Anesthetic Management for Transcatheter Aortic Valve Replacement: A National Anesthesia Clinical Outcomes Registry Analysis

Background: General anesthesia has traditionally been used in transcatheter aortic valve replacement; however, there has been increasing interest and momentum in alternative anesthetic techniques. Aims: To perform a descriptive study of anesthetic management options in transcatheter aortic valve replacements in the United States, comparing trends in use of monitored anesthesia care versus general anesthesia. Settings and Design: Data evaluated from the American Society of Anesthesiologists� (ASA) Anesthesia Quality Institute抯 National Anesthesia Clinical Outcomes Registry. Materials and Methods: Multivariable logistic regression was used to identify predictors associated with use of monitored anesthesia care compared to general anesthesia. Results: The use of monitored anesthesia care has increased from 1.8% of cases in 2013 to 25.2% in 2017 (p = 0.0001). Patients were more likely ages 80+ (66% vs. 61%; p = 0.0001), male (54% vs. 52%; p = 0.0001), ASA physical status > III (86% vs. 80%; p = 0.0001), cared for in the Northeast (38% vs. 22%; p = 0.0001), and residents in zip codes with higher median income ($63,382 vs. $55,311; p = 0.0001). Multivariable analysis revealed each one-year increase in age, every 50 procedures performed annually at a practice, and being male were associated with 3% (p = 0.0001), 33% (p = 0.012), and 16% (p = 0.026) increased odds of monitored anesthesia care, respectively. Centers in the Northeast were more likely to use monitored anesthesia care (all p < 0.005). Patients who underwent approaches other than percutaneous femoral arterial were less likely to receive monitored anesthesia care (adjusted odds ratios all < 0.51; all p = 0.0001). Conclusion: Anesthetic type for transcatheter aortic valve replacements in the United States varies with age, sex, geography, volume of cases performed at a center, and procedural approach.

Application of remimazolam combined with propofol in painless endoscopic retrograde cholangiopancreatography / 中国临床药理学与治疗学

AIM: To observe and compare the clinical efficacy and safety of remimazolam and propofol alone and in combination in endoscopic retrograde cholangiopancreatography (ERCP) anesthesia. METHODS: A total of 120 patients undergoing elective ERCP were divided into the propofol group (P group), the remimazolam group (R group), and the remimazolam combined with propofol group (RP group) according to a random number table, with 40 patients in each group, and the three groups completed anesthesia according to the designated drug regimen (propofol in group P; remimazolam in group R; and remimazolam combined with propofol in group RP). General information, operation time and awakening time of the patients in the three groups were compared, as well as oxygen saturation (SpO

Challenges in the performance of awake craniotomies in the Philippine General Hospital: A case series

@#Awake craniotomy is a neurosurgical technique that involves an awake neurological testing during the resection of an intracranial lesion in eloquent cerebral cortical areas representing motor, language, and speech. This technique is highlighted by an intra-operative cortical mapping that requires active participation by the patient and poses unique challenges to the anesthesiologist. The surgical and anesthetic techniques have evolved significantly over time, as the neurosurgeon and the anesthesiologist learn new steps in making this technique safe to achieve reasonable patient satisfaction. A thorough understanding of this surgical technique's rationale will guide the anesthesiologist in planning the anesthetic management depending on the surgery and neurologic testing. Constant communication between the neurosurgeon, anesthesiologist, and the patient will define this surgical technique's success. It is already a well-established procedure; however, factors that contribute to failures in awake craniotomy procedures have not been well characterized in the literature. Failure is defined as the inability to conduct awake neurologic testing during the awake craniotomy procedure because of various factors which will be described. This paper aims to review the challenges in the performance of three (3) cases of awake craniotomies performed in the Philippine General Hospital. The challenges described in these three (3) cases reveal that this can be experienced by the neurosurgeon, neuroanesthesiologist, and most especially the patient in an acute critical condition. Identification of the procedures' failure and the steps taken to manage such situations with the patient's safety in mind are discussed.

Monitored Anesthesia Care for Cardiovascular Interventions

The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.

Serratus anterior plane block combined with monitored anesthesia care for surgery of lateral side of breast: a case report / 대한마취과학회지

BACKGROUND: In breast surgery, regional anesthesia rather than primary anesthesia has been mainly used for postoperative analgesia. Serratus anterior plane block is a new method for ultrasound-guided thoracic wall block. It is less invasive and relatively safer than conventional regional anesthetic techniques. CASE: We report a case of breast surgery under serratus anterior plane block as primary anesthesia with monitored anesthesia for a 78-year-old patient with a medical history of cardiopulmonary resuscitation due to stress-induced cardiomyopathy caused by pneumonia. CONCLUSIONS: Serratus anterior plane block might be simple and effective technique for breast surgery when a lesion is located on lateral side.

The Effectiveness of Dexmedetomidine in Vacuum-Assisted Breast Biopsy Under Monitored Anesthesia Care / 고신대학교의과대학학술지

OBJECTIVES: Vacuum-assisted breast biopsy (VABB) is a widely used technique for the diagnosis of breast lesions. It is carried out with local anesthesia, but procedural pain and stress are still problematic. Dexmedetomidine is a α-2 receptor agonist that can sedate without significant respiratory depression. The study aimed to report the effectiveness of sedation with monitored anesthesia care (MAC) using dexmedetomidine in VABB. METHODS: This was a retrospective chart review of patients who received VABB under MAC with dexmedetomidine. Forty-seven patients during the period of February 2015 to July 2016 were included. We collected data on patient characteristics, infusion drug and dose, induction to incision time, anesthetic, operation, and recovery time and other complications and vital signs. RESULTS: The mean operating time was 50.1 ± 24.9 minutes, and the anesthetic time was 71.2 ± 28.3 minutes. The mean time from induction to incision was 17.0 ± 5.2 minutes, and the recovery time was 20.1 ± 10.3 minutes. None of the patients needed an advanced airway management. Further, none of them showed hemodynamic instability. CONCLUSIONS: VABB was successfully performed with MAC using dexmedetomidine, and there was no respiratory depression or hemodynamic instability.

The effect of the combination of dexmedetomidine and sufentanil on monitoring anesthesia care during burr-hole surgery for patients with chronic subdural hematoma / 实用医学杂志

Objective To evaluate the effect of the combination of dexmedetomidine and sufentanil on monitoring anesthesia care during burr-hole surgery for patients with chronic subdural hematoma. Methods 96 pa-tients underwent burr-hole surgery for chronic subdural hematoma with MAC were randomly divided into two groups:Group D and Group DS (n=48 in each group). Local anesthetic block was started at least 10 min after DEX and sufentanil infusion. Ramsay sedation scale of the two groups was maintained to 3. Anesthesia onset time, hemo-dynamics, the amount of rescue midazolam or fentanyl, the time to first dose of rescue midazolam or fentanyl, the to-tal number of intraoperative patient movements, postoperative recovery time, patient and surgeon satisfaction scores, and the adverse events were recorded. Results Compared with group D, anesthesia onset time was significantly less in group DS (13.68 ± 3.13 vs. 11.82 ± 2.43 min, P=0.002). More patients in group D required rescue midazol-am to achieve RSS=3 compared with group DS (31.25%15/48 vs. 12.50%6/48, P=0.023). Compared with group D, significantly fewer patients in group DS required rescue fentanyl to relieve pain (10.42%5/48 vs. 27.08%13/48, P = 0.036). Additionally, the total dose of rescue fentanyl in group DS was significantly higher (89.48 ± 23.27 vs. 125.28 ± 33.52μg, P=0.000), and the time to first dose of rescue fentanyl was longer than group D(18.34 ± 4.45 vs. 14.34 ± 3.63 min, P=0.000). The total number of patient movements during the burr-hole surgery was higher in group D than group DS (35.42%17/48 vs. 16.67%8/48, P=0.036). The time to recovery for discharge from the PA-CU (time to an Aldrete score ≥ 9) was significantly shorter in group DS compared with group D (17.54 ± 5.92 vs. 12.57 ± 5.28 min, P=0.000). Results from the patient and surgeon satisfaction scores showed significant differenc-es favoring group DS (P<0.05). More patients in group D showed higher levels of the overall incidence of bradycar-dia (37.50% 18/48 vs. 18.75% 9/48, P = 0.041) and hypotension(37.50%18/48 vs. 14.58%79/48, P=0.011)com-pared with group DS. Conclusions Compared with DEX alone, DEX-sufentanil associated with fewer number of in-traoperative patient movements, less amount of rescue scheme, could be safely and efficiently used for MAC during burr-hole surgery for patients with chronic subdural hematoma.

Application of bispectral index-guided monitored anesthesia care in surgical treatment of chronic subdural hematoma in elderly patients / 临床麻醉学杂志

Objective To explore the application of monitored anesthesia care (MAC) under the guidance of bispectral index in surgical treatment of chronic subdural hematoma in elderly patients.Methods Sixty patients (33 males, 27 females, aged 65-85 years, ASA physical status Ⅱ-Ⅳ) undergoing sphenotresia drainage of chronic subdural hematoma from March, 2014 to May, 2015 were randomly divided into BIS-guided monitored care anesthesia group (group M) and local anesthesia group (group C).Propofol and remifentanil were intravenously infused into patients from group M to maintain BIS index 65-75, vital signs stability and no movement.Local anesthesia was performed before skin incision for each patient.The frequency of medication, the incidence of adverse events were record.The satisfied degree of sedation and analgesia were also evaluated.Results The frequency of movement, local anesthesia drug and additional use of esmolol, were significantly less in group M than those in group C.The satisfaction degree of sedation and analgesia were significantly higher in group M than those in group C (P<0.05).There was no significant difference of respiratory depression and airway obstruction between the two groups.No nausea vomiting reflex and respiration occurred in all groups.Conclusion Bispectral index guidance can be safely applied in surgical treatment of chronic subdural hematoma in elderly patients, which can supply more sedative and analgesic satisfaction than local anesthesia.

Comparative study of different dosages of dexmedetomidine combined with fentanyl for monitored anesthesia care during endoscopic variceal ligation / 中华消化内镜杂志

Objective To investigate the ideal dosage of dexmedetomidine( DEX) with 1?0 μg/kg fentanyl for monitored anesthesia care ( MAC) during endoscopic variceal ligation ( EVL) . Methods A total of 60 patients scheduled for elective EVL were randomly divided into 3 groups ( n=20) . After fentanyl was infused intravenously at the dosage of 1?0 μg/kg, the loading dosage of DEX at 1?0 μg/kg ( group D1 ) , 1?5 μg/kg ( group D2 ) , or 2?0μg/kg ( group D3 ) was continuously infused in 10 min, respectively. When the modified OAA/S score reaching≥3 point, EVL was carried out. The change in modified OAA/S score, the operation duration time, recovery time, satisfaction rates of patient and doctor, and complications were recorded. Results There were no significant differences in regarding of general status, operation duration time and satisfaction score of patients between the 3 groups ( P>0?05 ) . Before endoscope insertion, the OAA/S score in group D3(4?4±0?2)was higher than that in D1(3?4±0?5)or D2 groups(3?8±0?3)(P0?05).At the time?point of 5 mins after endoscope insertion, the OAA/S score in group D3(4?5±0?3)was significantly higher than that in D1(3?5±0?6)or D2 groups(3?7±0?4)(P0?05) . At the end of the procedure,there was no significant difference in OAA/S score between the 3 groups(P>0?05).Compared with group D1(3?1±0?9)min and D2(3?8±0?8)min, the recovery time in group D3(6?6±1?2)min was significantly longer (P0?05). The satisfaction score of endoscopist in group D1(8?0±0?8) was significantly lower than that in group D2(9?4±0?6)or D3(9?5±0?5)(P0?05 ) . No tachycardia, hypertension or hypoxemia occurred during the procedure. There was no significant difference in rate of hypotension among the three groups ( P>0?05) . The incidences of nausea(30%) and body movement(15%) in group D1 were significantly higher than those in group D2 and D3(P0?05). The incidence of bradycardia in group D3(40%) was significantly higher than those in group D1(0) and D2(10%)(P0?05). Conclusion Combined with 1?0 μg/kg fentanyl, 1?5 μg/kg DEX is more efficient and safer for EVL in the status of MAC.

Local anesthesia with monitored anesthesia care for patients undergoing thyroidectomy: a case series / 대한마취과학회지

Because the current trend favors minimally invasive surgery for thyroid disease, increasing interest has developed for thyroidectomy under local anesthesia with monitored anesthesia care (MAC). Here, we retrospectively reviewed 18 cases of thyroidectomy performed under local anesthesia with MAC in a single center. All of the procedures were performed by a single surgeon, using local lidocaine infiltration around the incisional site and propofol plus remifentanil target-controlled infusion. Sore throat (4/18), hypocalcemia (1/18), and transient voice color change (1/18) were observed, but the patients recovered during the follow-up period. No cases of postoperative nausea and vomiting, hematoma, wound problems, or vocal cord paralysis were observed. Local anesthesia with MAC provided satisfactory sedation in most patients without conversion to general anesthesia.

Monitored anesthesia care in and outside the operating room / 대한마취과학회지

Monitored anesthesia care (MAC) is an anesthesia technique combining local anesthesia with parenteral drugs for sedation and analgesia. The use of MAC is increasing for a variety of diagnostic and therapeutic procedures in and outside of the operating room due to the rapid postoperative recovery with the use of relatively small amounts of sedatives and analgesics compared to general anesthesia. The purposes of MAC are providing patients with safe sedation, comfort, pain control and satisfaction. Preoperative evaluation for patients with MAC is similar to those of general or regional anesthesia in that patients should be comprehensively assessed. Additionally, patient cooperation with comprehension of the procedure is an essential component during MAC. In addition to local anesthesia by operators or anesthesiologists, systemic sedatives and analgesics are administered to provide patients with comfort during procedures performed with MAC. The discretion and judgment of an experienced anesthesiologist are required for the safety and efficacy profiles because the airway of the patients is not secured. The infusion of sedatives and analgesics should be individualized during MAC. Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.

Clinical application of fospropofol:research advances / 国际药学研究杂志

Fospropofol is a prodrug of propofol which hydrolyzes in the body by alkaline phosphatase to liberate propofol. Propofol liberated from fospropofol has unique pharmacological properties. Fospropofol in doses of 6.5 or 8 mg/kg, is effective and well tolerated for the sedation of patients undergoing colonoscopy,flexible bronchoscopy. When administered intravenously by a dentist anesthesiologist at the indicated dose, it appearsed to be a safe, well-tolerated alternative to midazolam for intravenous moderate sedation during minor oral surgery procedures. In addition, fospropofol provides safe and effective sedation, rapid time to full alert, and high satisfaction in the elderly subset undergoing flexible bronchoscopy, which is comparable with outcomes in younger patients. Study suggested that fospropofol, administered in an infusion/bolus regimen, be tolerable and effective for short-term induction and maintenance of sedation in intensive care unit patients. Fospropofol also could be used to provide general anesthesia in patients undergoing coronary artery bypass graft surgery.

Application of single-dose dexmedetomidine infusion in patients undergoing percutaneous dilatational tra-cheostomy / 实用口腔医学杂志

Objective:To observe the clinical effects of dexmedetomidine(DDM)under monitored anesthesia care(MAC)in oral and maxillofacial patients undergoing percutaneous dilatational tracheostomy(PDT).Methods:38 patients with oral and maxillofa-cial tumor undergoing PDT before surgery were randomly assigned into 2 groups(n =19).Patients in group D received a single-dose DDMof 0.5 μg/kg infused for 10 min;those in group Mreceived 2 mg of midazolam and 1 μg/kg of fentanil.Then all patients were given local anesthesia followed by PDT.MAP,HR and SpO2 were monitored before (T0 )and after drug administration (T1 ),at T2 (skin incision)and T3 (insert dilation catheter).Ramsay scorce,bucking,respiration depression and adverse cardiovascular reaction were recorded.All patients were followed up 24 h postoperatively for the observation of adverse recall of PDT.Results:Compared with T0 ,at T1 ,T2 MAP and HR in group D were lower,but MAP and HR at T3 in group Mwere higher(P <0.05).At T1 ,T2 and T3 ,MAP and HR in group D were significantly lower than those in group M(P <0.05).During operation,the incidence of bucking and respiration depression in group D was lower than that in group M(P <0.05).Conclusion:During PDT operation under MAC,a single-dose dexmedetomidine is effective in stablizing hemodynamics,reducing bucking and respiration depression.

Clinical application of fospropofol: Research advances / 国际药学研究杂志

Fospropofol is a prodrug of propofol which hydrolyzes in the body by alkaline phosphatase to liberate propofol. Propofol liberated from fospropofol has unique pharmacological properties. Fospropofol in doses of 6.5 or 8 mg/kg, is effective and well tolerated for the sedation of patients undergoing colonoscopy, flexible bronchoscopy. When administered intravenously by a dentist anesthesiologist at the indicated dose, it appearsed to be a safe, well-tolerated alternative to midazolam for intravenous moderate sedation during minor oral surgery procedures. In addition, fospropofol provides safe and effective sedation, rapid time to full alert, and high satisfaction in the elderly subset undergoing flexible bronchoscopy, which is comparable with outcomes in younger patients. Study suggested that fospropofol. administered in an infusion/bolus regimen, be tolerable and effective for short-term induction and maintenance of sedation in intensive care unit patients. Fospropofol also could be used to provide general anesthesia in patients undergoing coronary artery bypass graft surgery.

The Comparison of Post-Operative Pain between Topical Anesthesia and Monitored Anesthesia Care in Cataract Surgery

PURPOSE: To compare pain levels in cataract surgery under topical anesthesia only and topical anesthesia under monitored anesthesia care. METHODS: We recruited 243 patients who were scheduled to undergo cataract surgery under topical anesthesia only or topical anesthesia with monitored anesthesia care (MAC) using fentanyl and midazolam. Anesthesia methods were selected based on the patient's preference. All patients completed an anxiety and information scale survey preoperatively. Vital signs during the operations were recorded. A 0-to-10 visual analog scale pain score survey was conducted immediately and at 2 hours, 6 hours, and 1 day after surgery. RESULTS: Of the 237 patients who completed the study, 183 patients selected topical anesthesia, and 54 patients selected MAC. Mean pain scores according to the aforementioned time points after surgery were 0.50, 0.58, 0.29, and 0.12 in the topical anesthesia group, and 0.22, 0.16, 0.06, and 0.09 in the MAC group, respectively. The differences in pain score between the two groups was statistically significant at 2 hours (p = 0.019) and 6 hours (p = 0.040) after surgery. The mean patient anxiety score for anesthesia was 10.50 in the topical anesthesia group and 11.41 in the MAC group (p = 0.280). Mean systolic blood pressure at the start of surgery was 140.6 mm Hg in the topical anesthesia group, and 158.2 mmHg in the MAC group. CONCLUSIONS: Monitored anesthesia care consistently resulted in less pain throughout the post-operative period. However, transient systolic blood pressure should be carefully monitored for a rise related to intravenous anesthetics.

Validación al español de la escala «The Iowa satisfaction with anesthesia scale (ISAS)¼ para cuidado anestésico monitorizado en cirugía de oftalmología / Validation to Spanish of the Iowa Satisfaction with Anesthesia Scale (ISAS) for monitored anesthesia care in ophthalmic surgery

La herramienta «The IOWA satisfaction with anesthesia scale (ISAS)¼ fue desarrollada rigurosamente y ha demostrado ser válida y confiable para evaluar la satisfacción del paciente con el cuidado anestésico monitorizado (CAM) en múltiples escenarios; un instrumento de estas características es importante, dado el auge que el CAM está teniendo en el medio. Objetivo: Validar al español la escala ISAS y establecer los indicadores de validez y confiabilidad en pacientes tratados mediante cirugías de oftalmología bajo CAM. Métodos: Se hizo traducción y retrotraducción de la escala, validación de apariencia y pruebas piloto para ajustes. Se aplicó el instrumento definitivo a 117 sujetosmayores de 18 años, ASA I-III en 2 instituciones de salud en Villavicencio (departamento del Meta, Colombia) para medir la validez de criterio concurrente entre los pacientes y el anestesiólogo del caso; se estableció la consistencia interna de la escala en su primera aplicación a los sujetos y se aplicó por segunda y tercera vez el instrumento para verificar confiabilidad test-retest. Resultados: Se constató validez de criterio concurrente anestesiólogo-paciente, con Pearson 0,85 IC 95% (0,79-0,89), intraclase 0,82 IC 95% (0,77-0,88), se midió la consistencia interna con un alfa de Cronbach de 0,71, confiabilidad test-retest (40-65 min), Pearson e intraclase 0,95 IC 95% (0,93-0,96) (12-36 h) Pearson 0,65 IC 95% (0,52-0,75), intraclase 0,64 IC 95% (0,53-0,76). Conclusiones: La validación de la escala ISAS al español permite usar un instrumento válido y confiable para medir objetivamente la satisfacción del paciente en cirugía de oftalmología bajo CAM.

The Iowa Satisfaction with Anesthesia Scale (ISAS) was rigorously developed and has been shown to be valid and reliable for evaluating patient satisfaction with monitored anesthesia care (MAC) in several scenarios. Such an instrument is important given the success thatMAC is enjoying in the field. Objective: Validate the ISAS in Spanish and establish indicators of validity and reliability in patients undergoing ophthalmic surgeries with MAC. Methods: A translation and back-translation of the scale, face validity and pilot tests for adjustmentswere completed. The final instrumentwas applied to 117 subjects over18 years of age, ASA I-III, in two healthcare institutions in Villavicencio (Meta Department, Colombia) in order to measure the concurrent criterion validity between the patients and the anesthesiologist of the case. The internal consistency of the scale was established in its first application to the subjects and later applied for the second and third times to verify the test-retest reliability. Results: A Pearson anesthesiologist/patient concurrent criterion validity 0.85 CI 95% (0.79-0.89), intra-class 0.82 CI 95% (0.77-0.88),was confirmed. Internal consistencywas measured with a Cronbach's alpha of 0.71. Test-retest reliability (40-65 min) was measured with Pearson and intra-class 0.95 CI 95% (0.93-0.96) and, (12-36 h) Pearson 0.65 CI 95% (0.52-0.75), intra-class 0.64 CI 95% (0.53-0.76). Conclusions: The validation of the ISAS in Spanish allows for the use of a valid and reliable instrument to objectively measure the satisfaction of the patient in ophthalmic surgery under MAC.

Optimal effect-site concentration of remifentanil when combined with dexmedetomidine in patients undergoing cystoscopy / 대한마취과학회지

BACKGROUND: Cystoscopic procedure is a very common practice in the field of urology due to its ability to survey the bladder for a variety of indications. However, patients who undergo cystoscopy feel intense pain and discomfort. This study investigated the half maximal effective concentration (EC50) of remifentanil in preventing cystoscope insertion pain under sedation using dexmedetomidine. METHODS: The study was prospectively conducted on 18 male patients, aged 18 to 65. Remifentail infusion was initiated together with dexmedetomidine, and started at a dose of 2.4 ng/ml on the first patient. The effect-site concentration (Ce) of remifentanil for each subsequent patient was determined by the previous patient's response using Dixon's up-and-down method with an interval of 0.3 ng/ml. Patients received a loading dose of 1.0 microg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.6 microg/kg/hr. After the patient's OAA/S score (Observer's Assessment of Alertness/Sedation scale) reached 3-4, and the Ce of remifentanil reached target concentration, the urologist was allowed to insert the cystoscope and the pain responses were observed. RESULTS: The effect-site concentration of remifentanil required to prevent cystoscope insertion pain in 50% of patients under sedation using dexmedetomidine was 1.30 +/- 0.12 ng/ml by Dixon's up-and-down method. The logistic regression curve of the probability of response showed that the EC50 and EC95 values (95% confidence limits) of remifentanil were 1.33 ng/ml (1.12-1.52 ng/ml) and 1.58 ng/ml (1.44-2.48 ng/ml), respectively. CONCLUSIONS: Cystoscopic procedure can be carried out successfully without any pain or adverse effects by optimal remifentanil effect-site concentration (EC50, 1.33 ng/ml; EC95, 1.58 ng/ ml) combined with sedation using dexmedetomidine.

The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery

PURPOSE: The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. METHODS: Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 microg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 microg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. RESULTS: Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. CONCLUSION: We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patient's preference and medical condition.

Anesthesia for gastrointestinal endoscopy in patients with left ventricular assist devices: Initial experience with 68 procedures.

Aims and Objectives: Continuous flow left ventricular assist devices (LVAD) have emerged as a reliable treatment option for heart failure. Because of bleeding secondary to anticoagulation, these patients present frequently for gastrointestinal (GI) endoscopy. The presently available literature on perioperative management of these patients is extremely limited and is primarily based upon theoretical principles. Materials and Methods: Perioperative records of patients with LVAD undergoing (GI) endoscopy between 2008 and 2012 were reviewed. Patient, device and procedure specific information was analyzed. Results: A total of 105 LVADs were implanted, and 68 procedures were performed in 39 patients. The most common indication was GI bleed (48/68), with yearly risk of 8.57% per patient. A total of 63 procedures were performed under deep sedation, with five procedures requiring general anesthesia. Intra‑procedure hypotension was managed by fluids and (or) vasopressors/inotropes (phenylephrine, ephedrine or milrinone) guided by plethysmographic waveform, non‑invasive blood pressure (NIBP) and LVADs pulsatility index (for HeartMate II)/flow pulsatility (for HeartWare). No patient required invasive monitoring and both NIBP and pulse oximeter could be reliably used for monitoring (and guided management) in all patients due to the presence of native heart’s pulsatile output. Conclusion: In the presence of residual heart function, with optimal device settings, non‑invasive hemodynamic monitoring can be reliably used in these patients while undergoing GI endoscopy under general anesthesia or monitored anesthesia care. Transient hypotensive episodes respond well to fluids/vasopressors without the need of increasing device speed that can be detrimental.

Monitored anesthesia care using dexmedetomidine and remifentanil for the hip surgery in a high risk patient with brain metastasis of lung cancer, cerebral infarction, seizure and quadriplegia: A case report

To perform the major operation for high risk patients with both serious systemic diseases and major organ complications, the monitored anesthesia care could be available as a reasonable alternative for both general and regional anesthesia when it is impossible to administer; however, the choice of analgesics and sedatives is still an important and difficult task. We present a high risk patient who suffers from neurologic complications including decreased consciousness caused by brain metastasis of lung cancer, cerebral infarction, quadriplegia and seizure as well as decreased respiratory function and bleeding tendency. When performing the operation on hip joints, we administered both dexmedetomidine as a major sedative, and remifentanil as an adjunct analgesic; as a result, we could successfully perform the monitored anesthesia care without any complications including cardiovascular instability, respiratory depression, and seizure.