Anesthesiology Research and Practice The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. Achieving the Recommended Endotracheal Tube Cuff Pressure: A Randomized Control Study Comparing Loss of Resistance Syringe to Pilot Balloon Palpation Sun, 31 Dec 2017 00:00:00 +0000 Background. Both under- and overinflation of endotracheal tube cuffs can result in significant harm to the patient. The optimal technique for establishing and maintaining safe cuff pressures (20–30 cmH2O) is the cuff pressure manometer, but this is not widely available, especially in resource-limited settings where its use is limited by cost of acquisition and maintenance. Therefore, anesthesia providers commonly rely on subjective methods to estimate safe endotracheal cuff pressure. This study set out to determine the efficacy of the loss of resistance syringe method at estimating endotracheal cuff pressures. Methods. This was a randomized clinical trial. We enrolled adult patients scheduled to undergo general anesthesia for elective surgery at Mulago Hospital, Uganda. Study participants were randomized to have their endotracheal cuff pressures estimated by either loss of resistance syringe or pilot balloon palpation. The pressures measured were recorded. Results. One hundred seventy-eight patients were analyzed. 66.3% (59/89) of patients in the loss of resistance group had cuff pressures in the recommended range compared with 22.5% (20/89) from the pilot balloon palpation method. This was statistically significant. Conclusion. The loss of resistance syringe method was superior to pilot balloon palpation at administering pressures in the recommended range. This method provides a viable option to cuff inflation. Fred Bulamba, Andrew Kintu, Nodreen Ayupo, Charles Kojjo, Lameck Ssemogerere, Agnes Wabule, and Arthur Kwizera Copyright © 2017 Fred Bulamba et al. All rights reserved. Preoperative Anaemia and Associated Postoperative Outcomes in Noncardiac Surgery Patients in Central Region of Ghana Mon, 11 Dec 2017 04:32:13 +0000 Introduction. Several studies suggest that preoperative anaemia (PA) is associated with adverse postoperative outcomes, but little is known about these outcomes in the Central Region of Ghana. This study aims to determine the prevalence of PA among noncardiac surgical patients and its implications for their postoperative outcomes. Methods. This study was designed as an observational study; data including demographics and clinical and laboratory results were collected from the patients’ records and through interviews. Results. A total of 893 inpatient surgical cases undergoing elective and emergency operations, aged 15 years and above with mean age of 44.2 ± 17.0 yrs, were enrolled. The prevalence of PA was 54.3%, mostly microcytic with or without hypochromia (57.2%). The prevalence was higher in females than males (). Preoperative anaemia was significantly associated with prolonged length of hospital stay (OR: 2.12 (95% CI: 1.49–3.10)). Allogeneic blood transfusion significantly prolonged the length of hospital stay (OR 4.48 (95% CI: 2.67–7.51)). 15.5% of the anaemic patients received oral iron supplements compared to 2.2% of nonanaemic patients (). Conclusion. Preoperative anaemia is common among noncardiac surgical patients. It is independently and significantly associated with prolonged hospital stay leading to the use of increased healthcare resources. It is also the main predictor for perioperative allogeneic blood transfusions and the use of haematinics. Gladys Amponsah and Alice Charwudzi Copyright © 2017 Gladys Amponsah and Alice Charwudzi. All rights reserved. Intravenous Magnesium Sulphate for Analgesia after Caesarean Section: A Systematic Review Sun, 03 Dec 2017 00:00:00 +0000 Objective. To summarise the evidence for use of intravenous magnesium for analgesic effect in caesarean section patients. Background. Postcaesarean pain requires effective analgesia. Magnesium, an N-methyl-D-aspartate receptor antagonist and calcium-channel blocker, has previously been investigated for its analgesic properties. Methods. A systematic search was conducted of PubMed, Scopus, MEDLINE, Cochrane Library, and Google Scholar databases for randomised-control trials comparing intravenous magnesium to placebo with analgesic outcomes in caesarean patients. Results. Ten trials met inclusion criteria. Seven were qualitatively compared after exclusion of three for unclear bias risk. Four trials were conducted with general anaesthesia, while three utilised neuraxial anaesthesia. Five of seven trials resulted in decreased analgesic requirement postoperatively and four of seven resulted in lower serial visual analogue scale scores. Conclusions. Adjunct analgesic agents are utilised to improve analgesic outcomes and minimise opioid side effects. Preoperative intravenous magnesium may decrease total postcaesarean rescue analgesia consumption with few side effects; however, small sample size and heterogeneity of methodology in included trials restricts the ability to draw strong conclusions. Therefore, given the apparent safety and efficacy of magnesium, its role as an adjunct analgesic in caesarean section patients should be further investigated with the most current anaesthetic techniques. Andrew McKeown, Vyacheslav Seppi, and Raymond Hodgson Copyright © 2017 Andrew McKeown et al. All rights reserved. Lateral Supratrochanteric Approach to Sciatic and Femoral Nerve Blocks in Children: A Feasibility Study Sun, 29 Oct 2017 00:00:00 +0000 Background. Sciatic and femoral nerve blocks (SNB and FNB) result in effective lower limb analgesia. Classical SNB and FNB require patient repositioning which can cause pain and discomfort. Alternative approaches to sciatic and femoral nerve blocks in supine patients can be useful. Materials and Methods. Neurostimulator-guided SNB and FNB from the lateral supratrochanteric approach were performed. Local anesthetic spread in SNB and FNB after radiographic opacification was analyzed. Time and number of attempts to perform blocks, needle depth, and clinical efficacy were assessed. Results. Mean needle passes number and procedure time for SNB were 2.5 ± 0.3 and 2.4 ± 0.2 min, respectively. Mean needle passes number and procedure time for FNB were 2.7 ± 0.27 and 2.59 ± 0.23 min, respectively. Mean skin to nerve distance was 9.1 ± 0.45 cm for SNB and 8.8 ± 0.5 cm for FNB. Radiographic opacification of SNB showed local anesthetic spread close to the sacrum and involvement of sacral plexus nerve roots. Spread of local anesthetic in FNB was typical. Intraoperative fentanyl administration was required in 2 patients (9.5%) with mean dose 1.8 ± 0.2 mcg/kg. Mean postoperative pain score was 0.34 ± 0.08 of 10. Conclusion. The lateral supratrochanteric approach to SNB and FNB in children can be an effective lower limb analgesic technique in supine patients. The trial is registered with ISRCTN70969666. Andrew A. Albokrinov, Ulbolhan A. Fesenko, Taras B. Huz, and Valentyna M. Perova-Sharonova Copyright © 2017 Andrew A. Albokrinov et al. All rights reserved. Drug Errors and Protocol for Prevention among Anaesthetists in Nigeria Mon, 23 Oct 2017 08:48:44 +0000 Background. Drugs are often prescribed, dispensed, and administered by the same person during anaesthesia, and this may increase the risk of drug error. Objectives. To assess the frequency of drug administration errors by anaesthetists, the drugs commonly involved, and the effects of such errors. Method. A questionnaire-based study was carried out among participants at an annual conference of Nigerian anaesthetists. Sixty-six of the 80 participants returned the completed questionnaire. The respondents comprised 1 nurse anaesthetist, 34 resident doctors, 3 doctors with diploma in anaesthesia, and 28 consultant anaesthetists. The collated data on drug errors, the effect of such errors on patients, and formulated protocols to prevent future occurrence were subjected to descriptive analysis using Microsoft Excel. Result. Drug error was reported by 71.21% and witnessed by 22.72% of the respondents. Most of the drug errors occurred during general anaesthesia (90.3%) for emergency procedures (51.61%), and muscle relaxants were most commonly involved (58.06%). Conclusion. Drug errors are common among anaesthetists in Nigeria and their incidence is greater during general anaesthesia for emergency procedures, largely as a result of ampoule swaps due to similarities in ampoule design and packaging. Guidelines on their prevention should be developed by all health institutions. U. U. Johnson and L. N. Ebirim Copyright © 2017 U. U. Johnson and L. N. Ebirim. All rights reserved. Corrigendum to “Sugammadex-Enhanced Neuronal Apoptosis following Neonatal Sevoflurane Exposure in Mice” Tue, 17 Oct 2017 00:00:00 +0000 Maiko Satomoto, Zhongliang Sun, Yushi U. Adachi, and Koshi Makita Copyright © 2017 Maiko Satomoto et al. All rights reserved. What Do Anesthesiologists Know about p Values, Confidence Intervals, and Correlations: A Pilot Survey Thu, 12 Oct 2017 00:00:00 +0000 Background. Statistical methods form the basis for clinical decision-making in evidence-based anesthesia. Data on the knowledge of anesthesiologists about statistics are lacking. This pilot study aims to provide a first impression of the anesthesiologists’ understanding of commonly used concepts in statistics. Methods. A cross-sectional pilot survey was performed at a major international anesthesia conference. The questionnaire consisted of three basic multiple-choice questions on the topics “p value,” “confidence interval,” and “correlation.” Results of the questions are reported as percentage of correct answers (95% confidence interval). Results. 65 questionnaires were analyzed. Forty participants were male, and mean age was 40 (standard deviation: 10) years. The question addressing the p value was correctly answered by 15% (95% CI: 8 to 27%) of respondents. The question concerning the 95% confidence interval was answered correctly by 28% (95% CI: 18 to 40%) of participants. For the question about correlation, a correct answer was given by 52% (95% CI: 40 to 64%). None of the participants answered all questions correctly, and 19 participants provided a wrong answer to all questions. Conclusions. Anesthesiologists seem to demonstrate a poor understanding of statistical key concepts. Further studies are needed to address statistical knowledge gaps among anesthesiologists more comprehensively. Patrick Schober, Sebastiaan M. Bossers, Phi-Vu Dong, Christa Boer, and Lothar A. Schwarte Copyright © 2017 Patrick Schober et al. All rights reserved. Feasibility of Cervical Epidural Anesthesia for Breast Cancer Surgery Tue, 18 Jul 2017 00:00:00 +0000 Background. Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse. Methods. Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed. Results. In 26 patients (66,7%, 95% CI 51,7–81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0–7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7–19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7–30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4–96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed. Discussion. Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques. Manuel Wenk, Christina Massoth, Daniel M. Pöpping, and Michael Möllmann Copyright © 2017 Manuel Wenk et al. All rights reserved. Magnitude and Predisposing Factors of Difficult Airway during Induction of General Anaesthesia Tue, 11 Jul 2017 00:00:00 +0000 Objective. To assess magnitude and predisposing factors of difficult airway during induction of general anaesthesia. Methods. Hospital based cross sectional study carried out to determine the incidence of difficult mask ventilation, difficult laryngoscopy (Cormack and Lehane III and IV), difficult intubation (IDS ≥ 5), and failed intubation. The association between each predisposing factor and airway parameters with components of difficult airway is investigated with binary logistic regression. Sensitivity, specificity, positive and negative predictive value of the test, and odds ratio with 95% confidence interval were calculated to determine the association between independent and dependent variable. Result. The incidence of difficult laryngoscopy, difficult intubation, and failed intubation are 12.3%, 9%, and 0.005%, respectively. Mouth opening < 30 mm and Mallampati classes III and IV are the most sensitive tests and second high specific test next to combination of tests to predict difficult intubation and laryngoscopy ( value < 0.001). Unrestricted multiple attempt without alternative airway techniques resulted in exponential increase in desaturation episodes and further difficulty of airway management ( value < 0.001). Discussion and Conclusion. Mallampati classes III and IV, mouth opening ≤ 30 mm, jaw slide grade C, attempt > 3, and ineffective alternative technique have increased predictability value of difficult airway. Sileshi Abiy Workeneh, Amare Hailekiros Gebregzi, and Zewditu Abdissa Denu Copyright © 2017 Sileshi Abiy Workeneh et al. All rights reserved. Factors Associated with Postoperative Prolonged Mechanical Ventilation in Pediatric Liver Transplant Recipients Mon, 03 Jul 2017 09:23:30 +0000 Introduction. Almost all pediatric orthotopic liver transplant (OLT) recipients require mechanical ventilation in the early postoperative period. Prolonged postoperative mechanical ventilation (PPMV) may be a marker of severe disease and may be associated with morbidity and mortality. We determined the incidence and risk factors for PPMV in children who underwent OLT. Methods. This was a retrospective analysis of data collected on 128 pediatric OLT recipients. PPMV was defined as postoperative ventilation ≥ 4 days. Perioperative characteristics were compared between cases and control groups. Multivariable logistic regression analysis was used to calculate odds ratios for PPMV after controlling for relevant cofactors. Results. An estimated 25% (95% CI, 17.4%–32.6%) required PPMV. The overall incidence of PPMV varied significantly by age group with the highest incidence among infants. PPMV was associated with higher postoperative mortality () and longer intensive care unit () and hospital length of stay (). Multivariable analysis identified young patient age, preoperative hypocalcemia, and increasing duration of surgery as independent predictors of PPMV following OLT. Conclusion. The incidence of PPMV is high and it was associated with prolonged ICU and hospital LOS and higher posttransplant mortality. Surgery duration appears to be the only modifiable predictor of PPMV. Olubukola O. Nafiu, Katari Carello, Anjana Lal, John Magee, and Paul Picton Copyright © 2017 Olubukola O. Nafiu et al. All rights reserved. Organs Blood Flow during Elevation of Body Temperature in Sevoflurane Anesthetized Rats Sun, 04 Jun 2017 00:00:00 +0000 The aim of this study is to investigate how elevation of body temperature changes organs blood flow during sevoflurane anesthesia. We conducted in vivo research on 14 male Wistar rats to monitor pulse rate and arterial blood pressure and measure hepatic, small intestinal, renal, and descending aortic blood flow using a laser Doppler blood flowmeter. We assessed the changes in organ blood flow, pulse rate, and arterial blood pressure during elevation of the rats’ body temperatures up to 41.5°C under anesthesia with 2.0% or 3.0% sevoflurane. We concluded that elevation of body temperature up to 39.5°C does not change hepatic, small intestinal, and renal blood flow during 2.0 and 3.0% sevoflurane anesthesia. Koichi Shimo, Ko Takakura, and Kenji Shigemi Copyright © 2017 Koichi Shimo et al. All rights reserved. Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery Sun, 30 Apr 2017 13:47:52 +0000 Introduction. Pain after cardiac surgery affects long-term patient wellness. This study investigated the effect of preoperative pregabalin on acute and chronic pain after elective cardiac surgery with median sternotomy. Methods. Prospective double blind study. 93 cardiac surgery patients were randomly assigned into three groups: Group 1 received placebo, Group 2 received oral pregabalin 75 mg, and Group 3 received oral pregabalin 150 mg. Data were collected 8 hours, 24 hours, and 3 months postoperatively. Results. Patients receiving pregabalin required fewer morphine boluses (10 in controls versus 6 in Group 1 versus 4 in Group 2, ) and had lower pain scores at 8 hours (4 versus 3 versus 3, ) and 3 months (3 versus 2 versus 2, ) and lower morphine consumption at 8 hours (14 versus 13 versus 12 mg, ) and 24 hours (19.5 versus 16 versus 15 mg, ). Percentage of patients with sleep disturbances or requiring analgesics was lower in the pregabalin group and even lower with higher pregabalin dose (16/31 versus 5/31 versus 3/31, , and 26/31 versus 16/31 versus 10/31, , resp.) 3 months after surgery. Conclusion. Preoperative oral pregabalin 75 or 150 mg reduces postoperative morphine requirements and acute and chronic pain after cardiac surgery. Aik Bouzia, Vassilios Tassoudis, Menelaos Karanikolas, George Vretzakis, Argyro Petsiti, Nikolaos Tsilimingas, and Elena Arnaoutoglou Copyright © 2017 Aik Bouzia et al. All rights reserved. A Retrospective Analysis of Oxygen Desaturation during Acoustic Respiratory Rate Monitoring in Non-ICU Patients following Tracheal Extubation after General Anesthesia Wed, 12 Apr 2017 00:00:00 +0000 Purpose. Acoustic respiratory rate (RRa) monitoring provides an accurate estimation of the respiratory rate (RR). We investigated the incidence of oxygen desaturation under RRa monitoring in a postoperative setting and identified its related factors. Methods. This study was a retrospective chart review of postoperative patients outside an intensive care unit setting. Using the data collected during the first 8 h postoperatively, patients were divided into oxygen desaturated (SpO2 < 90% for >10 s) and nondesaturated groups under oxygen administration. Multivariate analysis was used to determine oxygen desaturation-associated explanatory factors. Results. Oxygen desaturation was detected in 102 of 935 patients (10.9%). % vital capacity [odds ratio (OR), 0.885 per 10% increase; 95% confidence interval (CI), 0.790 to 0.992], coexisting chronic obstructive pulmonary disease (OR, 2.195; 95% CI, 1.088 to 4.428), and absence of a critical RRa change (RR > 30 or <8 beats/min for >2 min) (OR, 1.972; 95% CI, 1.226 to 3.172) were independently associated with oxygen desaturation. Conclusion. Postoperative oxygen desaturation was observed in more than 10% of the patients whose RR was monitored by RRa under oxygen therapy. It is more likely to occur in patients with impaired pulmonary function or morbid pulmonary status and can also occur in the absence of abnormal RR. Hideaki Kawanishi, Satoki Inoue, and Masahiko Kawaguchi Copyright © 2017 Hideaki Kawanishi et al. All rights reserved. The Effect of Tracheal Intubation-Induced Autonomic Response on Photoplethysmography Sun, 02 Apr 2017 00:00:00 +0000 Introduction. Intraoperative stress responses and postoperative pain can be monitored using photoplethysmography (PPG). PPG signal has two components, AC and DC. Effects of noxious stimuli-induced stress responses have not been studied on the DC component of PPG. The aim of this study was to investigate the effect of a known noxious stimulus (endotracheal intubation) on both the AC and DC components of PPG. Methods. 15 surgical patients having general anesthesia were enrolled into this clinical study. PPG was recorded electronically from a pulse oximeter. Maximum changes in the AC and DC components of the PPG and pulse rate were determined in response to endotracheal intubation from high frequency (62.5 Hz) PPG recordings. Results. Endotracheal intubation-induced autonomic stress response resulted in a significant decrease in the AC component of the PPG and an increase in pulse rate in every subject ( for all). The decrease in the AC component of the PPG was % () and the increase in pulse rate was  bpm (). The response of the DC component was variable ( = NS). Conclusion. Endotracheal intubation-induced stress response resulted in a significant and consistent change in the AC, but not the DC component of the PPG. This trial is registered with Identifier NCT03032939. Pekka Talke Copyright © 2017 Pekka Talke. All rights reserved. Analgesic Effects of Preincision Ketamine on Postspinal Caesarean Delivery in Uganda’s Tertiary Hospital: A Randomized Clinical Trial Tue, 21 Feb 2017 00:00:00 +0000 Background. Good postoperative analgesic management improves maternal satisfaction and care of the neonate. Postoperative pain management is a challenge in Mulago Hospital, yet ketamine is accessible and has proven benefit. We determined ketamine’s postoperative analgesic effects. Materials and Methods. We did an RCT among consenting parturients that were randomized to receive either intravenous ketamine (0.25 mg/kg) or placebo after spinal anesthetic. Pain was assessed every 30 mins up to 24 hours postoperatively using the numerical rating scale. The first complaint of pain requiring treatment was noted as “time to first breakthrough pain.” Results. We screened 100 patients and recruited 88 that were randomized into two arms of 44 patients that received either ketamine or placebo. Ketamine group had 30-minute longer time to first breakthrough pain and lower 24-hour pain scores. Postoperative diclofenac consumption was lesser in the ketamine group compared to placebo and Kaplan-Meier graphs showed a higher probability of experiencing breakthrough pain earlier in the placebo group. Conclusion. Preincision intravenous ketamine (0.25 mg/kg) offered 30-minute prolongation to postoperative analgesia requirement with reduced 24-hour pain scores. We recommend larger studies to explore this benefit. This trial is registered with Pan African Clinical Trial Registry number PACTR201404000807178. Richard Mwase, Tonny Stone Luggya, John Mark Kasumba, Humphrey Wanzira, Andrew Kintu, Joesph V. B. Tindimwebwa, and Daniel Obua Copyright © 2017 Richard Mwase et al. All rights reserved. Injectable Anesthesia for Mice: Combined Effects of Dexmedetomidine, Tiletamine-Zolazepam, and Butorphanol Sun, 22 Jan 2017 11:08:39 +0000 Anesthetic protocols for murine models are varied within the literature and medetomidine has been implicated in the development of urethral plugs in male mice. Our objective was to evaluate the combination of butorphanol, dexmedetomidine, and tiletamine-zolazepam. A secondary objective was to identify which class of agent was associated with urethral obstructions in male mice. BALB/c male () and female () mice were assigned to dexmedetomidine and tiletamine-zolazepam with or without butorphanol or to single agent dexmedetomidine or tiletamine-zolazepam. Anesthesia was achieved in 58% (14/24) of mice without butorphanol and in 100% (24/24) of mice with butorphanol. The combination of dexmedetomidine (0.2 mg/kg), tiletamine-zolazepam (40 mg/kg), and butorphanol (3 mg/kg) resulted in an induction and anesthetic duration of 12 and 143 minutes, respectively. Urethral obstructions occurred in 66% (25/38) of trials in male mice that received dexmedetomidine with a mortality rate of 38% (5/13). Tiletamine-zolazepam, when used alone, resulted in a 0% (0/21) incidence of urethral obstructions. Combination use of dexmedetomidine, tiletamine-zolazepam, and butorphanol results in a longer and more reliable duration of anesthesia than the use of dexmedetomidine and tiletamine-zolazepam alone. Dexmedetomidine is not recommended for use in nonterminal procedures in male mice due to the high incidence of urethral obstructions and resultant high mortality rate. Laura A. Cagle, Lisa M. Franzi, Steven E. Epstein, Philip H. Kass, Jerold A. Last, and Nicholas J. Kenyon Copyright © 2017 Laura A. Cagle et al. All rights reserved. Regional Anaesthesia Is Associated with Shorter Postanaesthetic Care and Less Pain Than General Anaesthesia after Upper Extremity Surgery Wed, 16 Nov 2016 05:42:13 +0000 Introduction. For surgery on the upper extremity, the anaesthetist often has a choice between regional anaesthesia (RA) and general anaesthesia (GA). We sought to investigate the possible differences between RA and GA after upper extremity surgery with regard to postoperative patient comfort. Methods. This is a retrospective observational study that was performed at an acute care secondary referral centre. One hundred and eighty-seven procedures involving orthopaedic surgery on the upper extremity were included. The different groups (RA and GA) were compared regarding the primary outcome variable, length of stay in Postanaesthesia Unit, and secondary outcome variables, opioid consumption and nausea treatment. Results. RA was associated with significantly shorter median length of stay (99 versus 171 minutes). In the GA group, 32% of the patients received opioid analgesics and 21% received antiemetics. In the RA group, none received opioid analgesics and 3% received antiemetics. Conclusion. In this observational study, RA was superior to GA for surgery of the upper extremity regarding Postanaesthesia Care Unit length of stay, number of doses of analgesic, and number of doses of antiemetic administered. Sven Grauman, Jakob Boethius, and Joakim Johansson Copyright © 2016 Sven Grauman et al. All rights reserved. Sugammadex-Enhanced Neuronal Apoptosis following Neonatal Sevoflurane Exposure in Mice Tue, 08 Nov 2016 06:03:55 +0000 In rodents, neonatal sevoflurane exposure induces neonatal apoptosis in the brain and results in learning deficits. Sugammadex is a new selective neuromuscular blockade (NMB) binding agent that anesthesiologists can use to achieve immediate reversal of an NMB with few side effects. Given its molecular weight of 2178, sugammadex is thought to be unable to pass through the blood brain barrier (BBB). Volatile anesthetics can influence BBB opening and integrity. Therefore, we investigated whether the intraperitoneal administration of sugammadex could exacerbate neuronal damage following neonatal 2% sevoflurane exposure via changes in BBB integrity. Cleaved caspase-3 immunoblotting was used to detect apoptosis, and the ultrastructure of the BBB was examined by transmission electron microscopy. Exposure to 2% sevoflurane for 6 h resulted in BBB ultrastructural abnormalities in the hippocampus of neonatal mice. Sugammadex alone without sevoflurane did not induce apoptosis. The coadministration of sugammadex with sevoflurane to neonatal mice caused a significant increase (150%) in neuroapoptosis in the brain compared with 2% sevoflurane. In neonatal anesthesia, sugammadex could influence neurotoxicity together with sevoflurane. Exposure to 2% sevoflurane for 6 h resulted in BBB ultrastructural abnormalities in the hippocampus of neonatal mice. Maiko Satomoto, Zhongliang Sun, Yushi U. Adachi, and Koshi Makita Copyright © 2016 Maiko Satomoto et al. All rights reserved. Perioperative Elevation in Cell-Free DNA Levels in Patients Undergoing Cardiac Surgery: Possible Contribution of Neutrophil Extracellular Traps to Perioperative Renal Dysfunction Wed, 02 Nov 2016 13:18:04 +0000 Background. This study aimed to determine the perioperative change in serum double-strand DNA (dsDNA) as a marker potentially reflecting neutrophil extracellular trap concentration in samples from patients undergoing cardiac surgery and to analyze a relationship between serum dsDNA concentrations and perioperative renal dysfunction. Methods. Serum dsDNA concentrations in samples that were collected during a previously conducted, prospective, multicenter, observational study were measured. Eighty patients undergoing elective cardiac surgery were studied. Serum samples were collected at baseline, immediately after surgery, and the day after surgery (POD-1). Results. Serum dsDNA concentration was significantly increased from baseline (median, 398 ng/mL [interquartile range, 372–475 ng/mL]) to immediately after surgery (median, 540 ng/mL [437–682 ng/mL], ), and they were reduced by POD-1 (median, 323 ng/mL [256–436 ng/mL]). The difference in serum creatinine concentration between baseline and POD-1 was correlated with dsDNA concentration on POD-1 (, ). Conclusions. In patients undergoing cardiac surgery, serum dsDNA concentration is elevated postoperatively. Prolonged elevation in dsDNA concentration is correlated with perioperative renal dysfunction. Further large-scale studies are needed to determine the relationship between serum concentration of circulating dsDNA and perioperative renal dysfunction. Yu Qi, Tokujiro Uchida, Mamoru Yamamoto, Yudai Yamamoto, Koji Kido, Hiroyuki Ito, Nagara Ohno, Miho Asahara, Yoshitsugu Yamada, Osamu Yamaguchi, Chieko Mitaka, Makoto Tomita, and Koshi Makita Copyright © 2016 Yu Qi et al. All rights reserved. The AMBU® Aura-i™ Laryngeal Mask and LMA Supreme™: A Randomized Trial of Clinical Performance and Fibreoptic Positioning in Unparalysed, Anaesthetised Patients by Novices Tue, 25 Oct 2016 11:42:51 +0000 Introduction. Manikin studies’ data cannot accurately be extrapolated to real-life scenarios and inherent differences in design and materials of newer products may affect their clinical performance. Methods. Hence, we compared the AMBU® Aura-i™ and LMA Supreme™ in this randomized trial involving 100 ASA 1-2 unparalysed anaesthetised patients undergoing minor gynaecological surgery. Investigators had <20 Aura-i insertions. Primary outcome was time to achieve effective ventilation and secondarily insertion parameters, oropharyngeal leak pressures (OLP), fibreoptic positioning, and pharyngeal morbidity. The position of the Ambu Aura-i was evaluated with the Ascope; the fiberoptic view of the glottis was scored on a five-point scale. Results. 43 (86%) AMBU Aura-i and 44 (88%) LMA Supremes were successfully inserted on first attempt (), with similar ease (), and comparable times to first capnogram, mean (SD) 18.2 (6.0) versus 17.3 (6.4) sec, . The Aura-i needed significantly less volume of air to inflate its cuff to 60 cmH2O on the manometer, 17.7 (3.5) versus 23.1 (4.4) mL, . Both devices exhibited similar OLP, Aura-i versus LMA Supreme, mean (SD) 28.8 (7.1) versus 27.3 (5.3) cmH2O, . There was no difference in ease of insertion or adjustment manoeuvres to aid ventilation. 90% of patients had good positioning of Aura-i on fibreoptic check, yielding a view of the vocal cords and epiglottis. In 5 patients (10%), the vocal cords were not seen, but ventilatory function was unaffected. Conclusions. The Aura-i handled well in novices hands, with comparable times to insert and establish ventilation, similar leak pressures, and successful first attempt insertion rates compared to the LMA Supreme. Zanahriah Yahaya, Wendy H. Teoh, Nora A. Dintan, and Ravi Agrawal Copyright © 2016 Zanahriah Yahaya et al. All rights reserved. Current Trends in Neuromuscular Blockade, Management, and Monitoring amongst Singaporean Anaesthetists Thu, 13 Oct 2016 05:53:19 +0000 Introduction. This survey aimed to investigate the attitudes/practice pertaining the use, management, and monitoring of neuromuscular blockade amongst Singaporean anaesthetists. Methods. All specialist accredited anaesthetists registered with the Singapore Medical Council were invited to complete an anonymous online survey. Results. The response rate was 39.5%. Neuromuscular monitoring (NM) was used routinely by only 13.1% despite the widespread availability of monitors. 82% stated residual NMB (RNMB) was a significant risk factor for patient outcome, but only 24% believed NMB monitoring should be compulsory in all paralyzed patients. 63.6% of anaesthetists estimated the risk of RNMB in their own institutions to be <5%. 63.1% always gave reversal. Neostigmine was predominantly used (85.1%), with 28.2% using sugammadex at least sometimes, citing unavailability and high costs. However, 83.8% believed in sugammadex’s benefits for patients’ safety and >50% said such benefits may be able to offset the associated costs. Conclusions. There is a significant need for reeducation about RNMB, studies on local RNMB incidences, and strengthening of current monitoring practices and guidelines. Strategies are discussed. As NM monitors appear widely available and reversal of NMB standard practice, it is hopeful that Singaporean anaesthetists will change and strive for evidence-based best clinical practice to enhance patient safety. Wendy H. Teoh, Thomas Ledowski, and Phillip S. Tseng Copyright © 2016 Wendy H. Teoh et al. All rights reserved. Time Trends and Predictors of Abnormal Postoperative Body Temperature in Infants Transported to the Intensive Care Unit Thu, 29 Sep 2016 08:57:40 +0000 Background. Despite increasing adoption of active warming methods over the recent years, little is known about the effectiveness of these interventions on the occurrence of abnormal postoperative temperatures in sick infants. Methods. Preoperative and postoperative temperature readings, patient characteristics, and procedural factors of critically ill infants at a single institution were retrieved retrospectively from June 2006 until May 2014. The primary endpoints were the incidence and trend of postoperative hypothermia and hyperthermia on arrival at the intensive care units. Univariate and adjusted analyses were performed to identify factors independently associated with abnormal postoperative temperatures. Results. 2,350 cases were included. 82% were normothermic postoperatively, while hypothermia and hyperthermia each occurred in 9% of cases. During the study period, hypothermia decreased from 24% to 2% () while hyperthermia remained unchanged (13% in 2006, 8% in 2014, ). Factors independently associated with hypothermia were higher ASA status (), lack of intraoperative convective warming () and procedure date before 2010 (). Independent associations for postoperative hyperthermia included lower body weight () and procedure date before 2010 (). Conclusions. We report an increase in postoperative normothermia rates in critically ill infants from 2006 until 2014. Careful monitoring to avoid overcorrection and hyperthermia is recommended. Hedwig Schroeck, Angela K. Lyden, Wendy L. Benedict, and Satya Krishna Ramachandran Copyright © 2016 Hedwig Schroeck et al. All rights reserved. Hypnosis in the Perioperative Management of Breast Cancer Surgery: Clinical Benefits and Potential Implications Sun, 21 Aug 2016 12:46:59 +0000 The aim of this review is to summarize data published on the use of perioperative hypnosis in patients undergoing breast cancer surgery (BCS). Indeed, the majority of BCS patients experience stress, anxiety, nausea, vomiting, and pain. Correct management of the perioperative period and surgical removal of the primary tumor are clearly essential but can affect patients on different levels and hence have a negative impact on oncological outcomes. This review examines the effect of clinical hypnosis performed during the perioperative period. Thanks to its specific properties and techniques allowing it to be used as complementary treatment preoperatively, hypnosis has an impact most notably on distress and postoperative pain. During surgery, hypnosis may be applied to limit immunosuppression, while, in the postoperative period, it can reduce pain, anxiety, and fatigue and improve wound healing. Moreover, hypnosis is inexpensive, an important consideration given current financial concerns in healthcare. Of course, large randomized prospective studies are now needed to confirm the observed advantages of hypnosis in the field of oncology. Arnaud Potié, Fabienne Roelants, Audrey Pospiech, Mona Momeni, and Christine Watremez Copyright © 2016 Arnaud Potié et al. All rights reserved. The Effect of Dexmedetomidine on Lumbar Epidural Injection for Failed Back Surgery Syndrome Wed, 17 Aug 2016 08:53:51 +0000 Purpose. Failed back surgery syndrome is a chronic pain condition requiring rapid, effective, and efficient management. This study evaluates the effect of adding dexmedetomidine to lumbar epidural steroids in patients with failed back surgery syndrome. Methods. Fifty patients suffering from failed back surgery syndrome were randomly assigned to one of two groups, receiving an epidural injection of 20 mL of either a mixture of betamethasone (14 mg) and bupivacaine 0.5 mg (group C) or a mixture of betamethasone (14 mg), bupivacaine 0.5 mg, and dexmedetomidine (0.5 μg/kg) (group D) adjusted to the volume with normal saline. The effect was evaluated using visual analogue scale (VAS), analgesic requirement, and Oswestry disability index 2 weeks, 4 weeks, 8 weeks, and 12 weeks after injection. Results. VAS and ibuprofen consumption showed a significant reduction in group D. The Oswestry disability index was significantly improved in group D. There were no records of hypotension, bradycardia, sedation, or hypoxemia in both groups. Conclusion. The present study demonstrated potential safe and effective usage of adding dexmedetomidine to epidural steroid to control pain in patients with failed back surgery syndrome. Ashraf Eskandr and Sadik Abdel Maseeh Copyright © 2016 Ashraf Eskandr and Sadik Abdel Maseeh. All rights reserved. Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire Tue, 16 Aug 2016 10:46:22 +0000 Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, ). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients. Diwakar D. Balachandran, Saadia A. Faiz, Mike Hernandez, Alicia M. Kowalski, Lara Bashoura, Farzin Goravanchi, Sujith V. Cherian, Elizabeth Rebello, Spencer S. Kee, and Katy E. French Copyright © 2016 Diwakar D. Balachandran et al. All rights reserved. Intubation Success through I-Gel® and Intubating Laryngeal Mask Airway® Using Flexible Silicone Tubes: A Randomised Noninferiority Trial Sun, 10 Jul 2016 11:25:52 +0000 Introduction. The study aims to test whether flexible silicone tubes (FST) improve performance and provide similar intubation success through I-Gel as compared to ILMA. Our trial is registered in CTRI and the registration number is “CTRI/2016/06/006997.” Methods. One hundred and twenty ASA status I-II patients scheduled for elective surgical procedures needing tracheal intubation were randomised to endotracheal intubation using FST through either I-Gel or ILMA. In the ILMA group (), intubation was attempted through ILMA using FST and, in the I-Gel group (), FST was inserted through I-Gel airway. Results. Successful intubation was achieved in 36.67% (95% CI 24.48%–48.86%) on first attempt through I-Gel () compared to 68.33% (95% CI 56.56%–80.1%) in ILMA () (). The overall intubation success rate was also lower with I-Gel group [58.3% (95% CI 45.82%–70.78%); ] compared to ILMA [90% (95% CI 82.41%–97.59%); ] (). The number of attempts, ease of intubation, and time to intubation were longer with I-Gel compared to ILMA. There were no differences in the other secondary outcomes. Conclusion. The first pass success rate and overall success of FST through an I-Gel airway were inferior to those of ILMA. Latha Naik, Neerja Bhardwaj, Indu Mohini Sen, and Rakesh V. Sondekoppam Copyright © 2016 Latha Naik et al. All rights reserved. The Effect of Patient Weight and Provider Training and Experience on Dosing of Rocuronium Sun, 26 Jun 2016 11:49:43 +0000 Introduction. Maintenance dosing of neuromuscular blocking agents is complex and varies with patient, procedure, and clinical situation. With this in mind, we sought to identify factors impacting the maintenance dosing of neuromuscular blockers as a step toward identifying best practice with respect to minimizing residual neuromuscular blockade. Methods. Cases utilizing rocuronium from July 1, 2010, to June 30, 2014, at the sponsoring institution were analyzed. Using a mixed model to account for repeated measures, patients were analyzed by dose and weight category as defined by the World Health Organization (eight categories ranging from very severely underweight to very severely obese) as well as by the administering provider’s level of experience. Results. The study included 12,671 patients with a mean age of 49.7 (SD 16.7). Increasing weight category and higher levels of provider experience were associated with higher doses for rocuronium. There were no differences in initial dose or in frequency of maintenance dosing by weight category after controlling for case length. Discussion. The two dosing patterns identified, higher doses for overweight patients and higher doses administered by experienced providers, are modifiable factors that could enhance patient safety. N. C. Godwin, L. Rodriguez, S. Banks, B. T. Major, and Y. Rodriguez Copyright © 2016 N. C. Godwin et al. All rights reserved. Comparison of Medical Adhesive Tapes in Patients at Risk of Facial Skin Trauma under Anesthesia Sun, 12 Jun 2016 11:55:40 +0000 Introduction. Adhesive tapes are used for taping eyelids closed and securing endotracheal tubes during general anesthesia. These tapes can cause facial skin injury. We compared the incidence of facial skin injury and patient satisfaction with different tapes used. Methods. A total of 60 adult patients at risk of skin trauma were randomized to use 3M™ Kind Removal Silicone Tape or standard acrylate tapes: 3M Durapore (endotracheal tube) and Medipore (eyelids). Patients were blinded to tape used. Postoperatively, a blinded recovery nurse assessed erythema, edema, and denudation of skin. Anesthesiologist in charge also assessed skin injury. On postoperative day 1, patients rated satisfaction with the condition of their skin over the eyelids and face on a 5-point Likert scale. Results. More patients had denudation of skin with standard tapes, 4 (13.3%) versus 0 with silicone tape () and in anesthesiologist-evaluated skin injury 11 (37%) with standard versus 1 (3%) with silicone (). No significant differences were found in erythema and edema. Patient satisfaction score was higher with silicone tape: over eyelids: mean 3.83 (standard) versus 4.53 (silicone), Mann-Whitney test, ; over face: mean 3.87 (standard) versus 4.57 (silicone) (). Conclusion. Silicone tape use had less skin injury and greater patient satisfaction than standard acrylate tapes. Ling Antonia Zeng, Sui An Lie, and Shin Yuet Chong Copyright © 2016 Ling Antonia Zeng et al. All rights reserved. Effects of Addition of Systemic Tramadol or Adjunct Tramadol to Lidocaine Used for Intravenous Regional Anesthesia in Patients Undergoing Hand Surgery Mon, 30 May 2016 13:47:37 +0000 Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique with clinical advantages. The present study aimed to investigate the effects of addition of systemic tramadol or adjunct tramadol to lidocaine for IVRA in patients undergoing hand surgery. American Society of Anesthesiologists (ASA) I-II patients () who underwent hand surgery were included. For this purpose, only lidocaine (LDC), lidocaine+adjunct tramadol (LDC+TRA group), or lidocaine+systemic tramadol (LDC+SysTRA group) was administered to the patients for IVRA and the groups were compared in terms of onset and recovery time of sensory and motor blocks, quality of anesthesia, and the degree of intraoperative and postoperative pain. The onset time of sensorial block was significantly shorter in the LDC+TRA group than that in the LDC+SysTRA group. The motor block recovery time was significantly shorter in the LDC+SysTRA group than that in the LDC+TRA and LDC groups. Administration of tramadol as an adjunct showed some clinical benefits by providing a shorter onset time of sensory and motor block, decreasing pain and analgesic requirement, and improving intraoperative conditions during IVRA. It was determined that systemic tramadol administration had no superiority. Abdulkadir Yektaş, Funda Gümüş, Abdulhalim Karayel, and Ayşin Alagöl Copyright © 2016 Abdulkadir Yektaş et al. All rights reserved. Comparison of the Success of Two Techniques for the Endotracheal Intubation with C-MAC Video Laryngoscope Miller Blade in Children: A Prospective Randomized Study Sun, 15 May 2016 11:20:38 +0000 Background. Ease of endotracheal intubation with C-MAC video laryngoscope (VLS) with Miller blades 0 and 1 has not been evaluated in children. Methods. Sixty children weighing 3–15 kg with normal airway were randomly divided into two groups. Intubation was done with C-MAC VLS Miller blade using either nonstyletted endotracheal tube (ETT) (group WS) or styletted ETT (group S). The time for intubation and total procedure, intubation attempts, failed intubation, blade repositioning or external laryngeal maneuver, and complications were recorded. Results. The median (minimum/maximum) time for intubation in group WS and group S was 19.5 (9/48) seconds and 13.0 (18/55) seconds, respectively (). The median (minimum/maximum) time for procedure in group WS was 30.5 (18/72) seconds and in group S was 24.5 (14/67) seconds, respectively (). Intubation in first attempt was done in 28 children in group WS and in 30 children in group S. Repositioning was required in 14 children in group WS and in 7 children in group S (). There were no failure to intubate, desaturation, and bradycardia in both groups. Conclusion. Styletted ETT significantly reduces time for intubation and time for procedure in comparison to nonstyletted ETT. Renu Sinha, Ankur Sharma, Bikash Ranjan Ray, Ravinder Kumar Pandey, Vanlalnghka Darlong, Jyotsna Punj, Chandralekha Chandralekha, and Ashish Datt Upadhyay Copyright © 2016 Renu Sinha et al. All rights reserved.