0.178), even though there was a trend of increasing success rate with increasing bend angles. For overall success rate, there was similar result to that in the first attempt between the groups I, II, and III (82.6 %, 94.1 %, and 100 %, respectively, p = 0.141). However, search time took significantly longer in group I than groups II and III (p p = 0.016, and 0.4 vs. 1.8, p = 0.011, respectively). Conclusions The bend angle of the lighted stylet affected the time required for tracheal intubation and POST in our study. 80 and 90 degrees as a bend angle seem to be acceptable for clinicians in regard to success rate of lighted stylet intubation. Considering the success rate of lighted stylet intubation and POST, the bend angle of 80 degrees might be better than 70 and 90 degrees. Trial registration ClinicalTrials.gov Identifier NCT03693235, registered on 30 September 2018.

OBJECTIVES/HYPOTHESIS To compare effect of 1 and 2 mg/kg of sugammadex on the incidence of intraoperative bucking and intraoperative neuromonitoring (IONM) quality in thyroid surgery. STUDY DESIGN Randomized controlled trial. METHODS Patients qualified for thyroid surgery with IONM were eligible for this double-blind, randomized, controlled trial. After tracheal intubation with 0.6 mg/kg rocuronium, 1 or 2 mg/kg of sugammadex was administered to patients in group I or II, respectively. The quality of the IONM for the external branch of the superior laryngeal nerve (EBSLN) was evaluated (strong/intermediate/weak). The initial amplitude of electromyography for the vagus nerve (V1) and the recurrent laryngeal nerve (R1) were recorded. Intraoperative bucking movements was recorded. RESULTS A total of 102 patients (51 in each group) completed the study. Time from sugammadex administration to initial checking for the EBSLN was not different between group I and II (25.0 ± 7.9 vs. 25.5 ± 9.0 minutes, P = .788). There was no difference in the neuromonitoring quality for the EBSLN between group I and II (strong/intermediate/weak: 46/5/0 vs. 50/1/0, P = .205). The amplitudes of V1 (1,086.3 ± 673.3 μV vs. 1,161.8 ± 727.5 μV, P = .588) and R1 (1,328.2 ± 934.1 μV vs. 1,410.5 ± 919.6 μV, P = .655) were comparable between the groups. Patients who experienced bucking were significantly fewer in the group I than the group II (13.7% vs. 35.3%, P = .020). CONCLUSION A dose of 1 mg/kg sugammadex induced less bucking than 2 m/kg while providing comparable IONM quality during thyroid surgery. LEVEL OF EVIDENCE 2 Laryngoscope, 131:2154-2159, 2021.

Background The cross-sectional area of the subclavian vein (csSCV) is a crucial factor in the successful catheterization of the subclavian vein. This randomized controlled study investigated the effects of the csSCV on landmark-based subclavian vein catheterization. Methods This study was performed using a two-stage protocol. During stage I, the csSCV was measured in 17 patients placed in the supine, 20° ipsilateral tilt, and 20° contralateral tilt positions in a random order. During stage II, landmark-based subclavian vein catheterization was randomly performed in patients placed in either the supine (group S, n = 107) or the ipsilateral tilt (group I, n = 109) position. The primary outcome measure was the csSCV in stage I and the primary venipuncture success rate in stage II. Secondary outcome measures were the time to successful venipuncture, the total catheterization time, the first-pass success rate, and the incidence of mechanical complications during catheterization. Results The csSCV was significantly larger in the ipsilateral tilt than in either the supine or contralateral tilt position (1.01 ± 0.35 vs. 0.84 ± 0.32 and 0.51 ± 0.26 cm2, P = .006 and P = .344). There were also no significant differences in the secondary outcome measures of the two groups. Conclusions The csSCV was significantly larger in patients placed in the ipsilateral tilt than in the supine position, but the difference did not result in better clinical performance of landmark-based subclavian vein catheterization. Trial registration NCT03296735 for stage I (ClinicalTrials.gov, September 28, 2017) and NCT03303274 for stage II (ClinicalTrials.gov, October 6, 2017).

Intraoperative neuromuscular blockade affects the resting tension between the vocal cords. We assessed the effect of neuromuscular blockade on postoperative sore throat and hoarseness following tracheal intubation in patients undergoing lumbar spinal surgery in the prone position. Altogether, 99 patients were included; 50 patients did not receive neuromuscular blockade, and 49 patients received moderate neuromuscular blockade during the maintenance of anesthesia. Neuromuscular blockade was performed depending on the use of intraoperative neurophysiological monitoring. The number of intubation attempts, time to achieve tracheal intubation, and duration of intubation were recorded accordingly. The incidence and severity of postoperative sore throat and hoarseness was assessed at 1, 6, and 24 h after surgery. The overall cumulative incidence of postoperative sore throat (60% vs. 59%, respectively; P = 1.000) and postoperative hoarseness (68% vs. 61%, respectively; P = 0.532) did not differ between the no neuromuscular blockade and moderate neuromuscular blockade. The incidence and severity of postoperative sore throat and hoarseness was also not different between the moderate and no neuromuscular blockade at each time point after surgery. Nevertheless, the incidences of postoperative sore throat and hoarseness were quite high. Further studies investigating strategies to alleviate them are warranted accordingly.

Patients with symptomatic gallbladder diseases exhibit delayed gastric emptying. We evaluated the residual gastric content in fasted patients scheduled for elective laparoscopic cholecystectomy because of symptomatic gallbladder disease using ultrasonography.This prospective observational single-cohort study was approved by the Institutional Review Board, and written informed consent was obtained from all included patients. Before anesthesia induction, the gastric antrum was examined by ultrasound. Once the presence of solid content was excluded, the patients were classified using a three-point grading system (grade 0: no fluid; grade 1: fluid in the right lateral decubitus position; grade 2: fluid in both the supine and right lateral decubitus positions), and the fluid volume was measured. A stomach was considered empty if it had no contents or ≤ 1.5 mL·kgAmong 138 patients, 18 patients (13%) presented with a full stomach, 12 (9%) of whom had solid content, and six (4%) of whom had1.5 mL·kgThe gastric ultrasound assessment revealed that 13% of patients scheduled for elective cholecystectomy because of symptomatic gallbladder disease had a full stomach despite following the fasting guidelines. This was higher than the reported incidence of a full stomach among the general surgical population. Further studies are required to delineate the clinical implications of our findings.www.ClinicalTrials.gov (NCT03259841); registered 4 August, 2017.RéSUMé: CONTEXTE: Les patients atteints de maladies vésiculaires symptomatiques souffrent de retard de la vidange gastrique. Nous avons évalué par échographie le contenu gastrique résiduel chez des patients à jeun devant subir une cholécystectomie non urgente par laparoscopie en raison de maladie vésiculaire symptomatique. MéTHODE: Cette étude prospective observationnelle sur une cohorte unique a été approuvée par le Comité d’éthique indépendant et le consentement éclairé écrit a été obtenu de tous les patients inclus. Avant l’induction de l’anesthésie, l’antre gastrique a été examiné par échographie. Une fois la présence de solides exclue, les patients ont été catégorisés selon un système de notation de 3 grades (0 : aucun liquide; 1 : liquides détectés en position de décubitus latéral droit; 2 : liquides détectés en décubitus dorsal et en décubitus latéral droit), et le volume liquidien a été mesuré. Un estomac était considéré comme vide s’il n’avait aucun contenu solide et ≤ 1,5 mL·kg

An endoscopic bite block is a device to ensure that the patient’s mouth remains wide open during endoscopic procedures. Wide opening of the mouth may facilitate the efficiency of one-handed mask ventilation. We evaluated the effect of an endoscopic bite block on mask ventilation among three ventilation techniques: one-handed ventilation, one-handed ventilation with an endoscopic bite block, and two-handed ventilation. Fifty-nine anesthetized and paralyzed patients were included. After induction of anesthesia, one-handed ventilation, one-handed ventilation with an endoscopic bite block and two-handed ventilation were performed in a cross-over, randomized order. The primary outcome was the expiratory tidal volume (mL/kg of predicted body weight). Secondary outcomes included minute ventilation (L/min) and the incidence of inadequate mask ventilation or dead space ventilation. The expiratory tidal volume of one-handed ventilation with an endoscopic bite block was significantly improved when compared with that of one-handed ventilation (8.2 [6.8–10.2] mL/kg vs. 7.1 [4.5–9.0] mL/kg, respectively, difference = 1.1 mL/kg; 95% CI 0.8–2.4; P

BACKGROUND Cricoid pressure has been used as a component of the rapid sequence induction and intubation technique. However, concerns have been raised regarding the effectiveness and safety of cricoid pressure. Paratracheal pressure, a potential alternative to cricoid pressure to prevent regurgitation of gastric contents or aspiration, has been studied to be more effective to cricoid pressure in preventing gastric insufflation during positive pressure ventilation. However, to adopt paratracheal compression into our practice, adverse effects including its effect on the glottic view during direct laryngoscopy should be studied. We conducted a randomized, double-blind, noninferiority trial comparing paratracheal and cricoid pressures for any adverse effects on the view during direct laryngoscopy, together with other secondary outcome measures. METHODS In total, 140 adult patients undergoing general anesthesia randomly received paratracheal pressure (paratracheal group) or cricoid pressure (cricoid group) during anesthesia induction. The primary end point was the incidence of deteriorated laryngoscopic view, evaluated by modified Cormack-Lehane grade with a predefined noninferiority margin of 15%. Secondary end points included percentage of glottic opening score, ease of mask ventilation, change in ventilation volume and peak inspiratory pressure during mechanical mask ventilation, ease of tracheal intubation, and resistance encountered while advancing the tube into the glottis. The position of the esophagus was assessed by ultrasound in both groups to determine whether pressure applied to the respective area would be likely to result in esophageal compression. All secondary outcomes were tested for superiority, except percentage of glottic opening score, which was tested for noninferiority. RESULTS Paratracheal pressure was noninferior to cricoid pressure regarding the incidence of deterioration of modified Cormack-Lehane grade (0% vs 2.9%; absolute risk difference, -2.9%; 95% confidence interval, -9.9 to 2.6, P

The aim of this study was to evaluate conventional and modified aerosol boxes in terms of intubation time, first-pass intubation success, and mouth-to-mouth distance between the laryngoscopist and patient during tracheal intubation in simulated patients with normal and difficult airways. Sixteen anesthesiologists performed tracheal intubations with direct laryngoscope or three different videolaryngoscopes (McGRATH MAC videolaryngoscope, C-MAC videolaryngoscope, and Pentax-AWS) without an aerosol box or with a conventional or a modified aerosol boxes in simulated manikins with normal and difficult airways. Intubation time, first-pass intubation success, and mouth-to-mouth distance during tracheal intubation were recorded. Compared to no aerosol box, the use of a conventional aerosol box significantly increased intubation time in both normal and difficult airways (Bonferroni-corrected P-value (Pcorrected) = 0.005 and Pcorrected = 0.003, respectively). Intubation time was significantly shorter with the modified aerosol box than with the conventional one for both normal and difficult airways (Pcorrected = 0.003 and Pcorrected = 0.011, respectively). However, no significant differences were found in intubation time between no aerosol box and the modified aerosol box for normal and difficult airways (Pcorrected = 0.336 and Pcorrected = 0.112, respectively). The use of conventional or modified aerosol boxes significantly extended the mouth-to-mouth distances compared to not using an aerosol box during tracheal intubation with each laryngoscope (all Pcorrected

Objective Head and shoulder positioning may affect cross-sectional area (CSA) and location of the subclavian vein (SCV). We investigated the CSA of the SCV and the depth of the SCV, depending on the head and shoulder positions. Methods In 24 healthy obese volunteers, the short axis ultrasound images of the SCV and adjacent structures were obtained in three different head positions (neutral, 30° turned to the contralateral side, and 30° turned to the ipsilateral side) and two different shoulder positions (neutral and lowered). Images of the right and left SCVs were obtained in the supine and Trendelenburg positions. Subsequently, the CSA and depth of the SCV were measured. Results Significant differences were found in the CSA of the SCV in different head positions (30° turned to contralateral side vs. neutral: −0.06 cm2, 95% confidence interval [CI], −0.10 to −0.02; Pcorrected = 0.002, 30° turned to contralateral side vs. 30° turned to ipsilateral side: −0.16 cm2, 95% CI, −0.22 to −0.11; Pcorrected Conclusions Ipsilateral 30° head rotation, neutral shoulder position, and Trendelenburg position significantly enhanced the CSA of the SCV in obese participants.

Study designs Retrospective Observational Study Objectives: To compare the incidence of POD after propofol- and sevoflurane-based anesthesia in elderly patients undergoing spine surgery. Methods In this study, the medical records of elderly patients ≥ 65 years of age who underwent spine surgery under total intravenous anesthesia with propofol or inhalational anesthesia with sevoflurane were reviewed. The primary outcome was the incidence of POD after propofol- and sevoflurane-based anesthesia. Secondary outcomes included postoperative 30-day complications, length of postoperative hospital stay, associations of patient characteristics, and surgery- and anesthesia-related data with the development of POD, and associations of anesthetics with clinical outcomes such as postoperative 30-day complications, and length of postoperative hospital stay. Results Of the 281 patients, POD occurred in 29 patients (10.3%). POD occurred more frequently in the sevoflurane group than in the propofol group (15.7% vs. 5.0%, respectively; P=.003). The multivariable logistic regression analysis showed that sevoflurane-based anesthesia was associated with an increased risk of POD compared with propofol-based anesthesia (odds ratio [OR], 4.120; 95% confidence interval [CI], 1.549−10.954; P = .005), whereas anesthetics were not associated with postoperative 30-day complications and the length of postoperative hospital stay. Older age (OR, 1.242 CI, 1.130−1.366; P < .001) and higher mean pain score at postoperative day 1 (OR, 1.338 CI, 1.056−1.696; P = .016) were also associated with an increased risk of POD. Conclusions Propofol-based anesthesia was associated with a lower incidence of POD than sevoflurane-based anesthesia in elderly patients after spine surgery.

Background: High cuff pressure can induce ischemic injury to the trachea. An esophageal stethoscope can increase the cuff pressure. The purpose of this study was to evaluate the effect of an esophageal stethoscope insertion on the cuff pressure.Methods: Patients, who were scheduled for surgeries under general anesthesia, were enrolled in this prospective observational study. After induction of anesthesia, an anesthesiologist intubated a tracheal tube into the patient’s trachea and inflated the cuff manually. Then, an investigator checked the initial cuff pressure using a manometer. Next, the cuff pressure was adjusted to 24-26 mmHg. The cuff pressure was rechecked after insertion of an esophageal stethoscope. We recorded the change in cuff pressure by esophageal stethoscope.Results: One hundred twelve patients completed this study. The cuff pressure increased by an esophageal stethoscope in almost all patients and the mean cuff pressure change was 3.0 ± 3.4 cmH2O in all patients. Among all subjects, cuff pressure change over 5 cmH2O was recorded in 24 patients. When we compared the patient characteristics between patients whose cuff pressure changed over 5 cmH2O with that of other patients, females were more affected by insertion of an esophageal stethoscope, in terms of cuff pressure increase.Conclusion: Esophageal stethoscope insertion could increase cuff pressure, and females are more affected by it. Therefore, anesthesiologists should check the cuff pressure with a manometer after insertion of an esophageal stethoscope and readjust the pressure appropriately.Trial registration: ClinicalTrials.gov Identifier NCT03375554, registered on 12 December 2017 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0007N0H&selectaction=Edit&uid=U00026JX&ts=2&cx=-ivu5vz)

Background For nasotracheal intubation, the nasal pathway between the inferior turbinate and hard palate (lower pathway) is preferred for patient safety. However, selecting the lower pathway can be challenging because passage of the tube through the nasal pathway is usually performed blindly. Objectives We investigated whether facing the bevel of the tracheal tube in the cephalad direction of the patient could help in advancing the tracheal tube through the lower pathway during nasotracheal intubation. Design A randomised, blinded trial. Setting SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea from January 2019 to March 2020. Patients Sixty-eight adult patients undergoing oromaxillary surgeries were enrolled in this study. Interventions Patients were randomly allocated to undergo nasotracheal intubation with the bevel of the tube facing the cephalad direction (intervention group) or to the left (conventional group). Main outcome measures The effects of bevel direction on the pathway of the tube in the nasal cavity, and the incidence of epistaxis were evaluated by fibreoptic bronchoscopy. Results The success rate of the tracheal tube passing through the lower pathway was significantly higher in the intervention group than the conventional group (79.4 vs. 55.9%, relative risk 1.421, 95% CI 1.007 to 2.005, P = 0.038). The incidence of epistaxis was also lower in the intervention group than in the conventional group (41.2 vs. 73.5%, relative risk 0.560, 95% CI 0.357 to 0.878, P = 0.007). Conclusions Facing the bevel of the tracheal tube in the cephalad direction of the patient facilitated selection of the lower pathway and reduced the incidence of epistaxis during nasotracheal intubation in patients undergoing oromaxillary surgery. Trial registration ClinicalTrial.gov, NCT03740620.

We applied continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic surgery (VATS) lobectomy for left lung cancer and evaluated its safety and usefulness. An electrode was attached to a double-lumen tube, and placed at vocal cord level to detect the EMG signal evoked by vocal cord movement. Before 4 L lymph node dissection, an automatic periodic stimulation device was applied to the vagus nerve to stimulate vagus nerve continuously. Surgery was suspended if the amplitude decreased lower than the threshold and was resumed when the amplitude recovered. Ten patients (6 male, 4 female) were enrolled. CIONM was successfully performed in all patients without technical failure, and there was no hemodynamic instability. Amplitude decreased below the threshold in four patients. One patient did not recover amplitude and experienced transient vocal cord palsy. In the three other patients, the amplitude recovered above the threshold and no vocal cord palsy occurred. The six patients who did not exhibit amplitude decrease experienced no vocal cord palsy. Our results suggest that CIONM may be applied safely for VATS left lobectomy and may be used to predict postoperative vocal cord function. This approach may be helpful to prevent RLN injury during VATS left lobectomy.

Objective. Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator. Methods. Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point. Results. Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500 μV. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279 μV, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217 μV, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99 μV, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2. Conclusion. The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.

Background We analyzed the influence of anesthesia methods on surgical outcomes and renal function in retrograde intrarenal surgery (RIRS) in a prospective, randomized controlled study. Methods Seventy patients who underwent RIRS from September 2015 to February 2017 were randomly allocated to general anesthesia (GA) or spinal anesthesia (SA) groups. Renal function was assessed using estimated glomerular filtration rate, and separate renal function was evaluated using nuclear medicine tests. Maneuverability and accessibility were evaluated after every surgery. All procedures were performed by a single experienced surgeon (SY Cho). Results Stone-free rate was higher in the GA (92.3%, 36 of 39) than the SA (71.0%, 22 of 31) (P = 0.019) group. Pain score was higher in the GA than in the SA group on the first postoperative morning (P = 0.025), but pain scores of the two groups were similar before discharge (P = 0.560). There were no differences in the changes of serum creatinine level (P = 0.792) and changes of estimated glomerular filtration rate (P = 0.807). Differences of separate renal function between operative and contralateral site increased significantly in patients under GA than under SA at postoperative 3 months (P = 0.014). Maneuverability and accessibility were better in SA with sedation than GA (P Conclusions RIRS under SA showed advantages in renal function change using renogram at postoperative 3 months and in lower pain score on the first postoperative morning. Performance of operator under SA was worse than that under GA and significantly improved with sedation. RIRS under SA showed advantages in lower pain score at postoperative first day. Trial registration Clinicaltrials.gov ID is NCT03957109, and registration date is 17th May 2019. This study was retrospectively registered.

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.

Resumo Justificativa e objetivo A previsao de perda sanguinea excessiva no pos‐operatorio e util para o manejo em Unidade de Terapia Intensiva (UTI) apos cirurgia cardiaca. O objetivo do presente estudo foi examinar a eficacia do sistema de classificacao da Sociedade Internacional de Trombose e Hemostasia ( International Society on Thrombosis and Hemostasis – ISTH) em pacientes submetidos a cirurgia cardiaca. Metodo Apos obter a aprovacao do Comite de Pesquisa Institucional, os prontuarios de pacientes submetidos a cirurgia cardiaca eletiva com circulacao extracorporea (CEC) entre marco de 2010 e fevereiro de 2014 foram retrospectivamente revisados. O escore ISTH foi calculado na UTI e os pacientes foram alocados em dois grupos: grupo com coagulacao intravascular disseminada (CID) manifesta e grupo com CID nao manifesta. Para avaliar a correlacao com a Perda Estimada de Sangue (PES), o teste t de Student e as analises de correlacao foram usados. Resultados Dentre os 384 pacientes submetidos a cirurgia cardiaca, 70 com CID manifesta (n = 20) ou CID nao manifesta (n = 50) foram incluidos. As medias dos escores CID na admissao na UTI foram 5,35 ± 0,59 (Grupo CID manifesta) e 2,66 ± 1,29 (Grupo CID nao manifesta) e induzida CID manifesta em 29% (20/70). O grupo CID manifesta apresentou PES superior durante 24 horas ( p = 0,006) e um tempo maior de intubacao ( p = 0,005). Conclusao Apesar da limitacao do desenho retrospectivo, o uso do escore ISTH para o manejo de pacientes apos cirurgia cardiaca parece ser util para prever a perda sanguinea excessiva pos‐CEC e o prolongamento da intubacao traqueal.

// Jeong-Eun Lee 1,2,* , Jung-Man Lee 3,* , Young-Jun Park 1 , Byung-Seok Kim 1,2 , Young-Tae Jeon 4,5 and Yeonseok Chung 1,2 1 Laboratory of Immune Regulation, Institute of Pharmaceutical Sciences and College of Pharmacy, Seoul National University, Seoul, Republic of Korea 2 BK21 plus program, College of Pharmacy, Seoul National University, Seoul, Republic of Korea 3 Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea 4 Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea 5 Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea * These authors have equally contributed to this work Correspondence to: Yeonseok Chung, email: // Young-Tae Jeon, email: // Keywords : ketamine, Th17 cell, STAT3, IL-21, autoimmunity, Immunology and Microbiology Section, Immune response, Immunity Received : April 04, 2017 Accepted : May 23, 2017 Published : May 31, 2017 Abstract Ketamine is widely used in animals and humans as a systemic anesthetic. Although several immune-modulatory functions of ketamine have been reported, the effects of ketamine on the differentiation of Th17 cell are unknown. We found that ketamine significantly diminished the frequency of IL-17-producers among CD4 + T cells stimulated under Th17-skewing conditions. Mechanistic studies showed that ketamine had little effect on the production of Th17-inducing cytokines by dendritic cells and the proliferation of T cells in response to anti-CD3; however it significantly hampered IL-21 expression as well as STAT3 phosphorylation in T cells upon IL-6 stimulation. Moreover, MOG-reactive CD4 + T cells expanded in the presence of ketamine produced reduced amounts of Th17 cytokines, leading to diminished EAE severity when transferred into TCRβ-deficient mice in comparison to those treated with vehicle. These findings demonstrate that ketamine suppresses autoimmune Th17 cell responses by inhibiting the differentiation as well as the reactivation of Th17 cells.

Objective Guidewire-induced arrhythmias that occur during central venous catheterization can progress to malignant arrhythmias in rare cases. This study compared the incidence of arrhythmia during central venous catheterization using three different depths of guidewire insertion into the right internal jugular vein. Methods Sixty-nine patients undergoing elective surgery requiring central venous catheterization through the right internal jugular vein were enrolled in this double-blind, prospective, randomized, and controlled study. Patients were randomly allocated to receive guidewire insertions to 15 cm, 17.5 cm, or 20 cm before tissue dilation. Arrhythmic episodes were then monitored during dilation of the soft tissue. Results A total of 29 patients (42%) experienced arrhythmic episodes during tissue dilation. The guidewire-induced arrhythmia rates of the 15 cm group, 17.5 cm group, and 20 cm group were 0.26 (95% confidence interval [CI] = 0.10, 0.48), 0.35 (95% CI = 0.16, 0.57), and 0.65 (95% CI = 0.43, 0.84), respectively. The incidence of arrhythmic episodes was higher in the 20 cm group than in the 15 cm (odds ratio [OR] = 5.31; 95% CI = 1.50, 18.84) and 17.5 cm (OR = 3.52; 95% CI = 1.05, 11.83) groups. There was no significant difference in arrhythmia rates between the 15 cm group and 17.5 cm group (p = 0.542). Conclusions During central venous catheterization through the right internal jugular vein, inserting guidewires to depths of 15 or 17.5 cm before tissue dilation reduced the incidence of arrhythmic episodes compared to a depth of 20 cm.

Central obesity may be related to the spread of spinal anesthesia in female patients. Fifty-seven female patients undergoing spinal anesthesia were allocated to either the central obesity or noncentral obesity group. After induction of spinal anesthesia, maximal sensory blockade (primary outcome), time for maximal sensory block, maximum motor block, time to maximum motor block, time to L2 regression, and time to Bromage scale 0 were evaluated. Multiple linear regression analyses showed that maximal sensory blockade was related to central obesity (P = .004). Central obesity is related to a more extensive spread of spinal anesthesia in female patients.

This research studied the application of samplers under three fixity conditions during sampling tube penetration and evaluated the quality of the retrieved samples. Original and portable types of oil-operated fixed-piston samplers with identical sampling tubes were employed at a site in the Nakdong River Delta. Suction, shear wave velocity and consolidation tests were conducted to assess sample quality. The soil fabric, including holes, nodules, roots and shells, rather than soil sensitivity (4 to 28) was found to significantly affect sample quality, particularly suction. The sample quality indicators, except for the suction-based values, near the centre of each sampling tube tended to vary depending on the bulk density of the ground. The original type of sampler fixed at the centre of the steel casing produced samples of slightly better quality than those produced by the same sampler freely located in the borehole and those produced by a portable sampler tightly located in the steel casing. This finding was also supported by different qualities of samples obtained using the oil-operated and mechanical samplers at a different site. It is thus concluded that the fixity of samplers is a minor factor that influences sample quality.

Clinicians sometimes encounter resistance in advancing a tracheal tube, which is inserted via a nostril, from the nasal cavity into the oropharynx during nasotracheal intubation. The purpose of this study was to investigate the effect of neck extension on the advancement of tracheal tubes from the nasal cavity into the oropharynx during nasotracheal intubation. Patients were randomized to the ‘neck extension group (E group)’ or ‘neutral position group (N group)’ for this randomized controlled trial. After induction of anesthesia, a nasal RAE tube was inserted via a nostril. For the E group, an anesthesiologist advanced the tube from the nasal cavity into the oropharynx with the patient’s neck extended. For the N group, an anesthesiologist advanced the tube without neck extension. If the tube was successfully advanced into the oropharynx within two attempts by the same maneuver according to the assigned group, the case was defined as ‘success.’ We compared the success rate of tube advancement between the two groups. Thirty-two patients in the E group and 33 in the N group completed the trial. The success rate of tube passage during the first two attempts was significantly higher in the E group than in the N group (93.8% vs. 60.6%; odds ratio = 9.75, 95% CI = [1.98, 47.94], p = 0.002). Neck extension during tube advancement from the nasal cavity to the oropharynx before laryngoscopy could be helpful in nasotracheal intubation. ClinicalTrials.gov Identifier NCT03377114 , registered on 13 December 2017.

Background In the present study, we compare the LMA-Protector™ and the i-gel™ in terms of adequacy of the airway seal, insertion time, ease and accuracy of insertion, and the incidence of postoperative sore throat. Methods In 110 anesthetized and paralyzed adult patients, the i-gel™ (n = 55) or the LMA-Protector™ (n = 55) was inserted. The primary outcome was airway leak pressure. The secondary outcomes included the first-attempt success rate, insertion time, ease and accuracy of the device insertion, ease of gastric tube placement, blood staining on the device after removal, and incidence and severity of postoperative sore throat. Results The airway leak pressure was higher with the LMA-Protector™ than with the i-gel™ (31 [7] cmH2O vs. 27 [6] cmH2O, respectively; P = 0.016). Insertion time was longer with the LMA-Protector™ than with the i-gel™ (27 [16] sec vs. 19 [16] sec, respectively, P