The incidences of nausea and vomiting after general anesthesia with remimazolam versus sevoflurane: a prospective randomized controlled trial

Background

Postoperative nausea and vomiting (PONV) refers to nausea and vomiting that occurs within 24-h after surgery or in the post-anesthesia care unit (PACU). Previous studies have reported that the use of remimazolam, a newer benzodiazepine (BDZ) hypnotic, for anesthesia results in less PONV. In this study, we compared the rate of PONV between sevoflurane and remimazolam after general anesthesia.

Methods

In this prospective randomized controlled trial (RCT), participants aged 20-80 years who underwent elective laparoscopic cholecystectomy or hemicolectomy were randomized to either the remimazolam or sevoflurane group. The primary outcome was PONV incidence for 24-h after surgery. Secondary outcomes comprised of PONV at 30-min post-surgery, postoperative additional antiemetic use, and Quality of Recovery-15 (QOR-15) score at 24-h postoperatively.

Results

Forty patients were enrolled in the study. The remimazolam group exhibited significantly lower rates of PONV for 24-h after surgery than did the sevoflurane group (remimazolam group vs. sevoflurane group; 5% vs. 45%, P = 0.003, respectively). The use of dexamethasone, a rescue antiemetic administered within 24 h of surgery, was substantially lower in the remimazolam group than in the sevoflurane group (0% in remimazolam vs. 30% in sevoflurane, P = 0.020). The QOR-15 score at 24-h after surgery showed no significant difference between the two groups.

Conclusions

Compared to sevoflurane, opting for remimazolam as an intraoperative hypnotic may decrease the incidence of PONV and reduce antiemetic use for 24 h after laparoscopic surgery.

Use of oxygen reserve index during bronchoscopic balloon dilation for subglottic stenosis in a patient with left ventricular assist device implantation -a case report

BACKGROUND

Monitoring the oxygenation status is crucial during general anesthesia to ensure patient safety. Although noninvasive pulse oximetry is commonly used to monitor percutaneous oxygen saturation (SpO2), it may not accurately reflect changes in oxygen partial pressure when the latter is excessively high or low. The oxygen reserve index (ORi) provides real-time information about the oxygen reserve status.

CASE

We present a case of successful management of subglottic stenosis using balloon bronchoscopy in an infant with a left ventricular assist device implantation under ORi monitoring to predict hypoxemia during the surgical procedure.

CONCLUSIONS

Utilizing ORi monitoring during anesthesia for procedures involving apnea in critically ill infants can help predict impending desaturation before a drop in SpO2 occurs, allowing anesthesiologists to effectively anticipate and manage the apnea period. Continuous ORi monitoring offers valuable insights during surgical procedures, especially in infants with compromised respiratory and cardiovascular functions.

Concordance of esophageal and tracheal temperatures in patients using breathing circuit with heated wire humidifier: A prospective observational study

RESULTS

After excluding 4 patients with an anesthesia duration of < 2 hours, data from 34 patients (1163 sets of tracheal and esophageal temperatures) were analyzed. Concordance correlation coefficient was 0.78. The overall mean bias (95% limits of agreement) between the tracheal and esophageal temperatures was -0.16°C (-0.65°C to 0.34°C). The percentage of temperature differences within ± 0.25°C was 73.5% ± 32.3, with a median of 89.4% [0,100]. The linear mixed-effects model revealed that the estimated intercept was 0.17°C with a 95% confidence interval (CI) of 0.13°C to 0.22°C. The duration of anesthesia and the number of temperature measurements were associated with higher concordance between the tracheal and esophageal temperatures in univariate analysis.

General anesthesia using propofol infusion for implantation of an implantable cardioverter defibrillator in a pediatric patient with Andersen-Tawil syndrome: a case report

Andersen-Tawil syndrome (ATS) is a rare genetic disease characterized by a triad of episodic flaccid muscle weakness, ventricular arrhythmias, and physical anomalies. ATS patients have various cardiac arrhythmias that can cause sudden death. Implantation of an implantable cardioverter-defibrillator (ICD) is required when life-threatening cardiac arrhythmias do not respond to medical treatment. An 11-year-old girl underwent surgery for an ICD implantation. For general anesthesia in ATS patients, anesthesiologists should focus on the potentially difficult airway, serious cardiac arrhythmias, such as ventricular tachycardia (VT), and delayed recovery from neuromuscular blockade. We followed the difficult airway algorithm, avoided drugs that can precipitate QT prolongation and fatal cardiac arrhythmias, and tried to maintain normoxia, normocarbia, normothermia, normoglycemia, and pain control for prevention of sympathetic stimulation. We report the successful application of general anesthesia for ICD implantation in a pediatric patient with ATS and recurrent VT.

Comparison of the effect of electromyogram activity during emergence on anesthetic depth monitoring between phase lag entropy and bispectral index: a prospective observational study

BACKGROUND

The bispectral index (BIS) is the most widely used algorithm for measuring anesthetic depth. The BIS has been demonstrated as inaccurate when neuromuscular blocking drugs (NMBDs) are used. Compared with BIS, phase lag entropy (PLE), which measures the anesthetic depth based on a 4-channel EEG signal, is less affected by EMG. The purpose of this study was to compare the effect of EMG activity during emergence on anesthetic depth monitoring between PLE and BIS.

METHODS

Twenty five consecutive patients with physical status I-II of American Society of Anesthesiologists undergoing general anesthesia (age range, 20-60 years). The anesthesiologist attached the sensors of BIS and PLEM 100 on the patient's forehead. NMB reversal was performed by intravenously injecting sugammadex after confirmation of shallow NMB (TOF count 1-4) under neuromuscular monitoring. The BIS and PLE scores were recorded with neuromuscular monitoring at 1-min intervals for 5 min after administration of sugammadex.

RESULTS

The BIS and BIS-EMG measured at 1 min after sugammadex injection were significantly higher at 1 min [51.650 (46.100, 62.225) (P<0.001); 28.500 (27.800, 31.075) (P=0.003)] than at 0 min. However, there was no between-time point difference in the PLE score and PLE-EMG (P=0.0843, P=0.329).

CONCLUSIONS

In general anesthesia using propofol-remifentanil, the BIS at 1 min after sugammadex reversal during emergence appears to be more affected by EMG activity than the PLE score. Therefore, immediately after sugammadex administration (within 1 min), it may be clinically useful to evaluate the consciousness status through the PLE score.

The impact of pretransplant hepatic encephalopathy, model for end-stage liver disease (MELD) scale on long-term survival following deceased donor liver transplantation: a retrospective study

BACKGROUND

Liver transplantation (LT) has the incidence of 30-day mortality about 5-10%, Jo et al. reported that 30-day mortality and 1-year mortality for DDLT were 30%, and 39% respectively. It is not easy to create a model for predicting post-transplantation outcomes based on pretransplant variables. MELD does not take into account individual complications such as hepatic encephalopathy (HE), and research has shown that the greater the severity of pretransplant HE, the lower the survival rate after LT; the importance of monitoring for HE is therefore emphasized.

METHODS

The medical records of adult patients who underwent deceased donor LT (DDLT) were retrospectively reviewed for analysis of the effect of HE on the long-term survival rate of post-transplant for more than 1 year.

RESULTS

Presence of HE is not statistically associated to patient survival (P=0.062), but the hazard ratio is 1.954 (95% CI, 0.968, 3.943). In addition, the severe HE group significantly decreased survival compared to the non-HE group, and the cumulative 1- and 3-year overall survival rates were 80.9% and 78.7%, respectively, in non HE group, and 65.7% and 56.1%, respectively, in severe HE group (P=0.031).

CONCLUSIONS

Severe HE is a factor influencing the long-term survival over 3 years in the patients who underwent DDLT. Although prospective validation should be conducted to determine the prognostic value of HE severity, efforts could be made to reduce the severity of HE before DDLT, and consider severity of HE rather than MELD score in DDLT allocation.

Melatonin mitigates the adverse effect of hypoxia during myocardial differentiation in mouse embryonic stem cells

Background

Hypoxia causes oxidative stress and affects cardiovascular function and the programming of cardiovascular disease. Melatonin promotes antioxidant enzymes such as superoxide dismutase, glutathione reductase, glutathione peroxidase, and catalase.

Objectives

This study aims to investigate the correlation between melatonin and hypoxia induction in cardiomyocytes differentiation.

Methods

Mouse embryonic stem cells (mESCs) were induced to myocardial differentiation. To demonstrate the influence of melatonin under hypoxia, mESC was pretreated with melatonin and then cultured in hypoxic condition. The cardiac beating ratio of the mESC-derived cardiomyocytes, mRNA and protein expression levels were investigated.

Results

Under hypoxic condition, the mRNA expression of cardiac-lineage markers (Brachyury, Tbx20, and cTn1) and melatonin receptor (Mtnr1a) was reduced. The mRNA expression of cTn1 and the beating ratio of mESCs increased when melatonin was treated simultaneously with hypoxia, compared to when only exposed to hypoxia. Hypoxia-inducible factor (HIF)-1α protein decreased with melatonin treatment under hypoxia, and Mtnr1a mRNA expression increased. When the cells were exposed to hypoxia with melatonin treatment, the protein expressions of phospho-extracellular signal-related kinase (p-ERK) and Bcl-2-associated X proteins (Bax) decreased, however, the levels of phospho-protein kinase B (p-Akt), phosphatidylinositol 3-kinase (PI3K), B-cell lymphoma 2 (Bcl-2) proteins, and antioxidant enzymes including Cu/Zn-SOD, Mn-SOD, and catalase were increased. Competitive melatonin receptor antagonist luzindole blocked the melatonin-induced effects.

Conclusions

This study demonstrates that hypoxia inhibits cardiomyocytes differentiation and melatonin partially mitigates the adverse effect of hypoxia in myocardial differentiation by regulating apoptosis and oxidative stress through the p-AKT and PI3K pathway.

Successful removal of permanent spinal cord stimulators in patients with complex regional pain syndrome after complete relief of pain

Background

It is uncommon for patients who have received a permanent implant to remove the spinal cord stimulator (SCS) after discontinuation of medication in complex regional pain syndrome (CRPS) due to their completely painless state. This study evaluated CRPS patients who successfully removed their SCSs.

Methods

This 10-year retrospective study was performed on patients who had received the permanent implantation of an SCS and had removed it 6 months after discontinuation of stimulation, while halting all medications for neuropathic pain. Age, sex, duration of implantation, site and type of CRPS, and their return to work were compared between the removal and non-removal groups.

Results

Five (12.5%, M/F = 4/1) of 40 patients (M/F = 33/7) successfully removed the permanent implant. The mean age was younger in the removal group (27.2 ± 6.4 vs. 43.5 ± 10.7 years, P < 0.01). The mean duration of implantation in the removal group was 34.4 ± 18.2 months. Two of 15 patients (13.3%) and 3 of 25 patients (12%) who had upper and lower extremity pain, respectively, had removed the implant. The implants could be removed in 5 of 27 patients (18.5%) with CRPS type 1 (P < 0.01). All 5 patients (100%) who removed their SCS returned to work, while only 5 of 35 (14.3%) in the non-removal group did (P < 0.01).

Conclusions

Even though this study had limited data, younger patients with CRPS type 1 could remove their SCSs within a 5-year period and return to work with complete pain relief.

Prevention of inflammation-mediated neurotoxicity by Rg3 and its role in microglial activation

Considering the importance of inflammation and apoptosis in neurodegenerative conditions, the potential suppressive effects of the Rg3, a by-product obtained during the steaming of red ginseng, may indicate that Rg3 could provide a beneficial therapeutic approach to treating or preventing neurodegenerative disease. We investigated the effect of Rg3 on Abeta42-mediated microglial activation and inflammation-mediated neurotoxicity in murine BV-2 microglial and Neuro-2a neuroblastoma cells, respectively. Rg3 effectively reduced inflammatory cytokine expression in Abeta42-treated BV-2, and inhibited the binding of NF-kappaB p65 to its DNA consensus sequences, and significantly reduced the expression of TNF-alpha in activated microglia. Pretreatment with Rg3 increased the survival rate of Neuro-2a exposed to TNF-alpha. These observations suggest that Rg3 reduced neurotoxicity by inhibiting chronic inflammation through the suppression of activated microglia. In addition, the expression of pro-inflammatory cytokines in BV-2 stimulated by Abeta42 was decreased but not eliminated by Rg3 when binding to the macrophage scavenger receptor type A (MSRA) was blocked with fucoidan. This implies that the inflammatory response may not be exclusively triggered via MSRA. More interestingly, iNOS was almost completely inhibited in the presence of Rg3 when MSRA binding was blocked with fucoidan. Moreover, Rg3 increased the expression of MSRA in BV-2 transfected with siRNA targeting MSRA mRNA, and this increased MSRA expression may play a role in the phagocytosis of Abeta42 peptides. Our results indicate that inhibition of the inflammatory repertoire of microglia, neuroprotection, and increased MSRA expression induced by Rg3 may at least partly explain its therapeutic effects in chronic neurodegenerative diseases.

Molecular cloning and expression of a laccase from Ganoderma lucidum, and its antioxidative properties

Laccases are multicopper-containing oxidases that catalyze the oxidation of many aromatic compounds with concomitant reduction of oxygen to water. Interest in this enzyme has arisen in many fields of industry, including detoxification, wine stabilization, paper processing, and enzymatic conversion of chemical intermediates. In this study, we cloned a laccase gene (GLlac1) from the white-rot fungus Ganoderma lucidum. The cloned gene consists of 4,357 bp, with its coding region interrupted by nine introns, and the upstream region has putative CAAT and TATA boxes as well as several metal responsive elements (MREs). We also cloned a full-length cDNA of GLlac1, which contains an uninterrupted open reading frame (ORF) of 1,560 bp coding for 520 amino acids with a putative 21-residue signal sequence. The DNA and deduced amino acid sequences of GLlac1 were similar but not identical to those of other fungal laccases. GLlac1 was released from the cells when expressed in P. pastoris, and had high laccase activity. In addition, GLlac1 conferred antioxidative protection from protein degradation, and thus may be useful in bio-medical applications.

Articular Cartilage Repair with Autografting Under the Influence of Insulin-Like Growth Factor-1 in Rabbits

Insulin-like growth factor (IGF)-1 has been successfully demonstrated to stimulate proteoglycan synthesis, slow down its catabolism and promote cartilage formation through well defined in vitro studies. It was therefore, assumed that IGF-1 would eventually serve to augment current cartilage repair techniques in vivo. Study was therefore, designed to determine the influence of IGF-1 in cartilage repair with or without autografting. For this purpose articular cartilage repair model was created in the left knee of 48 New Zealand white rabbits of either sex, 6-7 months old, weighing 1-2 kg. The articular cartilage defect was created in the femoral groove of femoro-patellar joint using hand held trephine under xylazine and ketamine anaesthesia in all the animals. The defect created was 3 mm in diameter and 2 mm in depth. For autografting, osteochondral tissues harvested from the proximal patellar groove of the femur were placed in the distal defect and vice versa. The experimental animals were divided mainly into four groups, i.e. Group A (control), Group B (autografting), Group C (control + IGF-1) and Group D (autografting + IGF-1). Animals of group A and B were provided only with collagen scaffolds at 10 mug/cm(2) whereas animals of treatment group C and D were provided with collagen scaffolds holding 30 ng/30 mul of IGF-1 into the defect. Evaluation of cartilage repair was done on days 15, 30 and 45 after ethically killing the animals. Initially IGF-1 had shown the tendency for either in the maintenance of autografted cartilage or helped in proliferation of chondroblast for the repair process. However, later in the process, cartilage formation apparently declined and appeared to converge to osseous tissue. Collectively, non-responsiveness of osteoarthritic chondrocytes to IGF-1 could be partially attributed to either increased IGF-binding proteins in the joint space, micromovement of the graft, lack of nutrition, dose of IGF-1 or its half life in the current study.

Transdifferentiation of porcine satellite cells to adipoblasts with ciglitizone

Ciglitizone, a class of thiazolidinediones, acts as a potent activator of the adipose differentiation program in established preadipose cell lines. Thiazolidinediones have also been investigated in diabetic patients and have been reported to act as peroxisome proliferator-activated receptor-gamma ligands. Intramuscular adipogenesis or marbling through transdifferentiation of satellite cells in cattle was successfully conducted earlier. In this report, the effects of ciglitizone on the differentiation pathway of porcine myogenic satellite cells was investigated. Semitendinosus muscle was aseptically taken from 10-d-old piglets under general anesthesia, and porcine satellite cells were obtained and grown to near confluence. Postconfluent cells (d 0) were further cultured in differentiation medium containing an adipogenic mixture plus ciglitizone (10 microM) for 48 h. From d 2 onward, the cells were cultured only in the presence of ciglitizone until d 10. Controls were cultured in differentiation medium only. Exposure of porcine satellite cells to the adipogenic mixture plus ciglitizone generated lipid droplets on d 2, and subsequently, exposure of cells to ciglitizone alone helped in cytoplasmic lipid filling, providing them with the acquisition of adipocyte morphology. An increase (P < 0.05) in the fusion (structures containing 2 to 3 nuclei) of satellite cells was observed, and myosin heavy chain appeared with greater intensity (immunohistochemistry) in the control group from d 2 onward. Adipocyte-specific transcriptional factors (i.e., CCAAT/enhancer binding protein-alpha and peroxisome proliferator-activated receptor-gamma) were predominant during transdifferentiation and were observed with immunohistochemistry, Western blot (approximately 47.2 and approximately 60.4 kDa, respectively), and real-time PCR. Ciglitizone appeared to convert the differentiation pathway of satellite cells into that of adipoblasts.

Hemoglobin toxicity in experimental bacterial peritonitis is due to production of reactive oxygen species

Hemoglobin (Hb) is a toxic molecule responsible for the extreme lethality associated with experimental Escherichia coli peritonitis, but the mechanism has yet to be elucidated. Hb, but not globin, showed toxic effects in a live E. coli model but not in a model using killed E. coli. Methemoglobin, hematin, and the well-known Fenton reagents iron and iron-EDTA demonstrated the same lethal effect in E. coli peritonitis as Hb, while the addition of the Fenton inhibitors desferrioxamine (DF) and diethylenetriamine pentaacetate removed most of the cytotoxic activity of iron. Administration of a combined dose of superoxide dismutase and catalase minimized the action of Hb and iron-EDTA, suggesting that both O(2)(.-) and H(2)O(2) are involved in the toxic action of Hb in this rat model. The combination of the antioxidative enzymes and DF further suppressed iron-mediated lethality. An electron spin resonance technique with the spin-trapping reagent 5, 5-dimethyl-1-pyroline-N-oxide (DMPO) showed O(2)(.-) generation in the peritoneal fluid of rats injected with E. coli alone or E. coli plus iron-DF, and (.)OH generation was detected in the peritoneal fluid of the rats injected with iron-EDTA. Hb did not show any spin adduct of oxygen radicals, suggesting that Hb produces non-spin-trapping radical ferryl ion, which decayed the spin adduct of DMPO. In the presence of Hb or iron-EDTA, O(2)(-)-generating activity and viability of phagocytes decreased, whereas lipid peroxidation of peritoneal phagocytes increased. Generation of oxygen radicals and lipid peroxidation did not differ in the live and dead bacterial models. Bacterial numbers in the peritoneal cavity and blood were markedly increased in the live bacterial model with Hb and iron-EDTA. The Fenton inhibitor iron-DF prevented the loss of phagocyte function, lipid peroxidation, and bacterial proliferation. These results led us to conclude that the lethal toxicity of Hb in bacterial peritonitis is associated with a Fenton-type reaction, the products of which decrease phagocyte viability, through the induction of lipid peroxidation, allowing bacterial proliferation and resulting in mortality.

Nitric oxide protects PC12 cells from serum deprivation-induced apoptosis by cGMP-dependent inhibition of caspase signaling

Although nitric oxide (NO) induces neuronal cell death under some conditions, it also can prevent apoptosis resulting from growth factor withdrawal. We investigated the molecular mechanism by which NO protects undifferentiated and differentiated PC12 cells from trophic factor deprivation-induced apoptosis. PC12 cells underwent apoptotic death in association with increased caspase-3-like activity, DNA fragmentation, poly(ADP-ribose) polymerase (PARP) cleavage, and cytochrome c release after 24 hr of serum withdrawal. The apoptosis of PC12 cells was inhibited by the addition of NO-generating donor S-nitroso-N-acetylpenicillamine (SNAP) (5-100 microM) and the specific caspase-3-like protease inhibitor Ac-Asp-Glu-Val-Asp-aldehyde (Ac-DEVD-cho) but not the YVADase (or caspase-1-like protease) inhibitor N-acetyl-Tyr-Val-Ala-Asp-aldehyde (Ac-YVAD-cho). SNAP and Ac-DEVD-cho prevented the increase in DEVDase (caspase-3-like protease) activity. The SNAP-mediated suppression of DEVDase activity was only minimally reversed by the incubation of cell lysate with dithiothreitol, indicating that NO did not S-nitrosylate caspase-3-like proteases in PC12 cells. Western blot analysis showed that NO inhibited the proteolytic activation of caspase-3. The cGMP analog 8-bromo-cGMP (8-Br-cGMP) blocked apoptotic cell death, caspase-3 activity and activation, and cytochrome c release. The soluble guanylyl cyclase inhibitor 1-H-oxodiazol-[1,2,4]-[4,3-a] quinoxaline-1-one (CODQ) significantly attenuated NO-mediated, but not 8-Br-cGMP-dependent, inhibition of apoptotic cell death, PARP cleavage, cytochrome c release, and DEVDase activity. Furthermore, the protein kinase G inhibitor KT5823 reversed both SNAP- and 8-Br-cGMP-mediated anti-apoptotic events. All these apoptotic phenomena were also suppressed by NO production through neuronal NO synthase gene transfer into PC12 cells. Furthermore, similar findings were observed in differentiated PC12 cells stimulated to undergo apoptosis by NO donors and NGF deprivation. These findings indicate that NO protects against PC12 cell death by inhibiting the activation of caspase proteases through cGMP production and activation of protein kinase G.

Inaccuracy and inefficiency of urinary sediment analysis

When the efficiency of urine sediment analysis was studied: we found that: (1) In tests of repeatability, counts of red blood cells, white blood cells, and epithelial cells, but not of casts, showed high precision, even when they were conducted by relatively inexperienced technologists; (2) Correlation of counts of red blood cells, white blood cells, and epithelial cells was good for results obtained by an expert technologist and those obtained by relatively inexperienced technologists, but the correlation was low in the case of casts, perhaps because of their low incidence in urine sediment; (3) Hematuria and leukocyturia were often detected in specimens positive for occult blood, albumin, or both; (4) Most casts were hyaline, which are physiologic in nature. Pathologic casts such as granular casts, were found in specimens containing red and white blood cells; (5) Although urine sediment analysis was frequently requested by clinicians, most analyses showed negative results; (6) Microscopic sediment analysis requires considerable time, labor, and experience, and is more sensitive than tape tests. The results of our study indicate that there are advantages to the present method for analyzing urine sediment, but that its efficiency is doubtful.