BioMed Research International: Anesthesiology The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Red Cell Storage Duration Does Not Affect Outcome after Massive Blood Transfusion in Trauma and Nontrauma Patients: A Retrospective Analysis of 305 Patients Sun, 14 May 2017 00:00:00 +0000 Background. Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. Methods. We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. Results. 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, ). The relationship did not differ for trauma and nontrauma patients (). Results were similar after adjusting for multiple potential confounders. Conclusions. Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage. Alexander Bautista, Theodore B. Wright, Janice Meany, Sunitha K. Kandadai, Benjamin Brown, Kareim Khalafalla, Saeed Hashem, Jason W. Smith, Tayyeb M. Ayyoubi, Jarrod E. Dalton, Anupama Wadhwa, Daniel I. Sessler, and Detlef Obal Copyright © 2017 Alexander Bautista et al. All rights reserved. A Review of Modern Control Strategies for Clinical Evaluation of Propofol Anesthesia Administration Employing Hypnosis Level Regulation Thu, 30 Mar 2017 12:00:59 +0000 Regulating the depth of hypnosis during surgery is one of the major objectives of an anesthesia infusion system. Continuous administration of Propofol infusion during surgical procedures is essential but it unduly increases the load of an anesthetist working in a multitasking scenario in the operation theatre. Manual and target controlled infusion systems are not appropriate to handle instabilities like blood pressure and heart rate changes arising due to interpatient and intrapatient variability. Patient safety, large interindividual variability, and less postoperative effects are the main factors motivating automation in anesthesia administration. The idea of automated system for Propofol infusion excites control engineers to come up with more sophisticated systems that can handle optimum delivery of anesthetic drugs during surgery and avoid postoperative effects. A linear control technique is applied initially using three compartmental pharmacokinetic and pharmacodynamic models. Later on, sliding mode control and model predicative control achieve considerable results with nonlinear sigmoid model. Chattering and uncertainties are further improved by employing adaptive fuzzy control and control. The proposed sliding mode control scheme can easily handle the nonlinearities and achieve an optimum hypnosis level as compared to linear control schemes, hence preventing mishaps such as underdosing and overdosing of anesthesia. Muhammad Ilyas, Muhammad Fasih Uddin Butt, Muhammad Bilal, Khalid Mahmood, Ali Khaqan, and Raja Ali Riaz Copyright © 2017 Muhammad Ilyas et al. All rights reserved. Real-Time Ultrasound/MRI Fusion for Suprasacral Parallel Shift Approach to Lumbosacral Plexus Blockade and Analysis of Injectate Spread: An Exploratory Randomized Controlled Trial Wed, 15 Mar 2017 00:00:00 +0000 Fused real-time ultrasound and magnetic resonance imaging (MRI) may be used to improve the accuracy of advanced image guided procedures. However, its use in regional anesthesia is practically nonexistent. In this randomized controlled crossover trial, we aim to explore effectiveness, procedure-related outcomes, injectate spread analyzed by MRI, and safety of ultrasound/MRI fusion versus ultrasound guided Suprasacral Parallel Shift (SSPS) technique for lumbosacral plexus blockade. Twenty-six healthy subjects aged 21–36 years received two SSPS blocks (20 mL 2% lidocaine-epinephrine [1 : 200,000] added 1 mL diluted contrast) guided by ultrasound/MRI fusion versus ultrasound. Number (proportion) of subjects with motor blockade of the femoral and obturator nerves and the lumbosacral trunk was equal (ultrasound/MRI, 23/26 [88%]; ultrasound, 23/26 [88%]; ). Median (interquartile range) preparation and procedure times (s) were longer for the ultrasound/MRI fusion guided technique (686 [552–1023] versus 196 [167–228], and 333 [254–439] versus 216 [176–294], ). Both techniques produced perineural spread and corresponding sensory analgesia from L2 to S1. Epidural spread and lidocaine pharmacokinetics were similar. Different compartmentalized patterns of injectate spread were observed. Ultrasound/MRI fusion guided SSPS was equally effective and safe but required prolonged time, compared to ultrasound guided SSPS. This trial is registered with EudraCT (2013-004013-41) and (NCT02593370). Jennie Maria Christin Strid, Erik Morre Pedersen, Sinan Naseer Hussain Al-Karradi, Mathias Alrø Fichtner Bendtsen, Siska Bjørn, Mette Dam, Morten Daugaard, Martin Sejr Hansen, Katrine Danker Linnet, Jens Børglum, Kjeld Søballe, and Thomas Fichtner Bendtsen Copyright © 2017 Jennie Maria Christin Strid et al. All rights reserved. Comparison of Ramosetron with Palonosetron for Prevention of Postoperative Nausea and Vomiting in Patients Receiving Opioid-Based Intravenous Patient-Controlled Analgesia after Gynecological Laparoscopy Sun, 05 Mar 2017 10:06:41 +0000 We aimed to compare the effects of ramosetron and palonosetron in the prevention of postoperative nausea and vomiting (PONV) in patients that received opioid-based intravenous patient-controlled analgesia (IV-PCA) after gynecological laparoscopy. We reviewed the electronic medical records of 755 adults. Patients were classified into two groups, ramosetron (group R, ) versus palonosetron (group P, ). Based on their confounding factors, 152 subjects in each group were selected after the implementation of propensity score matching. The overall incidence of PONV at postoperative day (POD) 0 was lower in group R compared to group P (26.9% versus 36.8%; ). The severity of nausea was lower in group R than in group P on postoperative day (POD) 0 (). Also, the complete responder proportion of patients was significantly higher in group R compared to that in group P on POD 0 (). In conclusion, ramosetron showed a greater efficacy in the prevention of postoperative nausea at POD 0 compared to palonosetron in patients after gynecological laparoscopy. Eun Jin Ahn, Geun Joo Choi, Hyun Kang, Chong Wha Baek, Yong Hun Jung, and Young Cheol Woo Copyright © 2017 Eun Jin Ahn et al. All rights reserved. PainVision® Apparatus for Assessment of Efficacy of Pulsed Radiofrequency Combined with Pharmacological Therapy in the Treatment of Postherpetic Neuralgia and Correlations with Measurements Sun, 05 Mar 2017 00:00:00 +0000 Objective. PainVision device was a developed application for the evaluation of pain intensity. The objective was to assess the efficacy and safety of pulsed radiofrequency (PRF) combined with pharmacological therapy in the treatment of postherpetic neuralgia (PHN). We also discussed the correlation of the measurements. Method. Forty patients with PHN were randomized for treatment with PRF combined with pharmacological therapy (PRF group, ) or pharmacological therapy (control group, ) at postoperative 48 hours. The efficacy measure was pain degree (PD) that was assessed by PainVision and visual analog scale (VAS), short form Mcgill pain questionnaire (SF-Mcgill), and numeric rate scale sleep interference score (NRSSIS). Correlations between PD, VAS, SF-Mcgill, and NRSSIS were determined. Results. The PD for persistent pain (PP) and breakthrough pain (BTP) at postoperative 48 hours assessed by PainVision were significantly lower in PRF group than in control group (PD-PP, ; PD-BTP, ). PD and VAS were highly correlated for both persistent pain (, ) and breakthrough pain (, ). Conclusion. PRF was well tolerated and superior to isolated pharmacological therapy in the treatment of PHN. PainVision device showed great value in the evaluation of pain intensity and PD had an excellent correlation with VAS and SF-Mcgill. Dong Wang, Kai Zhang, ShaoLong Han, and LingZhi Yu Copyright © 2017 Dong Wang et al. All rights reserved. Caudal Epidural Block: An Updated Review of Anatomy and Techniques Sun, 26 Feb 2017 06:38:23 +0000 Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article. Sheng-Chin Kao and Chia-Shiang Lin Copyright © 2017 Sheng-Chin Kao and Chia-Shiang Lin. All rights reserved. Dexmedetomidine Attenuates Lipopolysaccharide Induced MCP-1 Expression in Primary Astrocyte Tue, 14 Feb 2017 07:26:01 +0000 Background. Neuroinflammation which presents as a possible mechanism of delirium is associated with MCP-1, an important proinflammatory factor which is expressed on astrocytes. It is known that dexmedetomidine (DEX) possesses potent anti-inflammatory properties. This study aimed to investigate the potential effects of DEX on the production of MCP-1 in lipopolysaccharide-stimulated astrocytes. Materials and Methods. Astrocytes were treated with LPS (10 ng/ml, 50 ng/ml, 100 ng/ml, and 1000 ng/ml), DEX (500 ng/mL), LPS (100 ng/ml), and DEX (10, 100, and 500 ng/mL) for a duration of three hours; expression levels of MCP-1 were measured by real-time PCR. The double immunofluorescence staining protocol was utilized to determine the expression of α2-adrenoceptors (α2AR) and glial fibrillary acidic protein (GFAP) on astrocytes. Results. Expressions of MCP-1 mRNA in astrocytes were induced dose-dependently by LPS. Administration of DEX significantly inhibited the expression of MCP-1 mRNA (). Double immunofluorescence assay showed that α2AR colocalize with GFAP, which indicates the expression of α2-adrenoceptors in astrocytes. Conclusions. DEX is a potent suppressor of MCP-1 in astrocytes induced with lipopolysaccharide through α2A-adrenergic receptors, which potentially explains its beneficial effects in the treatment of delirium by attenuating neuroinflammation. Huan Liu, Jacques R. J. Davis, Zhi-Lin Wu, and Amro Faez Abdelgawad Copyright © 2017 Huan Liu et al. All rights reserved. Ultrasound-Guided Obturator Nerve Block: A Focused Review on Anatomy and Updated Techniques Thu, 09 Feb 2017 07:01:29 +0000 This review outlines the anatomy of the obturator nerve and the indications for obturator nerve block (ONB). Ultrasound-guided ONB techniques and unresolved issues regarding these procedures are also discussed. An ONB is performed to prevent thigh adductor jerk during transurethral resection of bladder tumor, provide analgesia for knee surgery, treat hip pain, and improve persistent hip adductor spasticity. Various ultrasound-guided ONB techniques can be used and can be classified according to whether the approach is distal or proximal. In the distal approach, a transducer is placed at the inguinal crease; the anterior and posterior branches of the nerve are then blocked by two injections of local anesthetic directed toward the interfascial planes where each branch lies. The proximal approach comprises a single injection of local anesthetic into the interfascial plane between the pectineus and obturator externus muscles. Several proximal approaches involving different patient and transducer positions are reported. The proximal approach may be superior for reducing the dose of local anesthetic and providing successful blockade of the obturator nerve, including the hip articular branch, when compared with the distal approach. This hypothesis and any differences between the proximal ONB techniques need to be explored in future studies. Takayuki Yoshida, Tatsuo Nakamoto, and Takahiko Kamibayashi Copyright © 2017 Takayuki Yoshida et al. All rights reserved. The Effects of Intravenous Dexmedetomidine Injections on IOP in General Anesthesia Intubation: A Meta-Analysis Thu, 02 Feb 2017 00:00:00 +0000 Objective. The aim of this meta-analysis is to evaluate the effects of dexmedetomidine on intraocular pressure (IOP) in patients with general anesthesia administered via intubation. Methods. We searched randomized controlled trials (RCT) on the effects of intravenous injection of dexmedetomidine on IOP in patients with general anesthesia administered via intubation. Results. The meta-analysis study showed that (1) a statistically significant difference [WMD = −3.40 mmHg, 95% CI (−4.76, −2.04), ] was found between IOP of the two groups. (2) The IOP of the dexmedetomidine group that was administrated succinylcholine was lower than that of placebo group which was administrated succinylcholine [WMD = −4.13 mmHg, 95% CI (−6.01, −2.25), ]. (3) Compared with the IOP of patients in the placebo group, patients with intubation in the dexmedetomidine group maintained a lower IOP [WMD = −3.10 mmHg, 95% CI (−5.12, −1.07), ]. However, for incidences of bradycardia, the use of dexmedetomidine was higher than that of the placebo [RR = 0.23, 95% CI (0.07, 0.76), ]. Conclusion. This meta-analysis showed that, in many cases, dexmedetomidine can lower the IOP of patients with general anesthesia administered by intubation. Chengmao Zhou, Yu Zhu, Zhen Liu, and Lin Ruan Copyright © 2017 Chengmao Zhou et al. All rights reserved. The Performance of the Intubation Difficulty Scale among Obese Parturients Undergoing Cesarean Section Thu, 26 Jan 2017 08:19:35 +0000 Background. There have not yet been any studies to validate the intubation difficulty scale (IDS) in obese parturients. Objectives of this study were to determine the performance of the IDS in defining difficult intubation (DI) and to identify the optimal cutoff points of the IDS among obese parturients. Methods. This was a prospective observational study. Parturients with a body mass index ≥ 30 kg/m2 who underwent cesarean section utilizing endotracheal intubation were enrolled. The intubating performers were asked to assess the difficulty of endotracheal intubation and categorize it as easy, somewhat DI, and DI. Main Results. A total of 517 parturients were recruited with a mean BMI of 33.9 kg/m2. The incidence of some degree of DI was 14.5%. The area under the receiver operating characteristic curves of the IDS for detecting somewhat DI and DI was 1.0. The optimal cutoff point to define somewhat DI was ≥3 and DI was ≥5, which both had sensitivity and specificity of 100%. Conclusions. The IDS scoring is a good tool for defining DI among obese parturients. The IDS scores of ≥3 and ≥5 are the optimal cutoff points to define somewhat DI and DI, respectively. Jatuporn Eiamcharoenwit, Napon Itthisompaiboon, Panita Limpawattana, and Arunotai Siriussawakul Copyright © 2017 Jatuporn Eiamcharoenwit et al. All rights reserved. Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques Tue, 03 Jan 2017 10:37:05 +0000 Purpose of Review. Since the original publication on the quadratus lumborum (QL) block, the technique has evolved significantly during the last decade. This review highlights recent advances in various approaches for administering the QL block and proposes directions for future research. Recent Findings. The QL block findings continue to become clearer. We now understand that the QL block has several approach methods (anterior, lateral, posterior, and intramuscular) and the spread of local anesthetic varies with each approach. In particular, dye injected using the anterior QL block approach spread to the L1, L2, and L3 nerve roots and within psoas major and QL muscles. Summary. The QL block is an effective analgesic tool for abdominal surgery. However, the best approach is yet to be determined. Therefore, the anesthetic spread of the several QL blocks must be made clear. Hironobu Ueshima, Hiroshi Otake, and Jui-An Lin Copyright © 2017 Hironobu Ueshima et al. All rights reserved. Recruitment Maneuver in Elderly Patients with Different Peripheral Chemoreflex Sensitivity during Major Abdominal Surgery Tue, 13 Dec 2016 14:34:41 +0000 The goal of the study was to evaluate the effect of a recruitment maneuver on respiratory biomechanics, oxygenation, and hemodynamics in patients suffering from chronic heart failure with different peripheral chemoreflex sensitivity. The study was conducted in 115 elderly patients which underwent major abdominal surgery under general/epidural surgery. Peripheral chemoreflex sensitivity (PCS) was evaluated with breath-holding duration (BHD) during breath-holding test. All patients were divided into two groups: group H had a high PCS (BHD = 38 seconds or less, ); Group M had a middle PCS (BHD more than 38 seconds, ). Recruitment maneuver improved oxygenation and respiratory biomechanics in all cases. However, cardiac output decreased by an average of 18%–31% in group H compared to 18%–28% in group M. SVR either remained unchanged or decreased by up to 14% of the initial value in group H, while, in group M, it had a tendency to increase, which was 24% of the initial value. So, recruitment maneuver is an effective method to improve oxygenation and biomechanical properties of the respiratory system but in patients with increased peripheral chemoreflex sensitivity it associates with the risk of hemodynamic disturbances. Nikita Trembach and Igor Zabolotskikh Copyright © 2016 Nikita Trembach and Igor Zabolotskikh. All rights reserved. Assessment of Ventilation Distribution during Laparoscopic Bariatric Surgery: An Electrical Impedance Tomography Study Mon, 12 Dec 2016 11:07:07 +0000 Introduction. The aim of the study was to assess changes of regional ventilation distribution at the level of the 3rd intercostal space in the lungs of morbidly obese patients as a result of general anaesthesia and laparoscopic surgery as well as the relation of these changes to lung mechanics. We also wanted to determine if positive end-expiratory pressure of 10 cm H2O prevents the expected atelectasis in the morbidly obese patients during general anaesthesia. Materials and Methods. 49 patients completed the examination and were randomized to 2 groups: ventilated without positive end-expiratory pressure (PEEP 0) and with PEEP of 10 cm H2O (PEEP 10) preceded by a recruitment maneuver with peak inspiratory pressure of 40 cm H2O. Impedance Ratio (IR) was utilized to examine ventilation distribution changes as a result of anaesthesia, pneumoperitoneum, and change of body position. We also analyzed intraoperative respiratory mechanics and pulse oximetry values. Results. In both groups general anaesthesia caused a ventilation shift towards the nondependent lungs which was not further intensified after pneumoperitoneum. Reverse Trendelenburg position promoted homogeneous ventilation distribution. Respiratory system compliance was reduced after insufflation and improved after exsufflation of pneumoperitoneum. There were no statistically significant differences in ventilation distribution between the examined groups. Respiratory system compliance, plateau pressure, and pulse oximetry values were higher in PEEP 10. Conclusions. Changes of ventilation distribution in the obese do occur at cranial lung regions. During pneumoperitoneum alterations of ventilation distribution may not follow the direction of the changes of lung mechanics. In the obese patients PEEP level of 10 cm H2O preceded by a recruitment maneuver improves respiratory compliance and oxygenation but does not eliminate atelectasis induced by general anaesthesia. Michal Stankiewicz-Rudnicki, Wojciech Gaszynski, and Tomasz Gaszynski Copyright © 2016 Michal Stankiewicz-Rudnicki et al. All rights reserved. Ketorolac Tromethamine Spray Prevents Postendotracheal-Intubation-Induced Sore Throat after General Anesthesia Tue, 29 Nov 2016 07:33:02 +0000 Background. Postoperative sore throat is one of the major complaints of general anesthesia in the postanesthesia care unit. This prospective study investigated the preventive effect of ketorolac tromethamine spray in postendotracheal-intubation-induced sore throat after general anesthesia. Methods. Surgical patients undergoing general anesthesia with endotracheal intubation were recruited from a medical center. Patients were randomly assigned to group K (treated with 5% ketorolac tromethamine spray) or group D (treated with distilled water spray). Before intubation, each endotracheal tube was sprayed with the appropriate solution by physicians over the 20 cm length of the cuff. Each group comprised 95 patients fitting the inclusion and exclusion criteria for whom complete data sets were collected. The intensity of the sore throat was measured at 1, 3, 6, and 24 h after surgery, and data were compared. Results. The two groups had similar characteristics. Postoperative sore throat was significantly less frequent in group K than in group D () and the pain intensity was significantly lower in group K than in group D at each time point (all ). Conclusions. This study demonstrated that preanesthesia 5% ketorolac tromethamine spray could effectively decrease postendotracheal-intubation-induced sore throat in patients undergoing general anesthesia. H. L. Yang, F. C. Liu, S. C. Tsai, P. K. Tsay, H. T. Lin, and H. E. Liu Copyright © 2016 H. L. Yang et al. All rights reserved. Low-Volume Brachial Plexus Block Providing Surgical Anesthesia for Distal Arm Surgery Comparing Supraclavicular, Infraclavicular, and Axillary Approach: A Randomized Observer Blind Trial Mon, 21 Nov 2016 11:32:16 +0000 Background. Distal arm surgery is widely performed under regional anesthesia with brachial plexus block. The preponderance of evidence for the efficacy relies upon injection of local anesthetic in excess of 30 mL. We aimed to compare three different ultrasound-guided brachial plexus block techniques restricting the total volume to 20 mL. Methods. 120 patients were prospectively randomized to ultrasound-guided brachial plexus block with 20 mL ropivacaine 0.75% at either the supraclavicular, infraclavicular, or axillary level. Multiinjection technique was performed with all three approaches. Primary outcome measure was performance time. Results. Performance time and procedural pain were similar between groups. Needle passes and injection numbers were significantly reduced in the infraclavicular group (). Nerve visibility was significantly reduced in the axillary group (). Success-rate was significantly increased in the supraclavicular versus the axillary group (). Total anesthesia-related time was significantly reduced in the supraclavicular compared to the infraclavicular group (). Block duration was significantly increased in the infraclavicular group (). No early adverse effects occurred. Conclusion. Supraclavicular and infraclavicular blocks exhibited favorable characteristics compared to the axillary block. Supraclavicular brachial plexus block with the multiinjection intracluster technique exhibited significantly reduced total anesthesia-related time and higher success rate without any early adverse events. Mojgan Vazin, Kenneth Jensen, Danja L. Kristensen, Mathias Hjort, Katrine Tanggaard, Manoj K. Karmakar, Thomas F. Bendtsen, and Jens Børglum Copyright © 2016 Mojgan Vazin et al. All rights reserved. 5HT3 Antagonists versus Dexamethasone in the Prevention of PONV in Patients Undergoing Laparoscopic Cholecystectomy: A Meta-Analysis of RCTs Sun, 06 Nov 2016 07:20:43 +0000 Background. 5HT3 antagonist, an antiemetic alternative to dexamethasone, is an effective drug for the prevention of postoperative nausea and vomiting (PONV). Methods. PubMed and The Cochrane Library (from inception to June 2016) were searched for relevant RCTs (randomized controlled trials). Results. Seven trials, totaling 682 patients, were included in this meta-analysis. This meta-analysis demonstrated that 5HT3 antagonist was as effective as dexamethasone in preventing PONV (RR, 1.12; 95% CI, [0.86, 1.45]; ) within 24 hours of laparoscopic cholecystectomy, and no significant heterogeneity was observed among the studies (; ). During the early postoperative period (0–6 h), 5HT3 antagonists were superior to dexamethasone in reducing POV (RR, 0.31; 95% CI, [0.11, 0.93]; ), while, in other postoperative stages (6–12 h, 12–24 h, and 0–24 h), it was not more effective in the prevention of POV than dexamethasone. And no significant difference was found in the prevention of PON between 5HT3 antagonists and dexamethasone at different postoperative periods (0–6 h, 6–12 h, 12–24 h, and 0–24 h). Conclusions. As a result, it is advisable to encourage 5HT3 antagonists as an alternative to dexamethasone for the prevention of PONV in patients undergoing laparoscopic cholecystectomy. Chengmao Zhou, Yu Zhu, Zhen Liu, and Lin Ruan Copyright © 2016 Chengmao Zhou et al. All rights reserved. Jet Ventilation during Rigid Bronchoscopy in Adults: A Focused Review Wed, 26 Oct 2016 07:10:00 +0000 The indications for rigid bronchoscopy for interventional pulmonology have increased and include stent placements and transbronchial cryobiopsy procedures. The shared airway between anesthesiologist and pulmonologist and the open airway system, requiring specific ventilation techniques such as jet ventilation, need a good understanding of the procedure to reduce potentially harmful complications. Appropriate adjustment of the ventilator settings including pause pressure and peak inspiratory pressure reduces the risk of barotrauma. High frequency jet ventilation allows adequate oxygenation and carbon dioxide removal even in cases of tracheal stenosis up to frequencies of around 150 min−1; however, in an in vivo animal model, high frequency jet ventilation along with normal frequency jet ventilation (superimposed high frequency jet ventilation) has been shown to improve oxygenation by increasing lung volume and carbon dioxide removal by increasing tidal volume across a large spectrum of frequencies without increasing barotrauma. General anesthesia with a continuous, intravenous, short-acting agent is safe and effective during rigid bronchoscopy procedures. Laurie Putz, Alain Mayné, and Anne-Sophie Dincq Copyright © 2016 Laurie Putz et al. All rights reserved. Diagnosis Accuracy of Mean Arterial Pressure Variation during a Lung Recruitment Maneuver to Predict Fluid Responsiveness in Thoracic Surgery with One-Lung Ventilation Thu, 13 Oct 2016 05:54:19 +0000 Background. Lung recruitment maneuver (LRM) during thoracic surgery can reduce systemic venous return and resulting drop in systemic blood pressure depends on the patient’s fluid status. We hypothesized that changes in systemic blood pressure during the transition in LRM from one-lung ventilation (OLV) to two-lung ventilation (TLV) may provide an index to predict fluid responsiveness. Methods. Hemodynamic parameters were measured before LRM (); after LRM at the time of the lowest mean arterial blood pressure (MAP) () and at 3 minutes (); before fluid administration (); and 5 minutes after ending it (). If the stroke volume index increased by >25% following 10 mL/kg colloid administration for 30 minutes, then the patients were assigned to responder group. Results. Changes in MAP, central venous pressure (CVP), and stroke volume variation (SVV) between and were significantly larger in responders. Areas under the curve for change in MAP, CVP, and SVV were 0.852, 0.759, and 0.820, respectively; the optimal threshold values for distinguishment of responders were 9.5 mmHg, 0.5 mmHg, and 3.5%, respectively. Conclusions. The change in the MAP associated with LRM at the OLV to TLV conversion appears to be a useful indicator of fluid responsiveness after thoracic surgery. Trial Registration. This trial is registered at Clinical Research Information Service with KCT0000774. Woon-Seok Kang, Chung-Sik Oh, Chulmin Park, Bo Mi Shin, Tae-Gyoon Yoon, Ka-Young Rhee, Nam-Sik Woo, and Seong-Hyop Kim Copyright © 2016 Woon-Seok Kang et al. All rights reserved. Effect of Ulinastatin in the Treatment of Postperative Cognitive Dysfunction: Review of Current Literature Sun, 14 Aug 2016 11:47:52 +0000 Background. Ulinastatin, identified as a urinary trypsin inhibitor, has been widely used in patients with inflammatory disorders. However, little is known about its effect on postoperative cognitive dysfunction (POCD). The aim of our current work is to review the current body of literature. Methods. A systematic literature search in PubMed and EMBASE was performed to identify randomized controlled trials. Incidence of POCD, MMSE score, and laboratory indicators (IL-6, TNF-α, CRP, and S100β) were selected as outcomes. Results. Five RCTs involving 461 elderly patients that underwent surgical operations were identified. The meta-analysis suggested no statistical difference of incidence of POCD between ulinastatin and control groups on postoperative day 1; but ulinastatin could significantly decrease the incidence of POCD on postoperative day 3 and day 7 when compared with control treatment. Ulinastatin was effective in improving the MMSE score on day 1, day 3, and day 7 after operation. IL-6 and S100β concentrations were lower up to postoperative day 2. The incidences of postoperative complications in ulinastatin groups were lower than control. Conclusion. Ulinastatin administration was effective in treating early POCD (postoperative day 3 and day 7) and reducing IL-6 and S100β concentrations within two days after operations. Studies with larger-scale and rigorous design are urgently needed. Zheng-tao Lv, Jun-ming Huang, Jin-ming Zhang, Jia-ming Zhang, Jin-feng Guo, and An-min Chen Copyright © 2016 Zheng-tao Lv et al. All rights reserved. Docosahexaenoic Acid Rescues Synaptogenesis Impairment and Long-Term Memory Deficits Caused by Postnatal Multiple Sevoflurane Exposures Thu, 11 Aug 2016 16:14:41 +0000 Sevoflurane exposures were demonstrated to induce neurotoxicity in the developing brain in both human and animal studies. However, there is no effective approach to reverse it. The present study aimed to evaluate the feasibility of utilizing docosahexaenoic acid (DHA) to prevent sevoflurane-induced neurotoxicity. P6 (postnatal 6 days) mice were administrated DHA after exposure to 3% sevoflurane for two hours daily in three consecutive days. Molecular expressions of synaptic makers (PSD95, synaptophysin) and synaptic morphological changes were investigated by Western blot analysis and transmission electron microscopy, respectively. Meanwhile, Morris water maze test was used to assess spatial memory of mice at P31 (postnatal 31 days). DHA restored sevoflurane-induced decreased level of PSD95 and synaptophysin expressions and increased PSD areas and also improved long-term spatial memory. These results suggest that DHA could rescue synaptogenesis impairment and long-term memory deficits in postnatal caused by multiple sevoflurane exposures. Guorong Tao, Yan Luo, Qingsheng Xue, Guohui Li, Yongchang Tan, Jinglei Xiao, and Buwei Yu Copyright © 2016 Guorong Tao et al. All rights reserved. Maraviroc-Mediated Lung Protection following Trauma-Hemorrhagic Shock Sun, 31 Jul 2016 13:52:40 +0000 Objectives. The peroxisome proliferator-activated receptor gamma (PPARγ) pathway exerts anti-inflammatory effects in response to injury. Maraviroc has been shown to have potent anti-inflammatory effects. The aim of this study was to investigate whether PPARγ plays an important role in maraviroc-mediated lung protection following trauma-hemorrhage. Methods. Male Sprague-Dawley rats underwent trauma-hemorrhage (mean blood pressure maintained at approximately 35–40 mmHg for 90 minutes), followed by fluid resuscitation. During resuscitation, a single dose of maraviroc (3 mg/kg, intravenously) with and without a PPARγ inhibitor GW9662 (1 mg/kg, intravenously), GW9662, or vehicle was administered. Lung water content, tissue histology, and other various parameters were measured ( rats/group) 24 hours after resuscitation. One-way ANOVA and Tukey’s testing were used for statistical analysis. Results. Trauma-hemorrhage significantly increased lung water content, myeloperoxidase activity, intercellular adhesion molecule-1, interleukin-6, and interleukin-1β levels. These parameters significantly improved in the maraviroc-treated rats subjected to trauma-hemorrhage. Maraviroc treatment also decreased lung tissue damage as compared to the vehicle-treated trauma-hemorrhaged rats. Coadministration of GW9662 with maraviroc abolished the maraviroc-induced beneficial effects on these parameters and lung injury. Conclusion. These results suggest that PPARγ might play a key role in maraviroc-mediated lung protection following trauma-hemorrhage. Fu-Chao Liu, Chih-Wen Zheng, and Huang-Ping Yu Copyright © 2016 Fu-Chao Liu et al. All rights reserved. Comparison of TIVA and Desflurane Added to a Subanaesthetic Dose of Propofol in Patients Undergoing Coronary Artery Bypass Surgery: Evaluation of Haemodynamic and Stress Hormone Changes Wed, 27 Jul 2016 08:27:04 +0000 Introduction. Increased levels of stress hormones are associated with mortality in patients undergoing coronary artery bypass grafting (CABG). Aim. To compare total intravenous anaesthesia (TIVA) and desflurane added to a subanaesthetic dose of propofol. Material and Methods. Fifty patients were enrolled in this study. Fentanyl (3–5 mcg/kg/h) was started in both groups. Patients were divided into two groups. The PD group () received 1 minimum alveolar concentration (MAC) desflurane anaesthesia in addition to propofol infusion (2-3 mg/kg/h), while P group () received propofol infusion (5-6 mg/kg/h) only. Biochemical data, cortisol, and insulin levels were measured preoperatively (T0), after initiation of CPB but before cross-clamping the aorta (T1), after removal of the cross-clamp (T2), and at the 24th postoperative hour (T3). Results. Systolic, diastolic, and mean arterial pressure levels were significantly higher in PD group than those in P group in T1 and T2 measurements (). CK-MB showed a significant decrease in group P (). When we compared both groups, cortisol levels were significantly higher in PD group than P group (). Conclusion. Stress and haemodynamic responses were better controlled using TIVA than desflurane inhalation added to a subanaesthetic dose of propofol in patients undergoing CABG. Didem Onk, Tülin Akarsu Ayazoğlu, Oruç Alper Onk, Mehmet Aksüt, Murat Günay, Kultigin Turkmen, Aynur Özensoy, Çiğdem Yazıcı Ersoy, and Abdulkadir Çoban Copyright © 2016 Didem Onk et al. All rights reserved. Comparison of Postoperative Events between Spinal Anesthesia and General Anesthesia in Laparoscopic Cholecystectomy: A Systemic Review and Meta-Analysis of Randomized Controlled Trials Mon, 25 Jul 2016 16:33:03 +0000 Background. Laparoscopic cholecystectomy is usually carried out under general anesthesia. There were a few studies which have found spinal anesthesia as a safe alternative. We aimed to evaluate the postoperative events between spinal anesthesia and general anesthesia in patients undergoing laparoscopic cholecystectomy. Methods. We searched PubMed, Embase, and Cochrane Library (from inception to January 2016) for eligible studies. The primary outcome was the visual analogue scale score. Secondary outcomes included postoperative nausea and vomiting and urine retention 24 hours postoperatively. We calculated pooled risk ratios and 95% confidence interval using random- or fixed-effects models. Results. Eight trials involving 723 patients were listed. Meta-analysis showed that patients in spinal anesthesia groups have lower visual analogue scale score 24 hours postoperatively. There were significant decreases in the occurrence of postoperative nausea and vomiting in spinal anesthesia group when compared with general anesthesia group (odds ratios: 0.38, 95% confidence interval: 0.19–0.76; ) with heterogeneity accepted (; ), while urine retention rate was increased in patients with spinal anesthesia (odds ratios: 4.95, 95% confidence interval: 1.24–19.71; ) without any heterogeneity (; ). Conclusions. Spinal anesthesia may be associated with less postoperative pain and postoperative nausea and vomiting compared with general anesthesia. Xian-Xue Wang, Quan Zhou, Dao-Bo Pan, Hui-Wei Deng, Ai-Guo Zhou, Hua-Jing Guo, and Fu-Rong Huang Copyright © 2016 Xian-Xue Wang et al. All rights reserved. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis Thu, 23 Jun 2016 14:54:09 +0000 Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta-analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view. Eun Jin Ahn, Geun Joo Choi, Hyun Kang, Chong Wha Baek, Yong Hun Jung, Young Cheol Woo, and Si Ra Bang Copyright © 2016 Eun Jin Ahn et al. All rights reserved. Effects of Low-Flow Sevoflurane Anesthesia on Pulmonary Functions in Patients Undergoing Laparoscopic Abdominal Surgery Mon, 20 Jun 2016 12:26:01 +0000 Objective. The aim of this prospective, randomized study was to investigate the effects of low-flow sevoflurane anesthesia on the pulmonary functions in patients undergoing laparoscopic cholecystectomy. Methods. Sixty American Society of Anesthesiologists (ASA) physical status classes I and II patients scheduled for elective laparoscopic cholecystectomy were included in the study. Patients were randomly allocated to two study groups: high-flow sevoflurane anesthesia group (Group H, ) and low-flow sevoflurane anesthesia group (Group L, ). The fresh gas flow rate was of 4 L/min in high-flow sevoflurane anesthesia group and 1 L/min in low-flow sevoflurane anesthesia group. Heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen saturation (SpO2), and end-tidal carbon dioxide concentration (ETCO2) were recorded. Pulmonary function tests were performed before and 2, 8, and 24 hours after surgery. Results. There was no significant difference between the two groups in terms of HR, MABP, SpO2, and ETCO2. Pulmonary function test results were similar in both groups at all measurement times. Conclusions. The effects of low-flow sevoflurane anesthesia on pulmonary functions are comparable to high-flow sevoflurane anesthesia in patients undergoing laparoscopic cholecystectomy. Cihan Doger, Kadriye Kahveci, Dilsen Ornek, Abdulkadir But, Mustafa Aksoy, Derya Gokcinar, and Didem Katar Copyright © 2016 Cihan Doger et al. All rights reserved. Influence of Mental Workload on the Performance of Anesthesiologists during Induction of General Anesthesia: A Patient Simulator Study Mon, 11 Apr 2016 16:02:29 +0000 The aim of this study was to reveal the effect of anesthesiologist’s mental workload during induction of general anesthesia. Twenty-two participants were categorized into anesthesiology residents (RA group, ) and board certified anesthesiologists (CA group, ). Subjects participated in three simulated scenarios (scenario A: baseline, scenario B: simple addition tasks, and scenario C: combination of simple addition tasks and treatment of unexpected arrhythmia). We used simple two-digit integer additions every 5 seconds as a secondary task. Four kinds of key actions were also evaluated in each scenario. In scenario C, the correct answer rate was significantly higher in the CA versus the RA group (RA: 0.370 ± 0.050 versus CA: 0.736 ± 0.051, , 95% CI −0.518 to −0.215) as was the score of key actions (RA: 2.7 ± 1.3 versus CA: 4.0 ± 0.00, ). In a serious clinical situation, anesthesiologists might not be able to adequately perform both the primary and secondary tasks. This tendency is more apparent in young anesthesiologists. Hitoshi Sato, Tetsuya Miyashita, Hiromasa Kawakami, Yusuke Nagamine, Shunsuke Takaki, and Takahisa Goto Copyright © 2016 Hitoshi Sato et al. All rights reserved. Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery in the Sugammadex Era: A Retrospective Study Mon, 22 Feb 2016 16:39:02 +0000 Background. Residual neuromuscular block (NMB) after general anesthesia has been associated with pulmonary dysfunction and hypoxia, which are both associated with postoperative delirium (POD). We evaluated the effects of sugammadex on POD in elderly patients who underwent hip fracture surgery. Methods. Medical records of 174 consecutive patients who underwent hip fracture surgery with general anesthesia were reviewed retrospectively to compare the perioperative incidence of POD, pulmonary complications, time to extubation, incidence of hypoxia, and laboratory findings between patients treated with sugammadex and those treated with a conventional cholinesterase inhibitor. Results. The incidence of POD was not significantly different between the two groups (33.3% versus 36.5%, resp.; ). Postoperative pulmonary complications and laboratory findings did not showed significant intergroup difference. However, time to extubation (6 ± 3 versus 8 ± 3 min; ) and the frequency of postoperative hypoxia were significantly lower (23% versus 43%; ) in the sugammadex group than in the conventional cholinesterase inhibitor group. Conclusion. Sugammadex did not reduce POD or pulmonary complications compared to conventional cholinesterase inhibitors, despite reducing time to extubation and postoperative hypoxia in elderly patients who underwent hip fracture surgery under general anesthesia. Chung-Sik Oh, Ka Young Rhee, Tae-Gyoon Yoon, Nam-Sik Woo, Seung Wan Hong, and Seong-Hyop Kim Copyright © 2016 Chung-Sik Oh et al. All rights reserved. Isoflurane Is More Deleterious to Developing Brain Than Desflurane: The Role of the Akt/GSK3 Signaling Pathway Mon, 01 Feb 2016 14:03:15 +0000 Demand is increasing for safer inhalational anesthetics for use in pediatric anesthesia. In this regard, researchers have debated whether isoflurane is more toxic to the developing brain than desflurane. In the present study, we compared the effects of postnatal exposure to isoflurane with those of desflurane on long-term cognitive performance and investigated the role of the Akt/GSK3β signaling pathway. Postnatal day 6 (P6) mice were exposed to either isoflurane or desflurane, after which the phosphorylation levels of Akt/GSK3β and learning and memory were assessed at P8 or P31. The phosphorylation levels of Akt/GSK3β and learning and memory were examined after intervention with lithium. We found that isoflurane, but not desflurane, impaired spatial learning and memory at P31. Accompanied by behavioral change, only isoflurane decreased p-Akt (ser473) and p-GSK3β (ser9) expressions, which led to GSK3β overactivation. Lithium prevented GSK3β overactivation and alleviated isoflurane-induced cognitive deficits. These results suggest that isoflurane is more likely to induce developmental neurotoxicity than desflurane in context of multiple exposures and that the Akt/GSK3β signaling pathway partly participates in this process. GSK3β inhibition might be an effective way to protect against developmental neurotoxicity. Guorong Tao, Qingsheng Xue, Yan Luo, Guohui Li, Yimeng Xia, and Buwei Yu Copyright © 2016 Guorong Tao et al. All rights reserved. The Effect of Systemic and Regional Use of Magnesium Sulfate on Postoperative Tramadol Consumption in Lumbar Disc Surgery Thu, 28 Jan 2016 13:43:10 +0000 Aim. To investigate the effect of magnesium administered to the operative region muscle and administered systemically on postoperative analgesia consumption after lumbar disc surgery. Material and Method. The study included a total of 75 ASA I-II patients aged 18–65 years. The patients were randomly allocated into 1 of 3 groups of 25: the Intravenous (IV) Group, the Intramuscular (IM) Group, and the Control (C) Group. At the stage of suturing the surgical incision site, the IV Group received 50 mg/kg MgSO4 intravenously in 150 mL saline within 30 mins. In the IM Group, 50 mg/kg MgSO4 in 30 mL saline was injected intramuscularly into the paraspinal muscles. In Group C, 30 mL saline was injected intramuscularly into the paraspinal muscles. After operation patients in all 3 groups were given 100 mg tramadol and 10 mg metoclopramide and tramadol solution was started intravenously through a patient-controlled analgesia device. Hemodynamic changes, demographic data, duration of anesthesia and surgery, pain scores (NRS), the Ramsay sedation score (RSS), the amount of analgesia consumed, nausea- vomiting, and potential side effects were recorded. Results. No difference was observed between the groups. Nausea and vomiting side effects occurred at a rate of 36% in Group C, which was a significantly higher rate compared to the other groups (). Tramadol consumption in the IM Group was found to be significantly lower than in the other groups (). Conclusion. Magnesium applied to the operative region was found to be more effective on postoperative analgesia than systemically administered magnesium. Melek Demiroglu, Canan Ün, Dilsen Hatice Ornek, Oya Kıcı, Ali Erdem Yıldırım, Eyup Horasanlı, Semih Başkan, Emel Fikir, Mehmet Gamli, and Bayazit Dikmen Copyright © 2016 Melek Demiroglu et al. All rights reserved. Seawater Immersion Aggravates Burn Injury Causing Severe Blood Coagulation Dysfunction Mon, 18 Jan 2016 13:01:14 +0000 This study aimed to investigate the endothelial function in a canine model of burn injury combined with seawater immersion. The model of burn injury was established. The dogs were randomly divided into four groups including dogs with burn injury (B group), or burn injury combined with seawater immersion (BI group), or only immersion in seawater (I group), or control animals with no injury or immersion (C group). The circulating endothelial cell (CEC) count and coagulation-fibrinolysis parameters were measured. The CEC count in B group increased at 4 h, 7 h, and 10 h after injury and then reduced, whereas it continuously increased to a greater extent in BI group (). The von Willebrand factor (vWF) activity, plasminogen activator inhibitor (PAI-1), and the ratio of thromboxane B2 (TXB2) to 6-keto-prostaglandin F1α (6-K-PGF1α) in BI group had a marked increase after injury, and the tissue-type plasminogen activator (tPA) in the BI group decreased. Microscope observations revealed thrombus formation in lungs of the animals in BI group, but not in C, I, or B groups. Burn injury causes endothelial dysfunction, and seawater immersion lastingly aggravates this injury, leading to a higher risk of developing thrombosis. Hong Yan, Qingxiang Mao, Yongda Ma, Li Wang, Xian Chen, Yi Hu, and Hengjiang Ge Copyright © 2016 Hong Yan et al. All rights reserved. Advances and Controversies in Perioperative Airway Management Mon, 11 Jan 2016 08:27:37 +0000 Pavel Michalek, Magboul M. Magboul, Kamil Toker, William Donaldson, and Makoto Ozaki Copyright © 2016 Pavel Michalek et al. All rights reserved. The Role of Airway and Endobronchial Ultrasound in Perioperative Medicine Tue, 15 Dec 2015 06:38:17 +0000 Recent years have witnessed an increased use of ultrasound in evaluation of the airway and the lower parts of the respiratory system. Ultrasound examination is fast and reliable and can be performed at the bedside and does not carry the risk of exposure to ionizing radiation. Apart from use in diagnostics it may also provide safe guidance for invasive and semi-invasive procedures. Ultrasound examination of the oral cavity structures, epiglottis, vocal cords, and subglottic space may help in the prediction of difficult intubation. Preoperative ultrasound may diagnose vocal cord palsy or deviation or stenosis of the trachea. Ultrasonography can also be used for confirmation of endotracheal tube, double-lumen tube, or laryngeal mask placement. This can be achieved by direct examination of the tube inside the trachea or by indirect methods evaluating lung movements. Postoperative airway ultrasound may reveal laryngeal pathology or subglottic oedema. Conventional ultrasound is a reliable real-time navigational tool for emergency cricothyrotomy or percutaneous dilational tracheostomy. Endobronchial ultrasound is a combination of bronchoscopy and ultrasonography and is used for preoperative examination of lung cancer and solitary pulmonary nodules. The method is also useful for real-time navigated biopsies of such pathological structures. Jiri Votruba, Petra Zemanová, Lukas Lambert, and Michaela Michalkova Vesela Copyright © 2015 Jiri Votruba et al. All rights reserved. Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine Sun, 13 Dec 2015 12:05:51 +0000 Supraglottic airway devices are routinely used for airway maintenance in elective surgical procedures where aspiration is not a significant risk and also as rescue devices in difficult airway management. Some devices now have features mitigating risk of aspiration, such as drain tubes or compartments to manage regurgitated content. Despite this, the use of these device may be associated with various complications including aspiration. This review highlights the types and incidence of these complications. They include regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. The incidence of such complications is quite low, but as some carry with them a significant degree of morbidity the need to follow manufacturers’ advice is underlined. The incidence of gastric content aspiration associated with the devices is estimated to be as low as 0.02% with perioperative regurgitation being significantly higher but underreported. Other serious, but extremely rare, complications include pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation. Mild short-lasting adverse effects of the devices have significantly higher incidence than serious complications and involve postoperative sore throat, dysphagia, pain on swallowing, or hoarseness. Devices may have deleterious effect on cervical mucosa or vasculature depending on their cuff volume and pressure. Pavel Michalek, William Donaldson, Eliska Vobrubova, and Marek Hakl Copyright © 2015 Pavel Michalek et al. All rights reserved. Effects of Interscalene Nerve Block for Postoperative Pain Management in Patients after Shoulder Surgery Tue, 24 Nov 2015 08:30:16 +0000 Objectives. Shoulder surgery can produce severe postoperative pain and movement limitations. Evidence has shown that regional nerve block is an effective management for postoperative shoulder pain. The purpose of this study was to investigate the postoperative analgesic effect of intravenous patient-controlled analgesia (PCA) combined with interscalene nerve block in comparison to PCA alone after shoulder surgery. Methods. In this study, 103 patients receiving PCA combined with interscalene nerve block (PCAIB) and 48 patients receiving PCA alone after shoulder surgery were included. Patients’ characteristics, preoperative shoulder score and range of motion, surgical and anesthetic condition in addition to visual analog scale (VAS) pain score, postoperative PCA consumption, and adverse outcomes were evaluated. Results. The results showed that PCA combined with interscalene nerve block (PCAIB) group required less volume of analgesics than PCA alone group in 24 hours ( mL versus  mL, ) and 48 hours ( mL versus  mL, ) postoperatively. The incidence of dizziness in PCAIB group was significantly lower than PCA group (resp., 1.9% and 14.6%, ). VAS, nausea, and vomiting were less in group PCAIB, but in the absence of significant statistical correlation. Conclusion. Interscalene nerve block is effective postoperatively in reducing the demand for PCA analgesics and decreasing opioids-induced adverse events following shoulder surgery. Hsiu-Pin Chen, Shih-Jyun Shen, Hsin-I Tsai, Sheng-Chin Kao, and Huang-Ping Yu Copyright © 2015 Hsiu-Pin Chen et al. All rights reserved. Controversies in Pediatric Perioperative Airways Sun, 22 Nov 2015 13:03:44 +0000 Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient. Jozef Klučka, Petr Štourač, Roman Štoudek, Michaela Ťoukálková, Hana Harazim, and Martina Kosinová Copyright © 2015 Jozef Klučka et al. All rights reserved. Comparison of Direct and Indirect Laryngoscopes in Vomitus and Hematemesis Settings: A Randomized Simulation Trial Thu, 05 Nov 2015 11:15:20 +0000 Background. Videolaryngoscopes may not be useful in the presence of hematemesis or vomitus. We compared the utility of the Macintosh laryngoscope (McL), which is a direct laryngoscope, with that of the Pentax-AWS Airwayscope (AWS) and McGRATH MAC (McGRATH), which are videolaryngoscopes, in simulated hematemesis and vomitus settings. Methods. Seventeen anesthesiologists with more than 1 year of experience performed tracheal intubation on an adult manikin using McL, AWS, and McGRATH under normal, hematemesis, and vomitus simulations. Results. In the normal setting, the intubation success rate was 100% for all three laryngoscopes. In the hematemesis settings, the intubation success rate differed significantly among the three laryngoscopes (). In the vomitus settings, all participants succeeded in tracheal intubation with McL or McGRATH, while five failed in the AWS trial with significant difference (). The intubation time did not significantly differ in normal settings, while it was significantly longer in the AWS trial compared to McL or McGRATH trial in the hematemesis or vomitus settings (, compared to McL or McGRATH in both settings). Conclusion. The performance of McGRATH and McL can be superior to that of AWS for tracheal intubation in vomitus and hematemesis settings in adults. Ryosuke Mihara, Nobuyasu Komasawa, Sayuri Matsunami, and Toshiaki Minami Copyright © 2015 Ryosuke Mihara et al. All rights reserved. Isoflurane Damages the Developing Brain of Mice and Induces Subsequent Learning and Memory Deficits through FASL-FAS Signaling Sun, 01 Nov 2015 14:13:04 +0000 Background. Isoflurane disrupts brain development of neonatal mice, but its mechanism is unclear. We explored whether isoflurane damaged developing hippocampi through FASL-FAS signaling pathway, which is a well-known pathway of apoptosis. Method. Wild type and FAS- or FASL-gene-knockout mice aged 7 days were exposed to either isoflurane or pure oxygen. We used western blotting to study expressions of caspase-3, FAS (CD95), and FAS ligand (FASL or CD95L) proteins, TUNEL staining to count apoptotic cells in hippocampus, and Morris water maze (MWM) to evaluate learning and memory. Result. Isoflurane increased expression of FAS and FASL proteins in wild type mice. Compared to isoflurane-treated FAS- and FASL-knockout mice, isoflurane-treated wild type mice had higher expression of caspase-3 and more TUNEL-positive hippocampal cells. Expression of caspase-3 in wild isoflurane group, wild control group, FAS/FASL-gene-knockout control group, and FAS/FASL-gene-knockout isoflurane group showed FAS or FASL gene knockout might attenuate increase of caspase-3 caused by isoflurane. MWM showed isoflurane treatment of wild type mice significantly prolonged escape latency and reduced platform crossing times compared with gene-knockout isoflurane-treated groups. Conclusion. Isoflurane induces apoptosis in developing hippocampi of wild type mice but not in FAS- and FASL-knockout mice and damages brain development through FASL-FAS signaling. Xiuwen Yi, Yirong Cai, and Wenxian Li Copyright © 2015 Xiuwen Yi et al. All rights reserved. Comparison of Propofol, Propofol-Remifentanil, and Propofol-Fentanyl Administrations with Each Other Used for the Sedation of Patients to Undergo ERCP Wed, 21 Oct 2015 12:10:15 +0000 Introduction. Using single anesthetic agent in endoscopic retrograde cholangiopancreatography (ERCP) may lead to inadequate analgesia and sedation. To achieve the adequate analgesia and sedation the single anesthetic agent doses must be increased which causes undesirable side effects. For avoiding high doses of single anesthetic agent nowadays combination with sedative agents is mostly a choice for analgesia and sedation for ERCP. Aim. The aim of this study is to investigate the effects of propofol alone, propofol + remifentanil, and propofol + fentanyl combinations on the total dose of propofol to be administered during ERCP and on the pain scores after the process. Materials and Method. This randomized study was performed with 90 patients (ASA I-II-III) ranging between 18 and 70 years of age who underwent sedation/analgesia for elective ERCP. The patients were administered only propofol (1.5 mg/kg) in Group Ι, remifentanil (0.05 μg/kg) + propofol (1.5 mg/kg) combination in Group II, and fentanyl (1 μg/kg) + propofol (1.5 mg/kg) combination in Group III. All the patients’ sedation levels were assessed with the Ramsey Sedation Scale (RSS). Their recovery was assessed with the Aldrete and Numerical Rating Scale Score (NRS) at 10 min intervals. Results. The total doses of propofol administered to the patients in the three groups in this study were as follows: 375 mg in Group I, 150 mg in Group II, and 245 mg in Group III. Conclusion. It was observed that, in the patients undergoing ERCP, administration of propofol in combination with an opioid provided effective and reliable sedation, reduced the total dose of propofol, increased the practitioner satisfaction, decreased the pain level, and provided hemodynamic stability compared to the administration of propofol alone. Candan Haytural, Bahar Aydınlı, Berna Demir, Elif Bozkurt, Erkan Parlak, Selçuk Dişibeyaz, Ahmet Saraç, Ayşegül Özgök, and Dilek Kazancı Copyright © 2015 Candan Haytural et al. All rights reserved. Computational Depth of Anesthesia via Multiple Vital Signs Based on Artificial Neural Networks Tue, 13 Oct 2015 09:35:01 +0000 This study evaluated the depth of anesthesia (DoA) index using artificial neural networks (ANN) which is performed as the modeling technique. Totally 63-patient data is addressed, for both modeling and testing of 17 and 46 patients, respectively. The empirical mode decomposition (EMD) is utilized to purify between the electroencephalography (EEG) signal and the noise. The filtered EEG signal is subsequently extracted to achieve a sample entropy index by every 5-second signal. Then, it is combined with other mean values of vital signs, that is, electromyography (EMG), heart rate (HR), pulse, systolic blood pressure (SBP), diastolic blood pressure (DBP), and signal quality index (SQI) to evaluate the DoA index as the input. The 5 doctor scores are averaged to obtain an output index. The mean absolute error (MAE) is utilized as the performance evaluation. 10-fold cross-validation is performed in order to generalize the model. The ANN model is compared with the bispectral index (BIS). The results show that the ANN is able to produce lower MAE than BIS. For the correlation coefficient, ANN also has higher value than BIS tested on the 46-patient testing data. Sensitivity analysis and cross-validation method are applied in advance. The results state that EMG has the most effecting parameter, significantly. Muammar Sadrawi, Shou-Zen Fan, Maysam F. Abbod, Kuo-Kuang Jen, and Jiann-Shing Shieh Copyright © 2015 Muammar Sadrawi et al. All rights reserved. Comparison of Pressure Changes by Head and Neck Position between High-Volume Low-Pressure and Taper-Shaped Cuffs: A Randomized Controlled Trial Mon, 05 Oct 2015 08:34:32 +0000 The present study compared changes in cuff pressure by head and neck position between high-volume low-pressure (HVLP) and taper-shaped (taper) cuffs in a prospective randomized clinical trial. Methods. Forty patients were intubated using tracheal tubes with either HVLP (; HVLP group) or taper-shaped (; Taper group) cuffs. Initial cuff pressure was adjusted to 15, 20, or 25 cmH2O in the neutral position. Cuff pressure was evaluated after changing the head and neck positions to flexion, extension, and rotation. Results. Cuff pressure significantly increased with flexion in both HVLP and Taper groups at all initial cuff pressures. It significantly increased with extension in the HVLP group, but not in the Taper group. Cuff pressure did not significantly differ with rotation in either group and was significantly smaller in the Taper group during flexion and extension than in the HVLP group, regardless of initial cuff pressure. Conclusion. Cuff pressure changes with head and neck flexion and extension were smaller in the Taper group than in the HVLP group. Our results highlight the potential for taper cuffs to prevent excessive cuff pressure increases with positional changes in the head and neck. This trial is registered with UMIN000016119. Nobuyasu Komasawa, Ryosuke Mihara, Kentaro Imagawa, Kazuo Hattori, and Toshiaki Minami Copyright © 2015 Nobuyasu Komasawa et al. All rights reserved. Propofol Requirement for Induction of Unconsciousness Is Reduced in Patients with Parkinson’s Disease: A Case Control Study Thu, 01 Oct 2015 13:16:03 +0000 Parkinson’s disease (PD) is the second most prevalent neurodegenerative disease, but whether the neurodegenerative process influences the pharmacodynamics of propofol remains unclear. We aimed to evaluate the effect of PD on pharmacodynamics of propofol. A total of 31 PD patients undergoing surgical treatment (PD group) and 31 pair-controlled non-PD patients undergoing intracranial surgery (NPD group) were recruited to investigate the propofol requirement for unconsciousness induction. Unconsciousness was induced in all patients with target-controlled infusion of propofol. The propofol concentration at which unconsciousness was induced was compared between the two groups. EC50 and EC95 were calculated as well. Demographic data, bispectral index, and hemodynamic values were comparable between PD and NPD groups. The mean target concentration of propofol when unconsciousness was achieved was 2.32 ± 0.38 μg/mL in PD group, which was significantly lower than that in NPD group (2.90 ± 0.35 μg/mL). The EC50 was 2.05 μg/mL (95% CI: 1.85–2.19 μg/mL) in PD group, much lower than the 2.72 μg/mL (95% CI: 2.53–2.88 μg/mL) in NPD group. In conclusion, the effective propofol concentration needed for induction of unconsciousness in 50% of patients is reduced in PD patients. (This trial is registered with NCT01998204.) Xiao-ping Xu, Xi-ya Yu, Xi Wu, Xiao-wu Hu, Jian-chun Chen, Jin-bao Li, Jia-feng Wang, and Xiao-ming Deng Copyright © 2015 Xiao-ping Xu et al. All rights reserved. Respiratory Strategies and Airway Management in Patients with Pulmonary Alveolar Proteinosis: A Review Thu, 01 Oct 2015 08:33:50 +0000 Background. Pulmonary alveolar proteinosis is a rare disorder characterized by a large accumulation of lipoproteinaceous material within the alveoli. This causes respiratory failure due to a restriction of gas exchange and changes in the ventilation/perfusion ratio. Treatment methods include noninvasive pharmacological approaches and invasive procedures, such as whole-lung lavage under general anesthesia. Methods. Based on the literature search using free-term key words, we have analyzed published articles concerning the perioperative management of adult and pediatric patients with pulmonary alveolar proteinosis. Results and Discussion. In total, 184 publications were analyzed. Only a few manuscripts were related to anesthetic, respiratory, and airway management in patients suffering from pulmonary alveolar proteinosis. Airway should be strictly separated using a double-lumen tube. Respiratory strategies involve the use of manual clapping, continuous positive airway pressure, high-frequency jet ventilation of the affected lung, and employment of venovenous extracorporeal membrane oxygenation in the most serious of cases. Conclusion. The goal of this review is to summarize the current published information about an anesthetic management strategy with a focus on airway management, ventilation, and oxygenation techniques in PAP patients. Tomas Vymazal and Martina Krecmerova Copyright © 2015 Tomas Vymazal and Martina Krecmerova. All rights reserved. Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review Thu, 01 Oct 2015 08:22:03 +0000 Objectives. The objective of this narrative review was to examine the usage of ketamine as a postoperative analgesic agent across a wide variety of surgeries. Design. A literature search was performed using the phrases “ketamine” and “postoperative pain.” The authors analyzed the studies that involved testing ketamine’s effectiveness at controlling postoperative pain. Effectiveness was assessed through various outcomes such as the amount of opiate consumption, visual analog scale (VAS) pain scores, and persistent postoperative pain at long-term follow-up. Results. While many different administration protocols were evaluated, delivering ketamine both as a pre- or perioperative bolus and postoperative infusion for up to 48 hours appeared to be the most effective. These effects are dose-dependent. However, a number of studies analyzed showed no benefit in using ketamine versus placebo for controlling postoperative pain. While ketamine is a safe and well-tolerated drug, it does have adverse effects, and there are concerns for possible neurotoxicity and effects on memory. Conclusions. In a number of limited situations, ketamine has shown some efficacy in controlling postoperative pain and decreasing opioid consumption. More randomized controlled trials are necessary to determine the surgical procedures and administrations (i.e., intravenous, epidural) that ketamine is best suited for. Brian M. Radvansky, Khushbu Shah, Anant Parikh, Anthony N. Sifonios, Vanny Le, and Jean D. Eloy Copyright © 2015 Brian M. Radvansky et al. All rights reserved. Near-Infrared Spectroscopy for the Evaluation of Anesthetic Depth Thu, 01 Oct 2015 07:22:58 +0000 The standard-of-care guidelines published by the American Society of Anesthesiologists (ASA) recommend monitoring of pulse oximetry, blood pressure, heart rate, and end tidal CO2 during the use of anesthesia and sedation. This information can help to identify adverse events that may occur during procedures. However, these parameters are not specific to the effects of anesthetics or sedatives, and therefore they offer little, to no, real time information regarding the effects of those agents and do not give the clinician the lead-time necessary to prevent patient “awareness.” Since no “gold-standard” method is available to continuously, reliably, and effectively monitor the effects of sedatives and anesthetics, such a method is greatly needed. Investigation of the use of functional near-infrared spectroscopy (fNIRS) as a method for anesthesia or sedation monitoring and for the assessment of the effects of various anesthetic drugs on cerebral oxygenation has started to be conducted. The objective of this paper is to provide a thorough review of the currently available published scientific studies regarding the use of fNIRS in the fields of anesthesia and sedation monitoring, comment on their findings, and discuss the future work required for the translation of this technology to the clinical setting. Gabriela Hernandez-Meza, Meltem Izzetoglu, Mary Osbakken, Michael Green, and Kurtulus Izzetoglu Copyright © 2015 Gabriela Hernandez-Meza et al. All rights reserved. Utility of a Gum-Elastic Bougie for Difficult Airway Management in Infants: A Simulation-Based Crossover Analysis Thu, 01 Oct 2015 07:18:32 +0000 Background. Direct laryngoscopy with the Miller laryngoscope (Mil) for infant tracheal intubation is often difficult to use even for skilled professionals. We performed a simulation trial evaluating the utility of a tracheal tube introducer (gum-elastic bougie (GEB)) in a simulated, difficult infant airway model. Methods. Fifteen anesthesiologists performed tracheal intubation on an infant manikin at three different degrees of difficulty (normal [Cormack-Lehane grades (Cormack) 1-2], cervical stabilization [Cormack 2-3], and anteflexion [Cormack 3-4]) with or without a GEB, intubation success rate, and intubation time. Results. In the normal and cervical stabilization trials, all intubation attempts were successful regardless of whether or not the GEB was used. In contrast, only one participant succeeded in tracheal intubation without the GEB in the anteflexion trial; the success rate significantly improved with the GEB (). Intubation time did not significantly change under the normal trial with or without the GEB (without, 12.7 ± 3.8 seconds; with, 13.4 ± 3.6 seconds) but was significantly shorter in the cervical stabilization and anteflexion trials with the GEB. Conclusion. GEB use shortened the intubation time and improved the success rate of difficult infant tracheal intubation by anesthesiologists in simulations. Nobuyasu Komasawa, Akira Hyoda, Sayuri Matsunami, Nozomi Majima, and Toshiaki Minami Copyright © 2015 Nobuyasu Komasawa et al. All rights reserved. Pain following Craniotomy: Reassessment of the Available Options Thu, 01 Oct 2015 06:52:18 +0000 Pain following craniotomy has frequently been neglected because of the notion that postcraniotomy patients do not experience severe pain. However a gradual change in this outlook is observed because of increased sensitivity of neuroanaesthesiologists and neurosurgeons toward acute postcraniotomy pain. Multiple modalities exist for treating this variety of pain each with its own share of advantages and disadvantages. However, individually none of these modalities has been proclaimed as the best and applicable universally. A considerable amount of dispute remains to ascertain the appropriate therapeutic regimen for treating postcraniotomy pain in spite of numerous trials using different drugs and their combinations. This review aims to highlight the genesis, characteristics, and different strategies that are undertaken for management of acute postcraniotomy pain. Chronic postcraniotomy pain which can be debilitating sequelae is also discussed concisely. Rudrashish Haldar, Ashutosh Kaushal, Devendra Gupta, Shashi Srivastava, and Prabhat K. Singh Copyright © 2015 Rudrashish Haldar et al. All rights reserved. Can Acute Pain Treatment Reduce Postsurgical Comorbidity after Breast Cancer Surgery? A Literature Review Thu, 01 Oct 2015 06:50:28 +0000 Regional analgesia, opioids, and several oral analgesics are commonly used for the treatment of acute pain after breast cancer surgery. While all of these treatments can suppress the acute postsurgical pain, there is growing evidence that suggests that the postsurgical comorbidity will differ in accordance with the type of analgesic used during the surgery. Our current study reviewed the effect of analgesics used for acute pain treatments on the major comorbidities that occur after breast cancer surgery. A considerable number of clinical studies have been performed to investigate the relationship between the acute analgesic regimen and common comorbidities, including inadequate quality of recovery after the surgery, persistent postsurgical pain, and cancer recurrence. Previous studies have shown that the choice of the analgesic modality does affect the postsurgical comorbidity. In general, the use of regional analgesics has a beneficial effect on the occurrence of comorbidity. In order to determine the best analgesic choice after breast cancer surgery, prospective studies that are based on a clear definition of the comorbidity state will need to be undertaken in the future. Fumimasa Amaya, Toyoshi Hosokawa, Akiko Okamoto, Megumi Matsuda, Yosuke Yamaguchi, Shunsuke Yamakita, Tetsuya Taguchi, and Teiji Sawa Copyright © 2015 Fumimasa Amaya et al. All rights reserved. Comparison of Five 2nd-Generation Supraglottic Airway Devices for Airway Management Performed by Novice Military Operators Thu, 01 Oct 2015 06:32:51 +0000 Objectives. Five different second-generation supraglottic airway devices, ProSeal LMA, Supreme LMA, i-gel, SLIPA, and Laryngeal Tube Suction-D, were studied. Operators were inexperienced users with a military background, combat lifesavers, nurses, and physicians. Methods. This was a prospective, randomized, single-blinded study. Devices were inserted in the operating room in low light conditions after induction of general anesthesia. Primary outcome was successful insertion on the first attempt while secondary aims were insertion time, number of attempts, oropharyngeal seal pressure, ease of insertion, fibre optic position of device, efficacy of ventilation, and intraoperative trauma or regurgitation of gastric contents. Results. In total, 505 patients were studied. First-attempt insertion success rate was higher in the Supreme LMA (96%), i-gel (87.9%), and ProSeal LMA (85.9%) groups than in the Laryngeal Tube Suction-D (80.6%) and SLIPA (69.4%) groups. Insertion time was shortest in the Supreme LMA (70.4 ± 32.5 s) and i-gel (74.4 ± 41.1 s) groups (). Oropharyngeal seal pressures were higher in the Laryngeal Tube Suction-D and ProSeal LMA groups than in other three devices. Conclusions. Most study parameters for the Supreme LMA and i-gel were found to be superior to the other three tested supraglottic airway devices when inserted by novice military operators. Tomas Henlin, Michal Sotak, Petr Kovaricek, Tomas Tyll, Lukas Balcarek, and Pavel Michalek Copyright © 2015 Tomas Henlin et al. All rights reserved. Ischemic Postconditioning and Subanesthetic S(+)-Ketamine Infusion: Effects on Renal Function and Histology in Rats Thu, 27 Aug 2015 08:47:20 +0000 Background. Ischemic postconditioning (IP) in renal Ischemia reperfusion injury (IRI) models improves renal function after IRI. Ketamine affords significant benefits against IRI-induced acute kidney injury (AKI). The present study investigated the effects of IP and IP associated with subanesthetic S(+)-ketamine in ischemia-reperfusion-induced AKI. Methods. Forty-one Wistar rats were randomized into four groups: CG (10), control; KG (10), S(+)-ketamine infusion; IPG (10), IP; and KIPG (11), S(+)-ketamine infusion + IP. All rats underwent right nephrectomy. IRI and IP were induced only in IPG and KIPG by left kidney arterial occlusion for 30 min followed by reperfusion for 24 h. Complete reperfusion was preceded by three cycles of 2 min of reocclusion followed by 2 min of reperfusion. Renal function was assessed by measuring serum neutrophil gelatinase-associated lipocalin (NGAL), creatinine, and blood urea nitrogen (BUN). Tubular damage was evaluated by renal histology. Results. Creatinine and BUN were significantly increased. Severe tubular injury was only observed in the groups with IRI (IPG and KIPG), whereas no injury was observed in CG or KG. No significant differences were detected between IPG and KIPG. Conclusions. No synergic effect of the use of subanesthetic S(+)-ketamine and IP on AKI was observed in this rat model. Marco A. C. de Resende, Alberto V. Pantoja, Bruno M. Barcellos, Eduardo P. Reis, Thays D. Consolo, Renata P. Módolo, Maria A. C. Domingues, Alexandra R. Assad, Ismar L. Cavalcanti, Yara M. M. Castiglia, and Norma S. P. Módolo Copyright © 2015 Marco A. C. de Resende et al. All rights reserved. Morphine Reduces Myocardial Infarct Size via Heat Shock Protein 90 in Rodents Thu, 27 Aug 2015 08:14:51 +0000 Opioids reduce injury from myocardial ischemia-reperfusion in humans. In experimental models, this mechanism involves GSK3β inhibition. HSP90 regulates mitochondrial protein import, with GSK3β inhibition increasing HSP90 mitochondrial content. Therefore, we determined whether morphine-induced cardioprotection is mediated by HSP90 and if the protective effect is downstream of GSK3β inhibition. Male Sprague-Dawley rats, aged 8–10 weeks, were subjected to an in vivo myocardial ischemia-reperfusion injury protocol involving 30 minutes of ischemia followed by 2 hours of reperfusion. Hemodynamics were continually monitored and myocardial infarct size determined. Rats received morphine (0.3 mg/kg), the GSK3β inhibitor, SB216763 (0.6 mg/kg), or saline, 10 minutes prior to ischemia. Some rats received selective HSP90 inhibitors, radicicol (0.3 mg/kg), or deoxyspergualin (DSG, 0.6 mg/kg) alone or 5 minutes prior to morphine or SB216763. Morphine reduced myocardial infarct size when compared to control (42 ± 2% versus 60 ± 1%). This protection was abolished by prior treatment of radicicol or DSG (59 ± 1%, 56 ± 2%). GSK3β inhibition also reduced myocardial infarct size (41 ± 2%) with HSP90 inhibition by radicicol or DSG partially inhibiting SB216763-induced infarct size reduction (54 ± 3%, 47 ± 1%, resp.). These data suggest that opioid-induced cardioprotection is mediated by HSP90. Part of this protection afforded by HSP90 is downstream of GSK3β, potentially via the HSP-TOM mitochondrial import pathway. Bryce A. Small, Yao Lu, Anna K. Hsu, Garrett J. Gross, and Eric R. Gross Copyright © 2015 Bryce A. Small et al. All rights reserved. Lipid Emulsion Attenuates Acetylcholine-Induced Relaxation in Isolated Rat Aorta Mon, 27 Jul 2015 08:18:59 +0000 We investigated the effect of Lipofundin MCT/LCT and Intralipid on acetylcholine-induced nitric oxide- (NO-) mediated relaxation in rat aorta to determine which lipid emulsion (LE) is more potent in terms of inhibition of NO-induced relaxation. Dose-response curves of responses induced by acetylcholine, the calcium ionophore A23187, and sodium nitroprusside were generated using isolated rat aorta with or without LE. The effect of Lipofundin MCT/LCT on acetylcholine-induced endothelial nitric oxide synthase (eNOS) phosphorylation in human umbilical vein endothelial cells (HUVECs) was investigated using western blotting. Lipofundin MCT/LCT (0.1 and 0.2%) attenuated acetylcholine-induced relaxation in endothelium-intact aorta with or without tiron, whereas 0.2% Intralipid only inhibited relaxation. Lipofundin MCT/LCT inhibited relaxation induced by the calcium ionophore A23187 and sodium nitroprusside in endothelium-intact aorta, but Lipofundin MCT/LCT had no effect on sodium nitroprusside-induced relaxation in the endothelium-denuded aorta. Combined pretreatment with l-arginine plus Lipofundin MCT/LCT increased acetylcholine-induced maximal relaxation in endothelium-intact aorta compared with Lipofundin MCT/LCT alone. l-Arginine attenuated Lipofundin MCT/LCT-mediated inhibition of acetylcholine-induced eNOS phosphorylation in HUVECs. Taken together, Lipofundin MCT/LCT attenuated acetylcholine-induced NO-mediated relaxation via an inhibitory effect on the endothelium including eNOS, which is proximal to activation of guanylyl cyclase. Seong-Ho Ok, Soo Hee Lee, Jongsun Yu, Jungchul Park, Il-Woo Shin, Youngju Lee, Hyunhoo Cho, Mun-Jeoung Choi, Jiseok Baik, Jeong-Min Hong, Jeong Yeol Han, Heon Keun Lee, Young-Kyun Chung, and Ju-Tae Sohn Copyright © 2015 Seong-Ho Ok et al. All rights reserved. Effective Dose of Ramosetron for Prophylaxis of Postoperative Nausea and Vomiting in High-Risk Patients Tue, 14 Jul 2015 11:46:53 +0000 Background. Postoperative nausea and vomiting (PONV) are common adverse events with an incidence of up to 80% in high-risk patients. Ramosetron, a selective 5-HT3 receptor antagonist, is widely used to prevent PONV. The purpose of this study was to evaluate the effective dose of ramosetron for the prevention of PONV in high-risk patients. Methods. Fifty-one patients were randomly allocated to 3 groups and were administered ramosetron 0.3 mg (group A), 0.45 mg (group B), or 0.6 mg (group C), at the end of their surgery. The episodes of PONV were assessed 1, 6, 24, and 48 hours after the injection and all the adverse events were observed. Results. The complete response rate in the postoperative period 6–24 hours after the anesthesia was higher in group C than in group A: 93% versus 44%. Group C’s experience score of Rhodes index was lower than group A’s: 0.81 ± 2.56 versus 3.94 ± 5.25. No adverse drug reaction could be observed in all groups. Conclusions. The effective dose of ramosetron to be injected for the near-complete prophylaxis of PONV 6 to 24 hours after surgery in high-risk patients is a 0.6 mg bolus injection at the end of the surgery. Seongheon Lee, Sinho Jeong, Joungmin Kim, and Seongwook Jeong Copyright © 2015 Seongheon Lee et al. All rights reserved. Prevalence and Prognostic Value of Early Repolarization in Low Risk Surgical Patients Mon, 13 Jul 2015 08:33:02 +0000 Recent epidemiological studies documented that early repolarization may be associated with increased risk of serious cardiac events, including cardiac death. Little is known about the prognostic significance of this pattern in low risk surgical patients. This retrospective study included 3028 patients over 18 years of age and with ASA class I and II risk, undergoing noncardiac elective surgery. We followed the patients for one year. Early repolarization in preoperative ECG was found in 219 patients (7.2%) and patients with early repolarization were more likely to be male and younger. Newly observed cardiac events were significantly higher in the early repolarization group (1.37% versus 0.21%; ). Multivariate regression analysis reveals that early repolarization (odds ratio: 6.019, ) significantly increased newly observed cardiac events. Our retrospective study suggests that low risk surgical patients with early repolarization have statistically higher opportunity of newly observed cardiac events within one year after surgery. Chiho Ota, Sin-nosuke Shiono, Yuji Fujino, Takahiko Kamibayashi, and Yukio Hayashi Copyright © 2015 Chiho Ota et al. All rights reserved. Genotoxicity of Anesthetics Evaluated In Vivo (Animals) Wed, 24 Jun 2015 08:52:31 +0000 The anesthesia has been improved all over the years. However, it can have impact on health, in both patients and animals anesthetized, as well as professionals exposed to inhaled anesthetics. There is continuing effort to understand the possible effects of anesthetics at molecular levels. Knowing the effects of anesthetic agents on genetic material could be a valuable basic support to better understand the possible mechanisms of these agents. Thus, the purpose of this review is to provide an overview on the genotoxic potential, evaluated in animal models, of many anesthetics that have already been used and those currently used in anesthesia. Mariana G. Braz and Bensu Karahalil Copyright © 2015 Mariana G. Braz and Bensu Karahalil. All rights reserved. Intramuscular Administration of Drotaverine Hydrochloride Decreases Both Incidence of Urinary Retention and Time to Micturition in Orthopedic Patients under Spinal Anesthesia: A Single Blinded Randomized Study Sun, 21 Jun 2015 12:16:48 +0000 Purpose. Postoperative urinary retention (POUR) increases the duration of hospitalization and frequency and risk of urinary bladder catheterization. The objective of this study was to analyze the efficacy of intramuscularly administered drotaverine hydrochloride in the prevention of POUR in orthopedic patients. Methods. Two hundred and thirty patients 17–40 years of age undergoing lower limb orthopedic procedures under spinal anesthesia were enrolled in the study. The study group received 40 mg of drotaverine hydrochloride intramuscularly; the second group was the control. The main outcome measure was (1) the time to micturition and (2) the incidence of urinary bladder catheterization and time to catheterization. Results. Two hundred and one patients of 230 enrolled participants completed the study. Compared to the control group, the male patients in study group exhibited a shorter time to spontaneous micturition (441 versus 563 minutes, 95% CI of the difference of means between 39 and 205 minutes) and a lower incidence of urinary bladder catheterization (4/75 versus 10/54) (RR 0.29, 95% CI: 0.1–0.87; ). Conclusions. Intramuscular administration of drotaverine hydrochloride decreased the time to spontaneous micturition and decreased the incidence of urinary bladder catheterization in male patients who underwent orthopedic surgery under spinal anesthesia. This trial is registered with NCT02026427. Dariusz Tomaszewski and Mariusz Bałkota Copyright © 2015 Dariusz Tomaszewski and Mariusz Bałkota. All rights reserved. Anesthesia Related Toxic Effects on In Vitro Fertilization Outcome: Burden of Proof Tue, 16 Jun 2015 13:10:18 +0000 Management of pain and anxiety during oocyte retrieval makes anesthesia an important part of the in vitro fertilization (IVF) procedures. There are many studies investigating the influence of anesthesia on IVF success. This review article provides an overview of published data regarding the potential toxic effects of different anesthetic techniques (Loco-regional, general anesthesia (GA), and monitored anesthesia care (MAC)), different anesthetic agents, and alternative medicine approach (principally acupuncture) on the IVF outcome. From our analysis, evidence of serious toxicity in humans is not well established. Trials regarding different anesthetic techniques ended up without clear conclusions. Studies about GA came up with conflicting results. A few trials relate GA with lower pregnancy rates, although some others failed to prove this conclusion. Furthermore, detectable amounts of some anesthetic agents are measurable in the follicular fluid but these findings are not strongly associated with toxicity. MAC and Loco-regional anesthesia appear as safe alternative choices and there is evidence of improved outcome. Whereas acupuncture may provide assistance increasing IVF success according to some trials, some others could not obtain these effects. Questions about the appropriate time of application and the underlying mechanism of action are not answered yet, so further investigation should be done. Paraskevi Matsota, Eva Kaminioti, and Georgia Kostopanagiotou Copyright © 2015 Paraskevi Matsota et al. All rights reserved. Analgesic Effects of Intra-Articular Bupivacaine/Intravenous Parecoxib Combination Therapy versus Intravenous Parecoxib Monotherapy in Patients Receiving Total Knee Arthroplasty: A Randomized, Double-Blind Trial Thu, 11 Jun 2015 07:34:01 +0000 Objectives. The purpose of this double-blind, randomized study was to investigate whether the addition of intra-articular bupivacaine to intravenous parecoxib could improve pain relief in patients undergoing total knee arthroplasty. Methods. A total of 36 patients undergoing total knee arthroplasty were enrolled into our study. These patients were randomly allocated either to a placebo-controlled group or study group. Postoperative pain scores and analgesic consumption were evaluated. Results. Numeric rating scale (NRS) data of bupivacaine group in postoperative room were significantly lower than that of control group (control group versus bupivacaine group, 7.9 (6.7–9.1) (mean and 95% confidence interval) versus 4.5 (3.2–5.8) (mean and 95% confidence interval), ). NRS data of bupivacaine group in ward were also significantly lower than that of control group. A significantly lower dose of meperidine was used in the study group postoperatively during the first 24 hours (control group versus bupivacaine group, 3.08 ± 0.80 mg/Kg versus 2.34 ± 0.42 mg/Kg, ). Conclusion. Intra-articular bupivacaine in combination with intravenous parecoxib may improve pain relief and reduce the demand for rescue analgesics in patients undergoing total knee arthroplasty. The trial is registered with Australian New Zealand Clinical Trials Registry (ACTRN12615000463572). Shih-Jyun Shen, Pei-Yu Peng, Hsiu-Pin Chen, Jr-Rung Lin, Mel S. Lee, and Huang-Ping Yu Copyright © 2015 Shih-Jyun Shen et al. All rights reserved. Impact of Volatile Anesthetics on Oxidative Stress and Inflammation Mon, 25 May 2015 13:07:41 +0000 The safety of anesthesia, which is an important step for surgery, can be determined by its impact on oxidative stress and inflammation. The effects of volatile anesthetics such as isoflurane and sevoflurane on oxidative stress and inflammation are reviewed in various (1) cell lines, (2) rodents, and (3) human studies. Isoflurane and sevoflurane are reported to have antioxidant and anti-inflammatory effects in all cells with exception of neuronal cell lines. In addition, various animal studies have indicated that isoflurane and sevoflurane were not only safe but also reduced oxidative stress and inflammation in rodent models. In human studies, oxidative stress, inflammation, and DNA damage were not affected by isoflurane and sevoflurane in patients undergoing minor incision surgeries. On the other hand, elevated oxidative stress, inflammation, and DNA damage have been observed in patients undergoing major surgeries such as abdominal and orthopedic surgeries, hysterectomy, cholecystectomy, and thoracotomy. Although impact of anesthetics on oxidative stress and inflammation is still not clear due to the variations of patients’ health conditions, types of surgery and the quantities of anesthetics, isoflurane, and sevoflurane can be considered safe anesthetics with respect to their effect on oxidative stress and inflammation in subjects undergoing minor surgery. Continuous effort evaluating the safety of anesthesia in various aspects is required. Yoon-Mi Lee, Byeng Chun Song, and Kyung-Jin Yeum Copyright © 2015 Yoon-Mi Lee et al. All rights reserved. Sevoflurane Induces DNA Damage Whereas Isoflurane Leads to Higher Antioxidative Status in Anesthetized Rats Mon, 25 May 2015 07:30:19 +0000 Taking into account that there are controversial antioxidative effects of inhalational anesthetics isoflurane and sevoflurane and absence of comparison of genotoxicity of both anesthetics in animal model, the aim of this study was to compare DNA damage and antioxidant status in Wistar rats exposed to a single time to isoflurane or sevoflurane. The alkaline single-cell gel electrophoresis assay (comet assay) was performed in order to evaluate DNA damage in whole blood cells of control animals (unexposed; n = 6) and those exposed to 2% isoflurane (n = 6) or 4% sevoflurane (n = 6) for 120 min. Plasma antioxidant status was determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. There was no statistically significant difference between isoflurane and sevoflurane groups regarding hemodynamic and temperature variables (P > 0.05). Sevoflurane significantly increased DNA damage compared to unexposed animals (P = 0.02). In addition, Wistar rats anesthetized with isoflurane showed higher antioxidative status (MTT) than control group (P = 0.019). There were no significant differences in DNA damage or antioxidant status between isoflurane and sevoflurane groups (P > 0.05). In conclusion, our findings suggest that, in contrast to sevoflurane exposure, isoflurane increases systemic antioxidative status, protecting cells from DNA damage in rats. Thalita L. A. Rocha, Carlos A. Dias-Junior, Jose S. Possomato-Vieira, Victor H. Gonçalves-Rizzi, Flávia R. Nogueira, Kátina M. de Souza, Leandro G. Braz, and Mariana G. Braz Copyright © 2015 Thalita L. A. Rocha et al. All rights reserved. Validation of a Modified Algometer to Measure Mechanical Nociceptive Thresholds in Awake Dogs Tue, 05 May 2015 07:27:16 +0000 This study was conducted to validate the use of a modified algometer device to measure mechanical nociceptive thresholds in six dogs. Dogs were administered morphine intravenously (IV) at 1 mg/kg or saline at equivolume in a crossover design with one-week washout period. Mechanical nociceptive thresholds were determined before, after the administration of treatments at 5 minutes, and hourly for 8 hours. Thresholds were recorded at the carpal pad, metacarpal foot pad, tibia, femur, and abdomen. Heart rates, body temperature, and respiration were recorded at similar time points. Thresholds increased significantly () from baseline values for up to 3 hours at tibia and abdomen, 4 hours at metacarpal pad, and 5 hours at the carpal pad and femur. Hypothermia, bradycardia, and change in respiration were observed in all dogs after morphine injection. Saline did not alter any threshold levels during the eight-hour study period, indicating no evidence of tolerance, learned avoidance, or local hyperaesthesia. The device and methods of testing were well tolerated by all the dogs. Results suggest that the modified algometer and method of application are useful to measure nociceptive mechanical thresholds in awake dogs. Ubedullah Kaka, Hui Cheng Chen, Yong Meng Goh, Adamu Abdul Abubakar, Sharida Fakurazi, and Mahdi Ebrahimi Copyright © 2015 Ubedullah Kaka et al. All rights reserved. Pain Control after Total Knee Arthroplasty: Comparing Intra-Articular Local Anesthetic Injection with Femoral Nerve Block Sun, 03 May 2015 13:09:34 +0000 Background. Direct intra-articular injection of low doses of local anesthetic (IALA) after closure of the joint capsule remains controversial for pain control after total knee arthroplasty (TKA). Methods. A retrospective study comparing patients receiving IALA with high doses (0.5% bupivacaine 60 mL) of local anesthetics or FNB in addition to intravenous patient-controlled analgesia with opioids for pain management after TKA was conducted. The primary end point was to compare the analgesic efficacy and early ambulation between the two groups. Results. No significant differences between the two groups in pain intensity, cumulative opioid consumption, incidences of opioid-related side effects, the time interval from the end of operation to the first time the patient could walk assisted with a walker postoperatively, and postoperative hospital stay were identified. Three patients in the IALA group but none in the FNB group walked within 12 hours after the end of operation. Summary. IALA with high doses of local anesthetics provides comparable analgesic efficacy as single-shot FNB after TKA and might be associated with earlier ambulation than FNB postoperatively. Shengchin Kao, Hungchen Lee, Chihwen Cheng, Chingfeng Lin, and Hsini Tsai Copyright © 2015 Shengchin Kao et al. All rights reserved. Supplemental Interscalene Blockade to General Anesthesia for Shoulder Arthroscopy: Effects on Fast Track Capability, Analgesic Quality, and Lung Function Wed, 29 Apr 2015 12:25:39 +0000 Background. After shoulder surgery performed in patients with interscalene nerve block (without general anesthesia), fast track capability and postoperative pain management in the PACU are improved compared with general anesthesia alone. However, it is not known if these evidence-based benefits still exist when the interscalene block is combined with general anesthesia. Methods. We retrospectively analyzed a prospective cohort data set of 159 patients undergoing shoulder arthroscopy with general anesthesia alone () or combined with an interscalene nerve block catheter () for fast track capability time. Moreover, comparisons were made for VAS scores, analgesic consumption in the PACU, pain management, and lung function measurements. Results. The groups did not differ in mean time to fast track capability (22 versus 22 min). Opioid consumption in PACU was significantly less in the interscalene group, who had significantly better VAS scores during PACU stay. Patients receiving interscalene blockade had a significantly impaired lung function postoperatively, although this did not affect postoperative recovery and had no impact on PACU times. Conclusion. The addition of interscalene block to general anesthesia for shoulder arthroscopy did not enhance fast track capability. Pain management and VAS scores were improved in the interscalene nerve block group. Martin Zoremba, Thomas Kratz, Frank Dette, Hinnerk Wulf, Thorsten Steinfeldt, and Thomas Wiesmann Copyright © 2015 Martin Zoremba et al. All rights reserved. The Levels and Duration of Sensory and Motor Blockades of Spinal Anesthesia in Obese Patients That Underwent Urological Operations in the Lithotomy Position Wed, 29 Apr 2015 07:50:48 +0000 Obesity has a significant effect on the cephalic spread of a spinal block (SB) due to a reduction in cerebrospinal fluid (CSF). SB is controlled by the tissue blood flow in addition to the CSF. Some positions and techniques of surgery used can cause changes in hemodynamics. We investigated effects of hemodynamic changes that may occur during Transurethral prostate resection (TUR-P) and lithotomy position (LP) at the SB level in obese versus nonobese individuals. Sixty patients who had undergone TUR-P operation under spinal anesthesia were divided into a nonobese ( kg/m2, Group N) or obese ( kg/m2, Group O) group. SB assessments were recorded afterthe LP. SB at 6 and 120 min and the peak SB level were compared between two groups. Hemodynamics were recorded after LP. Peak and 6 min SB levels were similar between the groups, while 120 min SB levels were significantly higher for Group O (). Blood pressure (BP) after the LP was significantly higher for Group N (). LP and TUR-P increased the BP in Group N when compared to Group O. The increase in hemodynamics enhances the blood flow in the spinal cord and may form similar SB levels in nonobese patients to those in obese patients. However, SB time may be longer in obese patients. Taner Ciftci, Ali Bestemi Kepekci, Hatice Pınar Yavasca, Hayrettin Daskaya, and Volkan İnal Copyright © 2015 Taner Ciftci et al. All rights reserved. Does High Thoracic Epidural Analgesia with Levobupivacaine Preserve Myocardium? A Prospective Randomized Study Tue, 31 Mar 2015 06:17:10 +0000 Background. Our study aimed to compare HTEA and intravenous patient-controlled analgesia (PCA) in patients undergoing coronary bypass graft surgery (CABG), based on haemodynamic parameters and myocardial functions. Materials and Methods. The study included 34 patients that were scheduled for elective CABG, who were randomly divided into 2 groups. Anesthesia was induced and maintained with total intravenous anesthesia in both groups while intravenous PCA with morphine was administered in Group 1 and infusion of levobupivacaine was administered from the beginning of the anesthesia in Group 2 by thoracic epidural catheter. Blood samples were obtained presurgically, at 6 and 24 hours after surgery for troponin I, creatinine kinase-MB (CK-MB), total antioxidant capacity, and malondialdehyde. Postoperative pain was evaluated every 4 hours until 24 hours via VAS. Results. There were significant differences in troponin I or CK-MB values between the groups at postsurgery 6 h and 24 h. Heart rate and mean arterial pressure in Group 1 were significantly higher than in Group 2 at all measurements. Cardiac index in Group 2 was significantly higher than in Group 1 at all measurements. Conclusion. Patients that underwent CABG and received HTEA had better myocardial function and perioperative haemodynamic parameters than those who did not receive HTEA. Serife Gokbulut Bektas, Sema Turan, Umit Karadeniz, Burcin Ozturk, Soner Yavas, Dilan Biricik, Gul Sevim Saydam, and Ozcan Erdemli Copyright © 2015 Serife Gokbulut Bektas et al. All rights reserved. Chlorhexidine Gluconate Dressings Reduce Bacterial Colonization Rates in Epidural and Peripheral Regional Catheters Mon, 23 Mar 2015 08:34:46 +0000 Introduction. Bacterial colonization of catheter tips is common in regional anesthesia and is a suspected risk factor for infectious complications. This is the first study evaluating the effect of CHG-impregnated dressings on bacterial colonization of regional anesthesia catheters in a routine clinical setting. Methods. In this prospective study, regional anesthesia catheter infection rates were examined in two groups of patients with epidural and peripheral regional catheters. In the first group, regional anesthesia was dressed with a conventional draping. The second group of patients underwent catheter dressing using a CHG-impregnated draping. Removed catheters and the insertion sites were both screened for bacterial colonization. Results. A total of 337 catheters from 308 patients were analysed. There was no significant reduction of local infections in either epidural or peripheral regional anesthesia catheters in both CHG and conventional groups. In the conventional group, 21% of the catheter tips and 41% of the insertion sites showed positive culture results. In the CHG-group, however, only 3% of the catheter tips and 8% of the insertion sites were colonised. Conclusion. CHG dressings significantly reduce bacterial colonization of the tip and the insertion site of epidural and peripheral regional catheters. However, no reductions in rates of local infections were seen. Klaus Kerwat, Leopold Eberhart, Martina Kerwat, Dominik Hörth, Hinnerk Wulf, Thorsten Steinfeldt, and Thomas Wiesmann Copyright © 2015 Klaus Kerwat et al. All rights reserved. Corrigendum to “Regional Anesthesia for Postoperative Pain Control” Mon, 16 Mar 2015 09:02:45 +0000 Ahmet Eroglu, Engin Erturk, Alparslan Apan, and Ozgun Cuvas Apan Copyright © 2015 Ahmet Eroglu et al. All rights reserved. Sample Entropy Analysis of EEG Signals via Artificial Neural Networks to Model Patients’ Consciousness Level Based on Anesthesiologists Experience Sun, 08 Feb 2015 12:55:42 +0000 Electroencephalogram (EEG) signals, as it can express the human brain’s activities and reflect awareness, have been widely used in many research and medical equipment to build a noninvasive monitoring index to the depth of anesthesia (DOA). Bispectral (BIS) index monitor is one of the famous and important indicators for anesthesiologists primarily using EEG signals when assessing the DOA. In this study, an attempt is made to build a new indicator using EEG signals to provide a more valuable reference to the DOA for clinical researchers. The EEG signals are collected from patients under anesthetic surgery which are filtered using multivariate empirical mode decomposition (MEMD) method and analyzed using sample entropy (SampEn) analysis. The calculated signals from SampEn are utilized to train an artificial neural network (ANN) model through using expert assessment of consciousness level (EACL) which is assessed by experienced anesthesiologists as the target to train, validate, and test the ANN. The results that are achieved using the proposed system are compared to BIS index. The proposed system results show that it is not only having similar characteristic to BIS index but also more close to experienced anesthesiologists which illustrates the consciousness level and reflects the DOA successfully. George J. A. Jiang, Shou-Zen Fan, Maysam F. Abbod, Hui-Hsun Huang, Jheng-Yan Lan, Feng-Fang Tsai, Hung-Chi Chang, Yea-Wen Yang, Fu-Lan Chuang, Yi-Fang Chiu, Kuo-Kuang Jen, Jeng-Fu Wu, and Jiann-Shing Shieh Copyright © 2015 George J. A. Jiang et al. All rights reserved. Is Infusion of Subhypnotic Propofol as Effective as Dexamethasone in Prevention of Postoperative Nausea and Vomiting Related to Laparoscopic Cholecystectomy? A Randomized Controlled Trial Wed, 28 Jan 2015 12:18:40 +0000 Background. Postoperative nausea and vomiting (PONV) is one of common complications in patients undergoing laparoscopic cholecystectomy (LC). Aim of this study was to compare the efficacy of subhypnotic (1 mg/kg/h) infusion of propofol with dexamethasone on PONV in patients undergoing LC. Methods. A total of 120 patients were included in this randomized, double-blind, placebo-controlled study. Patients were randomly assigned to 3 groups; patients of group dexamethasone (group D) were administrated 8 mg dexamethasone before induction of anesthesia, patients of group propofol (group P) were infused to subhypnotic (1 mg/kg/h) propofol during operation and patients of group control (group C) were applied infusion of 10% intralipid. The incidence of PONV and needs for rescue analgesic and antiemetic were recorded in the first 24 h postoperatively. Results. In the 0–24 h, the incidence of PONV was significantly lower in the group D and group P compared with the group C (37.5%, 40%, and 72.5%, resp.). There was no significant difference in the incidence of PONV and use of antiemetics and analgesic between group D and group P. Conclusion. We concluded that infusion of propofol 1 mg/kg/h is as effective as dexamethasone for the prevention of PONV during the first 24 hours after anesthesia in patients undergoing LC. Mine Celik, Aysenur Dostbil, Mehmet Aksoy, Ilker Ince, Ali Ahiskalioglu, Mehmet Comez, and Ali Fuat Erdem Copyright © 2015 Mine Celik et al. All rights reserved. Electroencephalographic Changes Associated with Antinociceptive Actions of Lidocaine, Ketamine, Meloxicam, and Morphine Administration in Minimally Anaesthetized Dogs Wed, 28 Jan 2015 07:20:53 +0000 Effects of ketamine and lidocaine on electroencephalographic (EEG) changes were evaluated in minimally anaesthetized dogs, subjected to electric stimulus. Six dogs were subjected to six treatments in a crossover design with a washout period of one week. Dogs were subjected to intravenous boluses of lidocaine 2 mg/kg, ketamine 3 mg/kg, meloxicam 0.2 mg/kg, morphine 0.2 mg/kg and loading doses of lidocaine 2 mg/kg followed by continuous rate infusion (CRI) of 50 and 100 mcg/kg/min, and ketamine 3 mg/kg followed by CRI of 10 and 50 mcg/kg/min. Electroencephalogram was recorded during electrical stimulation prior to any drug treatment (before treatment) and during electrical stimulation following treatment with the drugs (after treatment) under anaesthesia. Anaesthesia was induced with propofol and maintained with halothane at a stable concentration between 0.85 and 0.95%. Pretreatment median frequency was evidently increased () for all treatment groups. Lidocaine, ketamine, and morphine depressed the median frequency resulting from the posttreatment stimulation. The depression of median frequency suggested evident antinociceptive effects of these treatments in dogs. It is therefore concluded that lidocaine and ketamine can be used in the analgesic protocol for the postoperative pain management in dogs. Ubedullah Kaka, Chen Hui Cheng, Goh Yong Meng, Sharida Fakurazi, Asmatullah Kaka, Atique Ahmed Behan, and Mahdi Ebrahimi Copyright © 2015 Ubedullah Kaka et al. All rights reserved. Cardiac Emergencies in Neurosurgical Patients Mon, 26 Jan 2015 06:21:05 +0000 Perioperative safety concerns are a major area of interest in recent years. Severe cardiac perturbation such as cardiac arrest is one of the most dreaded complications in the intraoperative period; however, little is known about the management of these events in the patients undergoing elective neurosurgery. This special group needs further attention, as it is often neither feasible nor appropriate to apply conventional advanced cardiac life support algorithms in patients undergoing neurosurgery. Factors such as neurosurgical procedure and positioning can also have a significant effect on the occurrence of cardiac arrest. Therefore, the aim of this paper is to describe the various causes and management of cardiac emergencies with special reference to cardiac arrest during elective neurosurgical procedures, including discussion of position-related factors and resuscitative considerations in these situations. This will help to formulate possible guidelines for management of such events. Tumul Chowdhury, Andrea Petropolis, and Ronald B. Cappellani Copyright © 2015 Tumul Chowdhury et al. All rights reserved. Prophylactic Antiarrhythmic Effect of Anesthetics at Subanesthetic Concentration on Epinephrine-Induced Arrhythmias in Rats after Brain Death Wed, 14 Jan 2015 14:18:32 +0000 The present study using brain death model of rats was designed to examine whether prophylactic administration of volatile anesthetics and propofol prevent the epinephrine-induced arrhythmias. A Fogarty catheter was placed intracranially for induction of brain death. After brain death, the rats were randomly assigned to five groups: the control group (no anesthetics), the sevoflurane group (0.8%), the isoflurane group (0.5%), the halothane group (0.3%), and the propofol group (195 μg·kg−1·min−1). These anesthetics were about 30% of of each anesthetic. The arrhythmogenic dose of epinephrine was determined in each anesthetic group. In addition, we examined left ventricular levels of connexin 43 phosphorylation 30 min after administration of each anesthetic with Western blot analysis. The arrhythmogenic dose of epinephrine in the sevoflurane group was significantly higher than that in the control group, while the arrhythmogenic dose of epinephrine in any other anesthetic group was not different. On the other hand, the ratio of phosphorylated-connexin 43/total connexin 43 was also similar among the study groups. Thus, prophylactic administration of subanesthetic dose of sevoflurane is effective in preventing epinephrine-induced arrhythmias after brain death, but phosphorylation of connexin is not involved in the antiarrhythmic property of sevoflurane. Yuka Miyata, Mitsuo Iwasaki, Hiroo Yamanaka, Masanori Sato, Takahiko Kamibayashi, Yuji Fujino, and Yukio Hayashi Copyright © 2015 Yuka Miyata et al. All rights reserved. Performance Analysis of Extracted Rule-Base Multivariable Type-2 Self-Organizing Fuzzy Logic Controller Applied to Anesthesia Sun, 21 Dec 2014 11:42:17 +0000 We compare type-1 and type-2 self-organizing fuzzy logic controller (SOFLC) using expert initialized and pretrained extracted rule-bases applied to automatic control of anaesthesia during surgery. We perform experimental simulations using a nonfixed patient model and signal noise to account for environmental and patient drug interaction uncertainties. The simulations evaluate the performance of the SOFLCs in their ability to control anesthetic delivery rates for maintaining desired physiological set points for muscle relaxation and blood pressure during a multistage surgical procedure. The performances of the SOFLCs are evaluated by measuring the steady state errors and control stabilities which indicate the accuracy and precision of control task. Two sets of comparisons based on using expert derived and extracted rule-bases are implemented as Wilcoxon signed-rank tests. Results indicate that type-2 SOFLCs outperform type-1 SOFLC while handling the various sources of uncertainties. SOFLCs using the extracted rules are also shown to outperform those using expert derived rules in terms of improved control stability. Yan-Xin Liu, Faiyaz Doctor, Shou-Zen Fan, and Jiann-Shing Shieh Copyright © 2014 Yan-Xin Liu et al. All rights reserved. Coapplication of Lidocaine and Membrane-Impermeable Lidocaine Derivative QX-222 Produces Divergent Effects on Evoked and Spontaneous Nociceptive Behaviors in Mice Mon, 24 Nov 2014 12:36:54 +0000 The present study was aimed at investigating the analgesic properties of a combination of lidocaine and QX-222 and its effects on evoked pain behavior (complete Freund’s adjuvant-induced allodynia and hyperalgesia in inflammatory condition) and spontaneous pain behavior (formalin-induced acute pain) in mice. Drugs were injected adjacent to sciatic nerve or into plantar. Motor function, thermal withdrawal latency, mechanical withdrawal threshold, and licking/biting were evaluated by behavioral tests. A combination of lidocaine and QX-222 adjacent sciatic nerve injection produced the long-lasting sensory-specific nerve block, and intraplantar injection inhibited spontaneous pain in the formalin-treated mice but did not detectably attenuated hyperalgesia and allodynia in the complete Freund’s adjuvant- (CFA-) treated mice. Our results suggest that a combination of lidocaine and QX-222 achieves a long-lasting differential block (sensory selective) and produces divergent effects on evoked and spontaneous pain behaviors in mice. Si-Ping Hu, Jing-Jing Zhao, Wei-Xing Wang, Yang Liu, He-Fen Wu, Chao Chen, Liang Yu, and Jing-Bing Gui Copyright © 2014 Si-Ping Hu et al. All rights reserved. Erratum to “Evidence for the Use of Isoflurane as a Replacement for Chloral Hydrate Anesthesia in Experimental Stroke: An Ethical Issue” Thu, 28 Aug 2014 00:00:00 +0000 Maud Pétrault, Thavarak Ouk, Cédrick Lachaud, Michèle Bastide, Vincent Bérézowski, Olivier Pétrault, and Régis Bordet Copyright © 2014 Maud Pétrault et al. All rights reserved. A Miracle That Accelerates Operating Room Functionality: Sugammadex Thu, 14 Aug 2014 11:23:53 +0000 Background. Sugammadex offers a good alternative to the conventional decurarisation process currently performed with cholinesterase inhibitors. Sugammadex, which was developed specifically for the aminosteroid-structured rocuronium and vecuronium neuromuscular blockers, is a modified cyclodextrin made up of 8 glucose monomers arranged in a cylindrical shape. Methods. In this study, the goal was to investigate the efficacy of sugammadex. Sugammadex was used when there was insufficient decurarisation following neostigmine. This study was performed on 14 patients who experienced insufficient decurarisation (TOF ) with neostigmine after general anaesthesia in the operating rooms of a university and a state hospital between June, 2012, and January, 2014. A dose of 2 mg/kg of sugammadex was administered. Results. Time elapsed until sugammadex administration following neostigmine min, following sugammadex it took min to reach TOF , and the extubation time was min. No statistically significant differences were detected in the hemodynamic parameters before and after sugammadex application. From the time of administration of sugammadex to the second postoperative hour, no side effects or complications occurred. None of the patients experienced acute respiratory failure or residual block during this time period. Conclusion. Sugammadex was successfully used to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient. Erdal Dogan, Mehmet Salim Akdemir, Abdulmenap Guzel, Mehmet Besir Yildirim, Zeynep Baysal Yildirim, Mahir Kuyumcu, Abdurrahman Gümüş, and Hakan Akelma Copyright © 2014 Erdal Dogan et al. All rights reserved. A Systematic Review and Meta-Analysis of Caudal Block as Compared to Noncaudal Regional Techniques for Inguinal Surgeries in Children Tue, 05 Aug 2014 08:50:46 +0000 This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE, EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from 1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively. Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99], ) and late (RR = 0.81 [0.69, 0.96], ) periods, but with a significant risk of motor block and urinary retention. According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound translates into better clinical success with the inguinal nerve blocks. Harsha Shanthanna, Balpreet Singh, and Gordon Guyatt Copyright © 2014 Harsha Shanthanna et al. All rights reserved. Predicting Postoperative Vomiting for Orthopedic Patients Receiving Patient-Controlled Epidural Analgesia with the Application of an Artificial Neural Network Tue, 05 Aug 2014 08:29:03 +0000 Patient-controlled epidural analgesia (PCEA) was used in many patients receiving orthopedic surgery to reduce postoperative pain but is accompanied with certain incidence of vomiting. Predictions of the vomiting event, however, were addressed by only a few authors using logistic regression (LR) models. Artificial neural networks (ANN) are pattern-recognition tools that can be used to detect complex patterns within data sets. The purpose of this study was to develop the ANN based predictive model to identify patients with high risk of vomiting during PCEA used. From January to March 2007, the PCEA records of 195 patients receiving PCEA after orthopedic surgery were used to develop the two predicting models. The ANN model had a largest area under curve (AUC) in receiver operating characteristic (ROC) curve. The areas under ROC curves of ANN and LR models were 0.900 and 0.761, respectively. The computer-based predictive model should be useful in increasing vigilance in those patients most at risk for vomiting while PCEA is used, allowing for patient-specific therapeutic intervention, or even in suggesting the use of alternative methods of analgesia. Cihun-Siyong Alex Gong, Lu Yu, Chien-Kun Ting, Mei-Yung Tsou, Kuang-Yi Chang, Chih-Long Shen, and Shih-Pin Lin Copyright © 2014 Cihun-Siyong Alex Gong et al. All rights reserved. Comparison of the Effects of Low Volume Prilocaine and Alkalinized Prilocaine for the Regional Intravenous Anesthesia Technique in Hand and Wrist Surgery Tue, 15 Jul 2014 09:55:01 +0000 Aim. Comparing the effectivity of prilocaine and prilocaine alkalinized with 8.4% NaHCO3 in terms of sensory and motor block onset and termination durations in RIVA technique considering patients’ satisfaction and tolerance with application of tourniquet undergoing hand-wrist surgery. Materials and Methods. 64 patients were randomised into two groups. First group (Group P) was administered prilocaine and second group (Group PN) was administered prilocaine + %8.4 NaHCO3. Sensory and motor block onset and termination times and onset of tourniquet pain were recorded. Results. No significant difference was found between the two groups in terms of onset and termination of sensory block and the onset of motor block. The duration of the motor block was longer in Group PN than in Group P . Tourniquet pain was more intense in Group P . In Group PN, the use of additional drugs was recorded at a lower rate and patients’ satisfaction was higher than Group P. Conclusion. In the present study, it was established that alkalinization of prilocaine had no effect on the duration of sensory block and it prolonged the duration of motor block, increased patients’ satisfaction, and decreased tourniquet pain. It is our suggestion that future studies should be carried out on the issue by using different volumes. Ozlem Kapusuz, Guldeniz Argun, Murat Arikan, Guray Toğral, Aysun Basarir, and Nihal Kadiogullari Copyright © 2014 Ozlem Kapusuz et al. All rights reserved. The Effects of Intravenous Fosaprepitant and Ondansetron for the Prevention of Postoperative Nausea and Vomiting in Neurosurgery Patients: A Prospective, Randomized, Double-Blinded Study Mon, 23 Jun 2014 13:06:40 +0000 The incidence of postoperative nausea and vomiting (PONV) is 30–50% after surgery. PONV occurs frequently, especially after craniotomy. In this study, we investigated the preventive effects on PONV in a randomized study by comparing patients who had been administered fosaprepitant, a neurokinin-1 (NK1) receptor antagonist, or ondansetron intravenously. Sixty-four patients undergoing craniotomy were randomly allocated to receive fosaprepitant 150 mg i.v. (NK1 group, n = 32) or ondansetron 4 mg i.v. (ONS group, n = 32) before anesthesia. The incidence of vomiting was significantly less in the NK1 group, where 2 of 32 (6%) patients experienced vomiting compared to 16 of 32 (50%) patients in the ONS group during the first 24 and 48 hours following surgery. Additionally, the incidence of complete response (no vomiting and no rescue antiemetic use) was significantly higher in the NK1 group than in the ONS group, and was 66% versus 41%, respectively, during the first 24 hours, and 63% versus 38%, respectively, during the first 48 hours. In patients undergoing craniotomy, fosaprepitant is more effective than ondansetron in increasing the rate of complete response and decreasing the incidence of vomiting at 24 and 48 hours postoperatively. Yasuo M. Tsutsumi, Nami Kakuta, Tomohiro Soga, Katsuyoshi Kume, Eisuke Hamaguchi, Rie Tsutsumi, and Katsuya Tanaka Copyright © 2014 Yasuo M. Tsutsumi et al. All rights reserved. Ischemia-Reperfusion Injury and Anesthesia Thu, 19 Jun 2014 05:08:19 +0000 Alexander Zarbock, Ahmet Eroglu, Engin Erturk, Can Ince, and Martin Westphal Copyright © 2014 Alexander Zarbock et al. All rights reserved. Regional Anesthesia for Postoperative Pain Control Wed, 18 Jun 2014 12:19:04 +0000 Ahmet Eroglu, Engin Erturk, Alparslan Apan, Urs Eichenberger, and Ozgun Cuvas Apan Copyright © 2014 Ahmet Eroglu et al. All rights reserved. 1-1-12 One-Step Wash-In Scheme for Desflurane-Nitrous Oxide Low-Flow Anesthesia: Rapid and Predictable Induction Wed, 04 Jun 2014 07:23:03 +0000 Background. We propose a 1-1-12 wash-in scheme for desflurane-nitrous oxide (N2O) low-flow anesthesia. The objective of our study was to determine the time to achieve alveolar concentration of desflurane () at 1, 2, 3, 4, 5, and 6%. Methods. We enrolled 106 patients scheduled for elective surgery under general anesthesia. After induction and intubation, wash-in was started with a fresh gas flow (FGF) of N2O : O2 1 : 1 L min−1 and vaporizer concentration of desflurane (FD) of 12%. Ventilation was controlled to maintain at 30–35 mmHg. Results. The rose rapidly from 0 to 4% in 2 min in a linear manner in 0.5 min increments. An of 6% was achieved in 4 min in a linear fashion from of 4% but in 1 min increments. An of 1 to 6% occurred at 0.6, 1, 1.5, 2, 3, and 4 min. Heart rate during wash-in showed a statistically, albeit not clinically, significant pattern of increase. By contrast, blood pressure slightly decreased during this period. Conclusions. We developed a 1-1-12 wash-in scheme using a FGF of N2O : O2 1 : 1 L min−1 and FD of 12% for desflurane-nitrous oxide low-flow anesthesia. A respective of 1, 2, 3, 4, 5, and 6% can be expected at 0.6, 1, 1.5, 2, 3, and 4 min. Thepakorn Sathitkarnmanee, Sirirat Tribuddharat, Chakthip Suttinarakorn, Duangthida Nonlhaopol, Maneerat Thananun, Wilawan Somdee, and Sunchai Theerapongpakdee Copyright © 2014 Thepakorn Sathitkarnmanee et al. All rights reserved. Magnetic Resonance Imaging in Children under Anesthesia: The Relationship between the Degree of Information Provided to Parents and Parents’ Anxiety Scores Sun, 25 May 2014 12:48:31 +0000 Background. We aimed to investigate the correlation between the anxiety scores of parents whose children are administered anesthesia for magnetic resonance imaging (MRI) and the level of information provided to them before the MRI. The study included 146 children and their parents. The demographic information of the children and their parents was recorded. The parents were divided into two groups. In Group I, the patient’s medical history and physical exam findings were recorded on a standard consultation form by an anesthesiologist. In Group II, the parents were additionally provided with more detailed information on how the anesthesia would be administered and the drugs to be used and their side effects and complications. The anxiety scores of the parents were found to be lower in Group II. A higher level of education was associated with higher anxiety scores. Intergroup comparison detected lower anxiety scores for Group II parents whose education levels were up to high school. However, no change upon receiving detailed information was detected in the anxiety scores of parents with higher education levels. In conclusion, this may lower the anxiety scores in parents informed about details of anesthesia administration and may raise parents’ sense of confidence in the doctor. Abdulmenap Güzel, Abdullah Atlı, Erdal Doğan, Feyzi Çelik, Adnan Tüfek, Abdurrahim Dusak, Velat Şen, and Zeynep Baysal Yıldırım Copyright © 2014 Abdulmenap Güzel et al. All rights reserved. Patient-Controlled Epidural Levobupivacaine with or without Fentanyl for Post-Cesarean Section Pain Relief Mon, 19 May 2014 10:55:45 +0000 Purpose. The purpose of this study was to compare the analgesic properties of levobupivacaine with or without fentanyl for patient-controlled epidural analgesia after Cesarean section in a randomized, double-blinded study. Methods. We enrolled American Society of Anesthesiologists class I/II, full-term pregnant women at National Taiwan University Hospital who received patient-controlled epidural analgesia after Cesarean section between 2009 and 2010. Eighty women were randomly assigned into two groups. In group A, the 40 subjects received drug solutions made of 0.6 mg/ml levobupivacaine plus 2 mcg/ml fentanyl, and in group B the 40 subjects received 1 mg/ml levobupivacaine. Maintenance was self-administered boluses and a continuous background infusion. Results. There were no significant differences in the resting and dynamic pain scales and total volume of drug used between the two groups. Patient satisfaction was good in both groups. Conclusion. Our study showed that pure epidural levobupivacaine can provide comparative analgesic properties to the levobupivacaine-fentanyl combination after Cesarean section. Pure levobupivacaine may serve as an alternative pain control regimen to avoid opioid-related adverse events in parturients. Shin-Yan Chen, Feng-Lin Liu, Yih-Giun Cherng, Shou-Zen Fan, Barbara L. Leighton, Hung-Chi Chang, and Li-Kuei Chen Copyright © 2014 Shin-Yan Chen et al. All rights reserved. Does the Addition of Tramadol and Ketamine to Ropivacaine Prolong the Axillary Brachial Plexus Block? Tue, 06 May 2014 07:11:20 +0000 Background and Objectives. A prospective, randomized, controlled, double-blind clinical trial to assess the effect of tramadol and ketamine, 50 mg, added to ropivacaine in brachial plexus anesthesia. Methods. Thirty-six ASA physical statuses I and II patients, between 18 and 60 years of age, scheduled for forearm and hand surgery under axillary brachial plexus block, were allocated to 3 groups. Group R received 0.375% ropivacaine in 40 mL, group RT received 0.375% ropivacaine in 40 mL with 50 mg tramadol, and group RK received 0.375% ropivacaine in 40 mL with 50 mg ketamine for axillary brachial plexus block. The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events (nausea, vomiting, and feeling uncomfortable) were recorded. Results. The onset time of sensorial block was the fastest in ropivacaine + tramadol group. Duration of sensorial and motor block was the shortest in the ropivacaine + tramadol group. Duration of analgesia was significantly longer in ropivacaine + tramadol group. Conclusion. We conclude that when added to brachial plexus analgesia at a dose of 50 mg, tramadol extends the onset and duration time of the block and improves the quality of postoperative analgesia without any side effects. Ahmet Can Senel, Ozlem Ukinc, and Alper Timurkaynak Copyright © 2014 Ahmet Can Senel et al. All rights reserved. The Effects of Single-Dose Rectal Midazolam Application on Postoperative Recovery, Sedation, and Analgesia in Children Given Caudal Anesthesia Plus Bupivacaine Mon, 05 May 2014 00:00:00 +0000 Background. This study aimed to compare the effects of rectal midazolam addition after applying bupivacaine and caudal anesthesia on postoperative analgesia time, the need for additional analgesics, postoperative recovery, and sedation and to find out its adverse effects in children having lower abdominal surgery. Methods. 40 children between 2 and 10 years of ASA I-II were randomized, and they received caudal anesthesia under general anesthesia. Patients underwent the application of caudal block in addition to saline and 1 mL/kg bupivacaine 0.25%. In the postoperative period, Group C (n = 20) was given 5 mL saline, and Group M (n = 20) was given 0.30 mg/kg rectal midazolam diluted with 5 mL saline. Sedation scale and postoperative pain scale (CHIPPS) of the patients were evaluated. The patients were observed for their analgesic need, first analgesic time, and adverse effects for 24 hours. Results. Demographic and hemodynamic data of the two groups did not differ. Postoperative sedation scores in both groups were significantly lower compared with the preoperative period. There was no significant difference between the groups in terms of sedation and sufficient analgesia. Conclusions. We conclude that caudal anesthesia provided sufficient analgesia in peroperative and postoperative periods, and rectal midazolam addition did not create any differences. This trial is registered with NCT02127489. Sedat Saylan, Ahmet Eroglu, and Davut Dohman Copyright © 2014 Sedat Saylan et al. All rights reserved. Gabapentin in Acute Postoperative Pain Management Mon, 14 Apr 2014 08:48:49 +0000 Gabapentin (1-aminomethyl-cyclohexaneacetic acid) is an amino acid that has the structure of the neurotransmitter γ-aminobutyric acid (GABA). It is a novel drug used for the treatment of postoperative pain with antihyperalgesic properties and a unique mechanism of action. Gabapentin and the related, more potent compound pregabalin have been shown to be beneficial in the treatment of neuropathic pain as well as postoperative pain following spinal surgery and hysterectomy. This study reviews five aspects of gabapentin: (1) chemical and structural characteristics; (2) pharmacokinetics and pharmacodynamics; (3) application in acute pain management; (4) adverse effects; and (5) drug safety. Overall, gabapentin has been reported to be a safe and efficacious drug for the treatment of postoperative pain. Connie Y. Chang, Chaitanya K. Challa, Janki Shah, and Jean Daniel Eloy Copyright © 2014 Connie Y. Chang et al. All rights reserved. Development of an Open-Heart Intraoperative Risk Scoring Model for Predicting a Prolonged Intensive Care Unit Stay Thu, 10 Apr 2014 14:17:53 +0000 Background. Based on a pilot study with 34 patients, applying the modified sequential organ failure assessment (SOFA) score intraoperatively could predict a prolonged ICU stay, albeit with only 4 risk factors. Our objective was to develop a practicable intraoperative model for predicting prolonged ICU stay which included more relevant risk factors. Methods. An extensive literature review identified 6 other intraoperative risk factors affecting prolonged ICU stay. Another 168 patients were then recruited for whom all 10 risk factors were extracted and analyzed by logistic regression to form the new prognostic model. Results. The multivariate logistic regression analysis retained only 6 significant risk factors in the model: age ≥ 60 years, PaO2/FiO2 ratio ≤ 200 mmHg, platelet count ≤ 120,000/mm3, requirement for inotrope/vasopressor ≥ 2 drugs, serum potassium ≤ 3.2 mEq/L, and atrial fibrillation grading ≥2. This model was then simplified into the Open-Heart Intraoperative Risk (OHIR) score, comprising the same 6 risk factors for a total score of 7—a score of ≥3 indicating a likely prolonged ICU stay (AUC for ROC of 0.746). Conclusions. We developed a new, easy to calculate OHIR scoring system for predicting prolonged ICU stay as early as 3 hours after CPB. It comprises 6 risk factors, 5 of which can be manipulated intraoperatively. Sirirat Tribuddharat, Thepakorn Sathitkarnmanee, Kriangsak Ngamsangsirisup, Somrat Charuluxananan, Cameron P. Hurst, Suparit Silarat, and Ganjana Lertmemongkolchai Copyright © 2014 Sirirat Tribuddharat et al. All rights reserved. Efficacy of Continuous Epidural Analgesia versus Total Intravenous Analgesia on Postoperative Pain Control in Endovascular Abdominal Aortic Aneurysm Repair: A Retrospective Case-Control Study Mon, 07 Apr 2014 13:37:48 +0000 We reviewed our experience to compare the effectiveness of epidural analgesia and total intravenous analgesia on postoperative pain control in patients undergoing endovascular abdominal aortic aneurysm repair. Records of 32 patients during a 2-year period were retrospectively investigated. TIVA group () received total intravenous anesthesia, and EA group () received epidural anesthesia and sedation. Pain assessment was performed on all patients on a daily basis during rest and activity on postoperative days until discharge from ward using the numeric rating scale. Data for demographic variables, required anesthetic level, perioperative hemodynamic variables, postoperative pain, and morbidities were recorded. There were no relevant differences concerning hospital stay (TIVA group: 14.1 ± 7.0, EA group: 13.5 ± 7.1), perioperative blood pressure variability (TIVA group: 15.6 ± 18.1, EA group: 14.8 ± 11.5), and perioperative hemodynamic complication rate (TIVA group: 17%, EA group: 14%). Postoperative pain scores differed significantly (TIVA group: 5.4 ± 0.9, EA group: 1.8 ± 0.8, ). Epidural anesthesia and postoperative epidural analgesia better reduce postoperative pain better compared with general anesthesia and systemic analgesia, with similar effects on hemodynamic status. Ahmet Şen, Başar Erdivanlı, Abdullah Özdemir, Hızır Kazdal, and Ersagun Tuğcugil Copyright © 2014 Ahmet Şen et al. All rights reserved. Comparison of the Effect of Lidocaine Adding Dexketoprofen and Paracetamol in Intravenous Regional Anesthesia Mon, 31 Mar 2014 10:14:29 +0000 Objective. Comparison of dexketoprofen and paracetamol added to the lidocaine in Regional Intravenous Anesthesia in terms of hemodynamic effects, motor and sensorial block onset times, intraoperative VAS values, and analgesia requirements. Method. The files of 73 patients between 18 and 65 years old in the ASA I-II risk group who underwent hand and forearm surgery were analyzed and 60 patients were included in the study. Patients were divided into 3 groups: Group D (), 3 mg/kg 2% lidocaine and 50 mg/2 mL dexketoprofen trometamol; Group P (), 3 mg/kg 2% lidocaine and 3 mg/kg paracetamol; Group K (), 3 mg/kg 2% lidocaine. Demographic data, motor and sensorial block times, heart rate, mean blood pressure, VAS values, and intraoperative and postoperative analgesia requirements were recorded. Results. Sensorial and motor block onset durations of Group K were significantly longer than other groups. Motor block termination duration was found to be significantly longer in Group D than in Group K. VAS values of Group K were found higher than other groups. There was no significant difference in VAS values between Group D and Group P. Analgesia requirement was found to be significantly more in Group K than in Group P. There was no significant difference between the groups in terms of heart rates and mean arterial pressures. Conclusion. We concluded that the addition of 3 mg/kg paracetamol and 50 mg dexketoprofen to lidocaine as adjuvant in Regional Intravenous Anesthesia applied for hand and/or forearm surgery created a significant difference clinically. Ali Akdogan and Ahmet Eroglu Copyright © 2014 Ali Akdogan and Ahmet Eroglu. All rights reserved. Investigation of an Intelligent System for Fiber Optic-Based Epidural Anesthesia Thu, 20 Mar 2014 12:24:54 +0000 Even though there have been many approaches to assist the anesthesiologists in performing regional anesthesia, none of the prior arts may be said as an unrestricted technique. The lack of a design that is with sufficient sensitivity to the targets of interest and automatic indication of needle placement makes it difficult to all-round implementation of field usage of objectiveness. In addition, light-weight easy-to-use realization is the key point of portability. This paper reports on an intelligent system of epidural space identification using optical technique, with particular emphasis on efficiency-enhanced aspects. Statistical algorithms, implemented in a dedicated field-programmable hardware platform along with an on-platform application-specific integrated chip, used to advance real-time self decision making in needle advancement are discussed together with the feedback results. Clinicians' viewpoint of improving the correct rate of our technique is explained in detail. Our study demonstrates not only that the improved system is able to behave as if it is a skillful anesthesiologist but also it has potential to bring promising assist into clinical use under varied conditions and small amount of sample, provided that several concerns are addressed. Cihun-Siyong Alex Gong and Chien-Kun Ting Copyright © 2014 Cihun-Siyong Alex Gong and Chien-Kun Ting. All rights reserved. The Effect of Intravenous Magnesium Sulfate Infusion on Sensory Spinal Block and Postoperative Pain Score in Abdominal Hysterectomy Wed, 19 Mar 2014 09:59:39 +0000 Aim. The aim of this study was to investigate the effect of i.v. infusion of magnesium sulphate during spinal anesthesia on duration of spinal block and postoperative pain. Methods. Forty ASA physical status I and status II, aged between 18 and 65, female patients undergoing abdominal hysterectomy under spinal anesthesia were enrolled in this study. Patients in the magnesium group (Group M, n = 20) received magnesium sulphate 65 mg kg−1 infusion in 250 mL 5% dextrose at 3.5 mL/min rate, and control group (Group C, n = 20) received at the same volume of saline during operation in a double-blind randomized manner. Duration of sensory and motor block, systolic, diastolic, and mean arterial blood pressures, heart rates, pain scores (VAS values), and side effects were recorded for each patient. Blood and CSF samples were taken for analysis of magnesium concentrations. Results. Regression of sensorial block was longer in Group M when compared with that in Group C (175 ± 39 versus 136 ± 32 min) (P < 0.01). The VAS scores were lower in Group M than those in Group C at the 2 time points postoperatively (P < 0.01). Conclusion. 65 mg kg−1 of magnesium sulphate i.v. infusion under spinal anesthesia prolongs spinal sensorial block duration and decreases pain VAS scores without complication in patients undergoing abdominal hysterectomy. Fatih Kahraman and Ahmet Eroglu Copyright © 2014 Fatih Kahraman and Ahmet Eroglu. All rights reserved. The Effects on Sensorial Block, Motor Block, and Haemodynamics of Levobupivacaine at Different Temperatures Applied in the Subarachnoid Space Tue, 18 Mar 2014 00:00:00 +0000 Aim. To evaluate the effects of 0.5% levobupivacaine at 37°C preheated from room temperature, on sensorial block, motor block, and haemodynamics in patients undergoing transurethral prostate resection (TUR-P). Material and Method. The patients were randomly allocated to two groups: Group I patients were injected with 3 mL 0.5% levobupivacaine solution which had been kept at room temperature for at least 24 hours and Group II patients were injected with 3 mL 0.5% levobupivacaine solution which had been kept at 37°C for at least 24 hours. The patients were examined in terms of sensorial block, motor block, haemodynamic profile, and incidence of side effects. Results. No significant difference was found between the groups in terms of demographic data. The time to reach T10 sensory block and the time of starting motor block were found to be significantly shorter in Group II . The duration of sensory block over T10 and T6, the duration of L1 regression, the duration of the sensory block, and the regression time of the motor blocks from 3 to 2 were found to be longer in Group II. Conclusion. The use of 0.5% levobupivacaine spinal anaesthesia heated to 37°C accelerated the start of sensory and motor block. Bahittin Nazli, Huseyin Oguzalp, Eyup Horasanli, Mehmet Gamli, Beyazit Dikmen, and Nermin Gogus Copyright © 2014 Bahittin Nazli et al. All rights reserved. The Effectiveness of Preemptive Thoracic Epidural Analgesia in Thoracic Surgery Thu, 13 Mar 2014 13:32:24 +0000 Background. The aim of this study is to investigate the effectiveness of preemptive thoracic epidural analgesia (TEA) comparing conventional postoperative epidural analgesia on thoracotomy. Material and Methods. Forty-four patients were randomized in to two groups (preemptive: Group P, control: Group C). Epidural catheter was inserted in all patients preoperatively. In Group P, epidural analgesic solution was administered as a bolus before the surgical incision and was continued until the end of the surgery. Postoperative patient controlled epidural analgesia infusion pumps were prepared for all patients. Respiratory rates (RR) were recorded. Patient’s analgesia was evaluated with visual analog scale at rest (VASr) and coughing (VASc). Number of patient’s demands from the pump, pump’s delivery, and additional analgesic requirement were also recorded. Results. RR in Group C was higher than in Group P at postoperative 1st and 2nd hours. Both VASr and VASc scores in Group P were lower than in Group C at postoperative 1st, 2nd, and 4th hours. Patient’s demand and pump’s delivery count for bolus dose in Group P were lower than in Group C in all measurement times. Total analgesic requirements on postoperative 1st and 24th hours in Group P were lower than in Group C. Conclusion. We consider that preemptive TEA may offer better analgesia after thoracotomy. Engin Erturk, Ferdane Aydogdu Kaya, Dilek Kutanis, Ahmet Besir, Ali Akdogan, Sükran Geze, and Ersagun Tugcugil Copyright © 2014 Engin Erturk et al. All rights reserved. Peri- and Postanalgesic Properties of Lidokain, Lornoxicam, and Nitroglycerine Combination at Intravenous Regional Anesthesia Sun, 09 Mar 2014 07:47:59 +0000 Background. This study was conducted to compare and evaluate the effect of adding lornoxicam or nitroglycerine as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Methods. 60 patients were randomly separated into three groups, lidocaine group (group L), lidocaine + lornoxicam group (group LL), and lidocaine + lornoxicam + transdermal nitroglycerine group (group LL-N). Hemodynamic parameters, sensory and motor blocks onset, and recovery times were recorded. Analgesic consumption for tourniquet pain and postoperative period were recorded. Results. Sensory block onset times and motor block onset times were shorter in the LL-N and LL groups compared with L group. Sensory block recovery time and motor block recovery time were prolonged in the LL and LL-N groups compared with group L. The amount of fentanyl required for tourniquet pain was less in group LL and group LL-N when compared with group L. VAS scores of tourniquet pain were higher in group L compared with the other study groups. Postoperative VAS scores were higher for the first 4 hours in group L compared with the other study groups. Conclusion. The adjuvant drugs (lornoxicam or TNG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance, and improving the postoperative analgesia. Biricik Melis Cakmak, Gokhan Cakmak, Elif Akpek, Gulnaz Arslan, and Mehmet Sukru Sahin Copyright © 2014 Biricik Melis Cakmak et al. All rights reserved. Evidence for the Use of Isoflurane as a Replacement for Chloral Hydrate Anesthesia in Experimental Stroke: An Ethical Issue Thu, 27 Feb 2014 11:57:42 +0000 Since an ethical issue has been raised regarding the use of the well-known anesthetic agent chloral hydrate, owing to its mutagenic and carcinogenic effects in animals, attention of neuroscientists has turned to finding out an alternative agent able to meet not only potency, safety, and analgesic efficacy, but also reduced neuroprotective effect for stroke research. The aim of this study was to compare the potential of chloral hydrate and isoflurane for both modulating the action of the experimental neuroprotectant MK801 and exerting analgesia. After middle cerebral artery occlusion in rats, no difference was observed in 24 h survival rate, success of ischemia, or infarct volume reduction between both anesthetics. However, isoflurane exerted a more pronounced analgesic effect than chloral hydrate as evidenced by formalin test 3 hours after anesthesia onset, thus encouraging the use of isoflurane in experimental stroke models. Pétrault Maud, Ouk Thavarak, Lachaud Cédrick, Bastide Michèle, Bérézowski Vincent, Pétrault Olivier, and Bordet Régis Copyright © 2014 Pétrault Maud et al. All rights reserved. Spinal Anesthesia for Knee Arthroscopy Using Isobaric Bupivacaine and Levobupivacaine: Anesthetic and Neuroophthalmological Assessment Thu, 20 Feb 2014 12:25:58 +0000 Introduction. The aim of the study was to compare the sensory, motor, and neuroophthalmological effects of isobaric levobupivacaine and bupivacaine when intrathecally administered. Materials and Methods. A prospective, double-blind, randomized study with 60 ASA grade I-II patients aged 18–65 years awaiting knee arthroscopy under spinal anesthesia. Patients received 12.5 mg of isobaric bupivacaine or levobupivacaine. Several features were recorded. Results. No significant intergroup differences were observed for ASA classification, time to micturate, demographic data, surgery duration, and patient/surgeon satisfaction. Similar hemodynamic parameters and sensory/motor blockade duration were found for both groups. There were no neuroophthalmological effects in either group. Sensory () and motor blockade onset () was faster in the bupivacaine group. T6 (T2–T12) and T3 (T2–T12) were the highest sensory block levels for the levobupivacaine and bupivacaine groups, respectively (). It took less time to regain maximum motor blockade in the bupivacaine group (), and the levobupivacaine group required use of analgesia earlier (). Conclusions. Isobaric bupivacaine and levobupivacaine are analogous and well-tolerated anesthetics for knee arthroscopy. However, for bupivacaine, sensory and motor blockade onset was faster, and greater sensory blockade with a longer postoperative painless period was achieved. Monica del-Rio-Vellosillo, Jose Javier Garcia-Medina, Antonio Abengochea-Cotaina, Maria Dolores Pinazo-Duran, and Manuel Barbera-Alacreu Copyright © 2014 Monica del-Rio-Vellosillo et al. All rights reserved. The Effects of Spinal, Inhalation, and Total Intravenous Anesthetic Techniques on Ischemia-Reperfusion Injury in Arthroscopic Knee Surgery Thu, 20 Feb 2014 07:24:20 +0000 Purpose. To compare the effects of different anesthesia techniques on tourniquet-related ischemia-reperfusion by measuring the levels of malondialdehyde (MDA), ischemia-modified albumin (IMA) and neuromuscular side effects. Methods. Sixty ASAI-II patients undergoing arthroscopic knee surgery were randomised to three groups. In Group S, intrathecal anesthesia was administered using levobupivacaine. Anesthesia was induced and maintained with sevoflurane in Group I and TIVA with propofol in Group T. Blood samples were obtained before the induction of anesthesia (), 30 min after tourniquet inflation (), immediately before (), and 5 min (), 15 min (), 30 min (), 1 h (), 2 h (), and 6 h () after tourniquet release. Results. MDA and IMA levels increased significantly compared with baseline values in Group S at and . MDA levels in Group T and Group I were significantly lower than those in Group S at and . IMA levels in Group T were significantly lower than those in Group S at . Postoperatively, a temporary 1/5 loss of strength in dorsiflexion of the ankle was observed in 3 patients in Group S and 1 in Group I. Conclusions. TIVA with propofol can make a positive contribution in tourniquet-related ischemia-reperfusion. Müge Koşucu, İlker Coşkun, Ahmet Eroglu, Dilek Kutanis, Ahmet Menteşe, S. Caner Karahan, Emre Baki, Servet Kerimoğlu, and Murat Topbas Copyright © 2014 Müge Koşucu et al. All rights reserved. Effects of Supplemental Oxygen on Maternal and Neonatal Oxygenation in Elective Cesarean Section under Spinal Anesthesia: A Randomized Controlled Trial Thu, 20 Feb 2014 00:00:00 +0000 The use of supplemental oxygen in uncomplicated cesarean deliveries under spinal anesthesia has been thoroughly investigated during recent decades. The aim of this study was to determine the benefits for both mother and infant of administering supplemental, low-dose oxygen via a nasal cannula versus having no supplement (i.e., room air only). Healthy parturients at term undergoing elective cesarean section under spinal anesthesia were randomly allocated into two groups: an oxygen group (), who received 3 LPM oxygen via a nasal cannula; and a room-air group (), who were assigned to breathe room air. Maternal oxygen saturation was measured continuously by using pulse oximeter. The desaturation was determined by oxygen saturation <94% over 30 seconds. Umbilical cord gases and Apgar scores were collected followed delivery of the infant. All maternal desaturation events occurred in 12 parturients assigned to the room-air group. Most events were concurrent with hypotension. The umbilical venous partial pressure of oxygen was significantly higher in the oxygen group. The other blood gas measurements and Apgar scores were not significantly different between the two groups. Based on our findings, the use of supplemental oxygen could prevent maternal desaturation resulting from receiving sedation and intraoperative hypotension. Arunotai Siriussawakul, Namtip Triyasunant, Akarin Nimmannit, Sopapan Ngerncham, Promphon Hirunkanokpan, Sasiwalai Luang-Aram, Nusaroch Pechpaisit, Aungsumat Wangdee, and Pornpimol Ruangvutilert Copyright © 2014 Arunotai Siriussawakul et al. All rights reserved. Investigation of the Effects of Preoperative Hydration on the Postoperative Nausea and Vomiting Mon, 20 Jan 2014 07:48:40 +0000 Introduction. Postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy operations still continue to be a serious problem. Intravenous fluid administration has been shown to reduce PONV. Some patients have higher risk for PONV described by APFEL score. In this study, our aim was to determine the effects of preoperative intravenous hydration on postoperative nausea and vomiting in high Apfel scored patients undergoing laparoscopic cholecystectomy surgery. Patients and Methods. This study is performed with 50 female patients who had APFEL score 3-4 after ethics committee approval and informed consent was taken from patients. The patients were divided into 2 groups: group 1 (P1): propofol + preoperative hydration and group 2 (P2): propofol + no preoperative hydration. Results. When the total nausea VAS scores of groups P1 and P2 to which hydration was given or not given were compared, a statistically significant difference was detected at 8th and 12th hours ( and ). It was observed that in group P1, which was given hydration, the nausea VAS score was lower. When the total number of patients who had nausea and vomiting in P1 and P2, more patients suffered nausea in P2 group. Discussion. Preoperative hydration may be effective in high Apfel scored patients to prevent postoperative nausea. M. Selçuk Yavuz, Dilek Kazancı, Sema Turan, Bahar Aydınlı, Gökçe Selçuk, Ayşegül Özgök, and Ahmet Coşar Copyright © 2014 M. Selçuk Yavuz et al. All rights reserved. Role of Ethyl Pyruvate in Systemic Inflammatory Response and Lung Injury in an Experimental Model of Ruptured Abdominal Aortic Aneurysm Sun, 19 Jan 2014 15:32:31 +0000 Objectıve. The purpose of this study is to evaluate the effect of ethyl pyruvate (EP) on systemic inflammatory response and lung injury in an experimental rat model of ruptured abdominal aortic anurysm (RAAA). Methods. Anaesthetized 30 Sprague-Dawley male rats were randomized to sham (Sh ) (Sh + EP ) or shock and clamp (S/C) groups (S/C ) (S/C + EP ). In the S/C and S/C + EP groups, hemorrhagic shock, lower torso ischemia, and reperfusion were created, S/C group was given 1 mL saline and S/C + EP group was given 40 mg/kg EP. At the end of reperfusion process some biochemical and histological parameters were studied in serum and lung tissues. Results. An increase was observed in all parameters except interleukin-6 (IL-6) in the S/C group in comparison to the sham groups. In the S/C + EP group, serum myeloperoxydase (MPO), malondialdehyde (MDA), and tumor necrosis factor alpha (TNF-α) as well as lung MPO and MDA values decreased significantly (). In the lung tissues, histological injury scores and lung tissue wet/dry ratio were significantly decreased in the S/C + EP group as compared to the S/C group (). Conclusions. Ethyl pyruvate may reduce systemic inflammatory response and lung injury which resulted from shock and ischemia/reperfusion in an experimental model of RAAA. Zerrin Pulathan, Gökalp Altun, Doğuş Hemşinli, Ahmet Menteşe, Esin Yuluğ, and Ali Civelek Copyright © 2014 Zerrin Pulathan et al. All rights reserved. A Standardized Method for 4D Ultrasound-Guided Peripheral Nerve Blockade and Catheter Placement Sun, 19 Jan 2014 09:31:02 +0000 We present a standardized method for using four-dimensional ultrasound (4D US) guidance for peripheral nerve blocks. 4D US allows for needle tracking in multiple planes simultaneously and accurate measurement of the local anesthetic volume surrounding the nerve following injection. Additionally, the morphology and proximity of local anesthetic spread around the target nerve is clearly seen with the described technique. This method provides additional spatial information in real time compared to standard two-dimensional ultrasound. N. J. Clendenen, C. B. Robards, and S. R. Clendenen Copyright © 2014 N. J. Clendenen et al. All rights reserved. Adalimumab Ameliorates Abdominal Aorta Cross Clamping Which Induced Liver Injury in Rats Thu, 16 Jan 2014 07:42:28 +0000 The aim of this study was to investigate the possible protective effects of adalimumab (ADA) on cell damage in rat liver tissue during ischemia/reperfusion (I/R) injury of infrarenal abdominal aorta. Thirty male Wistar-albino rats were divided into three groups: control, I/R, and I/R+ADA, each group containing 10 animals. Laparotomy without I/R injury was performed in the control group animals. Laparotomy in the I/R group was followed by two hours of infrarenal abdominal aortic cross ligation and then two hours of reperfusion. ADA (50 mg/kg) was administered intraperitoneally as a single dose, to the I/R+ADA group, five days before I/R. The tumor necrosis factor-alpha (TNF-) (pg/mg protein) and nitric oxide (NO) (mol/g protein) levels in the I/R group (430.8 ± 70.1, 8.0 ± 1.1, resp.) were significantly higher than those in the I/R+ADA group (338.0 ± 71.6, ; 6.3 ± 1.2, ) and the control group (345.5 ± 53.3, ; 6.5 ± 1.5, , resp.). I/R causes severe histopathological injury to the liver tissue, but ADA leads to much less histopathological changes. ADA treatment significantly decreased the severity of liver I/R injury. ADA pretreatment may have protective effects on experimental liver injury. Erkan Cure, Medine Cumhur Cure, Levent Tumkaya, Yildiray Kalkan, Ibrahim Aydin, Aynur Kirbas, Arif Yilmaz, Suleyman Yuce, and Ahmet Fikret Yücel Copyright © 2014 Erkan Cure et al. All rights reserved. The Effect of Intravenous Anesthetics on Ischemia-Reperfusion Injury Thu, 16 Jan 2014 07:15:22 +0000 The effects of intravenous anesthetics on ischemia-reperfusion injury (IRI) have been investigated in both animals and clinical studies. The protective effects and the dosages of the intravenous anesthetics on IRI were discussed in this paper. The prevention of the tissue injury after the IRI was demonstrated with intravenous anesthetics in some studies. In the future, the studies should be focused on the dosage of the anesthetics related to diminishing the tissue injuries. Further studies might be required in order to investigate the effects of the anesthetics on molecular levels. Ahmet Eroglu Copyright © 2014 Ahmet Eroglu. All rights reserved. Premedication with Oral Alprazolam and Melatonin Combination: A Comparison with Either Alone—A Randomized Controlled Factorial Trial Sun, 12 Jan 2014 00:00:00 +0000 We assessed if the addition of melatonin to alprazolam has superior premedication effects compared to either drug alone. A prospective, double blind placebo controlled trial randomly assigned 80 adult patients (ASA 1&2) with a Visual Analogue Score (VAS) for anxiety ≥3 to receive a tablet containing a combination of alprazolam 0.5 mg and melatonin 3 mg, alprazolam 0.5 mg, melatonin 3 mg, or placebo orally 90 min before a standard anesthetic. Primary end points were change in anxiety and sedation score at 15, 30, and 60 min after premedication, and number of patients with loss of memory for the five pictures shown at various time points when assessed after 24 h. One-way ANOVA, Friedman repeated measures analysis of variance, Kruskal Wallis and chi square tests were used as relevant. Combination drug produced the maximum reduction in anxiety VAS (3 (1.0–4.3)) from baseline at 60 min (). Sedation scores at various time points and number of patients not recognizing the picture shown at 60 min after premedication were comparable between combination drug and alprazolam alone. Addition of melatonin to alprazolam had superior anxiolysis compared with either drugs alone or placebo. Adding melatonin neither worsened sedation score nor the amnesic effect of alprazolam alone. This study was registered, approved, and released from Identifier number: NCT01486615. Krishna Pokharel, Mukesh Tripathi, Pramod Kumar Gupta, Balkrishna Bhattarai, Sindhu Khatiwada, and Asish Subedi Copyright © 2014 Krishna Pokharel et al. All rights reserved. The Effects of Remote Ischemic Preconditioning and N-Acetylcysteine with Remote Ischemic Preconditioning in Rat Hepatic Ischemia Reperfusion Injury Model Wed, 08 Jan 2014 07:53:23 +0000 Background. Remote ischemic preconditioning (RIP) and pharmacological preconditioning are the effective methods that can be used to prevent ischemia reperfusion (IR) injury. The aim of this study was to evaluate the effects of RIP and N-Acetylcysteine (NAC) with RIP in the rat hepatic IR injury model. Materials and Methods. 28 rats were divided into 4 groups. Group I (sham): only laparotomy was performed. Group II (IR): following 30 minutes of hepatic pedicle occlusion, 4 hours of reperfusion was performed. Group III (RIP + IR): following 3 cycles of RIP, hepatic IR was performed. Group IV (RIP + NAC + IR): following RIP and intraperitoneal administration of NAC (150 mg/kg), hepatic IR was performed. All the rats were sacrificed after blood samples were taken for the measurements of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and liver was processed for conventional histopathology. Results. The hepatic histopathological injury scores of RIP + IR and RIP + NAC + IR groups were significantly lower than IR group (, , resp.). There were no significant differences in AST and ALT values between the IR, RIP + IR, and RIP + NAC + IR groups. Conclusions. In the present study, it was demonstrated histopathologically that RIP and RIP + NAC decreased hepatic IR injury significantly. Ali Ihsan Uysal, Elvan Ocmen, Mert Akan, Sevda Ozkardesler, Bekir Ugur Ergur, Ensari Guneli, Tuncay Kume, Uğur Koca, and Belgin Unal Togrul Copyright © 2014 Ali Ihsan Uysal et al. All rights reserved. The Effect of Dexmedetomidine on Oxidative Stress during Pneumoperitoneum Wed, 08 Jan 2014 07:48:53 +0000 Purpose. This study was intended to investigate the effect of dexmedetomidine on oxidative stress response in pneumoperitoneum established in rats. Methods. Animals were randomized into three groups, group S: with no pneumoperitoneum, group P: with pneumoperitoneum established, and group D: given 100 mcg intraperitoneal dexmedetomidine 30 min before establishment of pneumoperitoneum. Plasma total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI) activity were measured 30 min after conclusion of pneumoperitoneum. Results. The mean TOS level was significantly higher in group P than in the other two groups, and the TOS level was significantly higher in group D than in group S (). Plasma TAS level was found to be lower in group P than in the other two groups, and the TAS level was lower in group D than in group S (). Consequently, the OSI was significantly higher in group P than in groups D and S (). Conclusions. Ischemia-reperfusion phenomenon that occurs during pneumoperitoneum causes oxidative stress and consumption of plasma antioxidants. Dexmedetomidine decreases oxidative stress caused by pneumoperitoneum and strengthens the antioxidant defense system. Bahanur Cekic, Sukran Geze, Gulsum Ozkan, Ahmet Besir, Mehmet Sonmez, S. Caner Karahan, and Ahmet Mentese Copyright © 2014 Bahanur Cekic et al. All rights reserved. The Comparison of the Effects of Sevoflurane Inhalation Anesthesia and Intravenous Propofol Anesthesia on Oxidative Stress in One Lung Ventilation Sun, 05 Jan 2014 12:54:23 +0000 Background. The aim of this study is to compare the effects of sevoflurane and propofol on one lung ventilation (OLV) induced ischemia-reperfusion injury (IRI) by determining the blood gas, ischemia-modified albumin (IMA), and malonyldialdehyde (MDA). Material and Methods. Forty-four patients undergoing thoracic surgery with OLV were randomized in two groups (sevoflurane Group S, propofol Group P). Anesthesia was inducted with thiopental and was maintained with 1–2.5% of sevoflurane within the 40/60% of O2/N2O mixture in Group S. In Group P anesthesia was inducted with propofol and was maintained with infusion of propofol and remifentanil. Hemodynamic records and blood samples were obtained before anesthesia induction (), 1 min before two lung ventilation (), 30 min after two lung ventilation (), and postoperative sixth hours (). Results. Heart rate at and in Group P was significantly lower than that in Group S. While there were no significant differences in terms of pH and pCO2, pO2 at and in Group S was significantly lower than that in Group P. IMA levels at in Group S were significantly lower than those in Group P. Conclusion. Sevoflurane may offer protection against IRI after OLV in thoracic surgery. Engin Erturk, Selma Topaloglu, Davut Dohman, Dilek Kutanis, Ahmet Beşir, Yucel Demirci, Selcuk Kayir, and Ahmet Mentese Copyright © 2014 Engin Erturk et al. All rights reserved. Ischemia-Reperfusion Injury and Volatile Anesthetics Thu, 02 Jan 2014 15:36:14 +0000 Ischemia-reperfusion injury (IRI) is induced as a result of reentry of the blood and oxygen to ischemic tissue. Antioxidant and some other drugs have protective effect on IRI. In many surgeries and clinical conditions IRI is counteract inevitable. Some anesthetic agents may have a protective role in this procedure. It is known that inhalational anesthetics possess protective effects against IRI. In this review the mechanism of preventive effects of volatile anesthetics and different ischemia-reperfusion models are discussed. Engin Erturk Copyright © 2014 Engin Erturk. All rights reserved. Complex Assessment of the Incidence and Risk Factors of Delirium in a Large Cohort of Cardiac Surgery Patients: A Single-Center 6-Year Experience Sun, 22 Dec 2013 14:50:24 +0000 Background. Previous reports provided inconsistent data on the occurrence of postoperative delirium and emphasized its considerable impact on outcome. This study sought to evaluate the incidence and predictors of delirium, together with its relation to cerebral ischemia in a large cohort of cardiac surgery patients in a tertiary high-volume center. Methods and Results. Consecutive patients () were prospectively enrolled from 2003 to 2008. Exclusion criteria were history of psychiatric disorders, use of psychoactive drugs, alcohol abuse, and data incompleteness. Finally, 5781 patients were analyzed in terms of 100 perioperative patient-specific and treatment variables. The incidence of postoperative delirium (DSM IV criteria) was 4.1% and it coexisted with cerebral ischemia in 1.1% of patients. In bivariate analysis, 49 variables were significantly linked to postoperative delirium. Multivariate analysis confirmed that delirium was independently associated with postoperative stroke (logistic odds ratio (logOR) = 2.862, ), any blood transfusions (logOR = 4.178, ), age > 65 years (logOR = 2.417, ), carotid artery stenosis (logOR = 2.15, ), urgent/emergent surgery (logOR = 1.982, ), fasting glucose level, intraoperative oxygen partial pressure fluctuations, and hematocrit. Area under ROC curve for the model was 0.8933. Conclusions. Early identification of nonpsychiatric perioperative determinants of delirium facilitates its diagnosis and might help develop preventive strategies to improve long-term outcome after cardiac surgery procedures. Łukasz J. Krzych, Maciej T. Wybraniec, Irena Krupka-Matuszczyk, Michał Skrzypek, Anna Bolkowska, Mirosław Wilczyński, and Andrzej A. Bochenek Copyright © 2013 Łukasz J. Krzych et al. All rights reserved. Efficacy and Safety of Hepatectomy Performed with Intermittent Portal Triad Clamping with Low Central Venous Pressure Thu, 12 Dec 2013 09:13:39 +0000 Background. This retrospective study was designed to investigate the efficacy and safety of intermittent portal triad clamping (PTC) with low central venous pressure (CVP) in liver resections. Methods. Between January 2007 and August 2013, 115 patients underwent liver resection with intermittent PTC. The patients’ data were retrospectively analyzed. Results. There were 58 males and 57 females with a mean age of 55 years (±13.7). Cirrhosis was found in 23 patients. Resections were performed for malignant disease in 62.6% () and for benign disease in 37.4% (). Major hepatectomy was performed in 26 patients (22.4%). Mean liver ischemia period was 27.1 min (±13.9). The mortality rate was 1.7% and the morbidity rate was 22.6%. Cumulative clamping time (, ) and operation time (, ) were significantly correlated with AST alterations (D-AST). Cumulative clamping time (, ) was significantly correlated with D-ALT. Operation time (, ) was significantly correlated with D-LDH. Conclusions. Intermittent PTC under low CVP was performed with low morbidity and mortality. Intermittent PTC can be safely applied up to 60 minutes in both normal and impaired livers. Serdar Topaloglu, Kıymet Yesilcicek Calik, Adnan Calik, Coskun Aydın, Sema Kocyigit, Huseyin Yaman, Dilek Kutanis, Erdem Karabulut, Davut Dohman, Asim Orem, and Mithat Kerim Arslan Copyright © 2013 Serdar Topaloglu et al. All rights reserved. Ropivacaine-Induced Contraction Is Attenuated by Both Endothelial Nitric Oxide and Voltage-Dependent Potassium Channels in Isolated Rat Aortae Wed, 20 Nov 2013 17:32:22 +0000 This study investigated endothelium-derived vasodilators and potassium channels involved in the modulation of ropivacaine-induced contraction. In endothelium-intact rat aortae, ropivacaine concentration-response curves were generated in the presence or absence of the following inhibitors: the nonspecific nitric oxide synthase (NOS) inhibitor Nω-nitro-L-arginine methyl ester (L-NAME), the neuronal NOS inhibitor Nω-propyl-L-arginine hydrochloride, the inducible NOS inhibitor 1400W dihydrochloride, the nitric oxide-sensitive guanylyl cyclase (GC) inhibitor ODQ, the NOS and GC inhibitor methylene blue, the phosphoinositide-3 kinase inhibitor wortmannin, the cytochrome p450 epoxygenase inhibitor fluconazole, the voltage-dependent potassium channel inhibitor 4-aminopyridine (4-AP), the calcium-activated potassium channel inhibitor tetraethylammonium (TEA), the inward-rectifying potassium channel inhibitor barium chloride, and the ATP-sensitive potassium channel inhibitor glibenclamide. The effect of ropivacaine on endothelial nitric oxide synthase (eNOS) phosphorylation in human umbilical vein endothelial cells was examined by western blotting. Ropivacaine-induced contraction was weaker in endothelium-intact aortae than in endothelium-denuded aortae. L-NAME, ODQ, and methylene blue enhanced ropivacaine-induced contraction, whereas wortmannin, Nω-propyl-L-arginine hydrochloride, 1400W dihydrochloride, and fluconazole had no effect. 4-AP and TEA enhanced ropivacaine-induced contraction; however, barium chloride and glibenclamide had no effect. eNOS phosphorylation was induced by ropivacaine. These results suggest that ropivacaine-induced contraction is attenuated primarily by both endothelial nitric oxide and voltage-dependent potassium channels. Seong-Ho Ok, Jeong Yeol Han, Hui-Jin Sung, Seong Min Yang, Jungchul Park, Seong-Chun Kwon, Mun-Jeoung Choi, and Ju-Tae Sohn Copyright © 2013 Seong-Ho Ok et al. All rights reserved. Cerebral Activation during Von Frey Filament Stimulation in Subjects with Endothelin-1-Induced Mechanical Hyperalgesia: A Functional MRI Study Wed, 18 Sep 2013 11:47:30 +0000 Endothelin-1 (ET-1) is an endogenously expressed potent peptide vasoconstrictor. There is growing evidence that ET-1 plays a role in the pain signaling system and triggers overt nociception in humans. The underlying neuronal pathways are still a matter of great debate. In the present study, we applied an intradermal ET-1 sensitization model to induce mechanical hyperalgesia in healthy subjects. Functional magnetic resonance imaging (fMRI) was used to tease out the cortical regions associated with the processing of ET-1-induced punctate hyperalgesia, as compared to a nonnoxious mechanical stimulation of the contralateral arm. Von Frey hair testing revealed the presence of increased responsiveness to punctate stimulation in all subjects. Activational patterns between nonpainful control stimulation and hyperalgesic stimulation were compared. Two major observations were made: (1) all cortical areas that showed activation during the control stimulation were also present during hyperalgesic stimulation, but in addition, some areas showed bilateral activation only during hyperalgesic stimulation, and (2) some brain areas showed significantly higher signal changes during hyperalgesic stimulation. Our findings suggest that injection of ET-1 leads to a state of punctate hyperalgesia, which in turn causes the activation of multiple brain regions. This indicates that ET-1 activates an extended neuronal pathway. Guy H. Hans, Everhard Vandervliet, Kristof Deseure, and Paul M. Parizel Copyright © 2013 Guy H. Hans et al. All rights reserved. Effects of Repeated Central Administration of Endothelin Type A Receptor Antagonist on the Development of Neuropathic Pain in Rats Thu, 29 Aug 2013 16:01:45 +0000 Endothelin-1 (ET-1) predominates in the endothelin family effectively in vascular tone control, mitogenesis, and neuromodulation. Its receptors are widespread in the central nervous system (CNS) associated with endogenous pain control, suggesting an important role of ET-1 in central pain processing. This study aimed to evaluate the effect of central ET-1 on the development of neuropathic pain behaviour by repeated intrathecal administration of endothelin type A receptor (ETAR) antagonist (BQ-123) in a sciatic nerve ligation (SNL) animal model. BQ-123 was administered intrathecally to rats at dosages 15 μg, 20 μg, 25 μg, and 30 μg, daily for 3 days. Mechanical allodynia was assessed daily 30 minutes before/after injection, 1 hour after injection of BQ-123 from post-SNL day 4 to day 6, and once on day 7 (without BQ-123 administration) before rats were sacrificed. Increasing trends of mechanical threshold were observed, and they reached significance at all dosages on post-SNL day 7 ( at dosage 15 μg and at dosages 20 μg, 25 μg, and 30 μg) in comparison to control group. BQ-123 at dosage 30 μg showed the most stable and significant mechanical threshold rise. Repeated central administration of BQ-123 alleviated mechanical allodynia after SNL. Our results provide insight into the therapeutic strategies, including timing, against neuropathic pain development with ETAR antagonist. Lydia W. Tai, Victor K. L. Hung, Wei Mei, Qiu Qiu, Sookja K. Chung, and C. W. Cheung Copyright © 2013 Lydia W. Tai et al. All rights reserved. Evaluating Compliance with Institutional Preoperative Testing Guidelines for Minimal-Risk Patients Undergoing Elective Surgery Sun, 07 Jul 2013 10:22:14 +0000 Background. Few investigations preoperatively are important for low-risk patients. This study was designed to determine the level of compliance with preoperative investigation guidelines for ASA I patients undergoing elective surgery. Secondary objectives included the following: to identify common inappropriate investigations, to evaluate the impact of abnormal testing on patient management, to determine factors affecting noncompliant tests, and to estimate unnecessary expenditure. Methods. This retrospective study was conducted on adult patients over a one-year period. The institute’s guidelines recommend tests according to the patients’ age groups: a complete blood count (CBC) for those patients aged 18–45; CBC, chest radiograph (CXR) and electrocardiography (ECG) for those aged 46–60; and CBC, CXR, ECG, electrolytes, blood glucose, blood urea nitrogen (BUN), and creatinine (Cr) for patients aged 61–65. Results. The medical records of 1,496 patients were reviewed. Compliant testing was found in only 12.1% (95% CI, 10.5–13.9). BUN and Cr testings were the most frequently overprescribed tests. Overinvestigations tended to be performed on major surgery and younger patients. Overall, overinvestigation incurred an estimated cost of US 200,000 dollars during the study period. Conclusions. The need to utilize the institution’s preoperative guidelines should be emphasized in order to decrease unnecessary testing and the consequential financial burden. Arunotai Siriussawakul, Akarin Nimmannit, Sirirat Rattana-arpa, Siritda Chatrattanakulchai, Puttachard Saengtawan, and Aungsumat Wangdee Copyright © 2013 Arunotai Siriussawakul et al. All rights reserved. Inhalation Anesthesia with Sevoflurane during Intravitreal Bevacizumab Injection in Infants with Retinopathy of Prematurity Thu, 06 Jun 2013 08:49:50 +0000 Bacground. To investigate the anesthetic management in premature infants with retinopathy of prematurity (ROP) treated with intravitreal bevacizumab (IVB) injections. Methods. A retrospective chart review was performed for the patients with ROP who had IVB injection. Clinical characteristics, demographic variables, anesthetic medications, operation techniques, time intervals, and complications were recorded. Results. Sixty-six eyes of 33 patients (23 males, 10 females) with type 1 ROP who were treated with IVB were included. A total of 66 anesthetic applications were performed. Mean gestational age at birth was 28.3 weeks (range 25–33). Mean birth weight was 1300 g (range 600–1850). Serious ocular and systemic complications were not observed in any infant. Conclusion. Inhalation anesthesia with sevoflurane during IVB treatment in premature infants with ROP may be appropriate for anesthetic management. Orhan Tokgöz, Alparslan Şahin, Adnan Tüfek, Yasin Çınar, Abdülmenap Güzel, Taner Çiftçi, Feyzi Çelik, and Harun Yüksel Copyright © 2013 Orhan Tokgöz et al. All rights reserved. Vasoconstriction Potency Induced by Aminoamide Local Anesthetics Correlates with Lipid Solubility Sun, 17 Jun 2012 19:07:50 +0000 Aminoamide local anesthetics induce vasoconstriction in vivo and in vitro. The goals of this in vitro study were to investigate the potency of local anesthetic-induced vasoconstriction and to identify the physicochemical property (octanol/buffer partition coefficient, pKa, molecular weight, or potency) of local anesthetics that determines their potency in inducing isolated rat aortic ring contraction. Cumulative concentration-response curves to local anesthetics (levobupivacaine, ropivacaine, lidocaine, and mepivacaine) were obtained from isolated rat aorta. Regression analyses were performed to determine the relationship between the reported physicochemical properties of local anesthetics and the local anesthetic concentration that produced 50% (ED50) of the local anesthetic-induced maximum vasoconstriction. We determined the order of potency (ED50) of vasoconstriction among local anesthetics to be levobupivacaine > ropivacaine > lidocaine > mepivacaine. The relative importance of the independent variables that affect the vasoconstriction potency is octanol/buffer partition coefficient > potency > pKa > molecular weight. The ED50 in endothelium-denuded aorta negatively correlated with the octanol/buffer partition coefficient of local anesthetics (𝑟2=0.9563; 𝑃<0.001). The potency of the vasoconstriction in the endothelium-denuded aorta induced by local anesthetics is determined primarily by lipid solubility and, in part, by other physicochemical properties including potency and pKa. Hui-Jin Sung, Seong-Ho Ok, Jin-Young Sohn, Yong Hyeok Son, Jun Kyu Kim, Soo Hee Lee, Jeong Yeol Han, Dong Hoon Lim, Il-Woo Shin, Heon-Keun Lee, Young-Kyun Chung, Mun-Jeoung Choi, and Ju-Tae Sohn Copyright © 2012 Hui-Jin Sung et al. All rights reserved.