Novel custom designed toric piggyback intraocular lens for the correction of residual postoperative astigmatism

We report the outcomes of a custom-designed toric piggyback intraocular lens in a patient with high postoperative residual astigmatism. A 60-year-old male patient underwent customized toric piggyback IOL for postoperative residual astigmatism of 13 D, with follow-up examinations for IOL stability and refractive outcomes. The refractive error stabilized at two months and remained stable at one year, with a correction of nearly 9 D of astigmatism. The IOP remained within normal limits, and there were no postoperative complications. The IOL remained stable in the horizontal position. To our knowledge, this is the first case report of correction of unusually high astigmatism by a novel smart toric design of piggyback IOL.

Risk factors of residual tumor in single small hepatocellular carcinoma after thermal ablation treatment / 中华内科杂志

Objective:To evaluate the risk factors of residual tumor after thermal ablation in patients with small hepatocellular carcinoma.Methods:This was a retrospective study recruiting 107 patients diagnosed as single hepatocellular carcinoma with maximum diameter ≤3 cm from December 2009 to August 2015 in National Cancer Center. The cohort enrolled 81 males and 26 females, including 83 patients younger than 70 years old. All patients were treated with radiofrequency ablation or microwave ablation, and evaluated by CT or MRI after 4-6 weeks compared with baseline data. Potentially related factors were analyzed such as patients′ characteristics, tumor location and adjacent, ablation pattern, hepatitis B/C infection. A multivariate logistic regression analysis was conducted for the independence of risk factors.Results:Six patients (5.6%) with residual tumor was detected in the whole population of 101 cases. Univariate analysis suggested that tumor adjacent to vascular structure, poor differentiation, AFP≥200 μg/L were the risk factors of residue disease (all P<0.05). Multivariate logistic regression suggested that pathological type of poorly differentiated tumor was the only independent risk factor ( HR=2.26,95% CI 0.25-20.50, P=0.030). Conclusions:Poorly differentiated pathology is an independent predictive factor for residual disease in small hepatocellular carcinoma after thermal ablation. Such patients should be routinely followed up after operation.

Sugammadex by ideal body weight versus 20% and 40% corrected weight in bariatric surgery - double-blind randomized clinical trial / Uso de sugamadex pelo peso corporal ideal versus corrigido em 20% e 40% em cirurgia bariátrica - ensaio clínico randômico e duplo-cego

Abstract Background and objectives: The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. Methods: A prospective clinical trial was conducted with sixty participants with body mass index ≥ 40 kg.m-2 during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6 mg.kg-1 of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6 mg.kg-1.h-1. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2 mg.kg-1 of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF ≥ 0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability to swallow saliva and clarity of vision. Results: Groups were homogenous in gender, age, total body weight, ideal body weight, body mass index, type and time of surgery. The reversal times (s) were (mean ± standard deviation) 225.2 ± 81.2, 173.9 ± 86.8 and 174.1 ± 74.9 respectively, in the IW, CW20 and CW40 groups (p = 0.087). Conclusions: No differences were observed between groups with neuromuscular blockade reversal time and frequency of postoperative residual curarization. We concluded that ideal body weight can be used to calculate sugammadex dose to reverse moderate neuromuscular blockade in morbidly obese patients.

Resumo Justificativa e objetivos: Os parâmetros de peso para o uso de sugamadex em pacientes com obesidade mórbida ainda precisam ser definidos. Métodos: Um ensaio clínico prospectivo foi feito com 60 participantes com índice de massa corporal ≥ 40 kg.m-2, submetidos a cirurgia bariátrica, randomizados em três grupos: peso ideal (PI), peso corrigido em 20% (PC20) e peso corrigido em 40% (PC40). Todos os pacientes receberam anestesia intravenosa total. Rocurônio foi administrado em dose de 0,6 mg.kg-1 para intubação traqueal pelo peso ideal, seguido de infusão (0,3 a 0,6 mg.kg-1.h-1). A sequência de quatro estímulos (TOF) foi usada para monitorar a profundidade do bloqueio. Após recuperação espontânea da segunda resposta do TOF no fim da cirurgia, 2 mg.kg-1 de sugamadex foi administrado. O desfecho primário foi o tempo de reversão do bloqueio neuromuscular até obter TOF ≥ 0,9. O desfecho secundário foi a ocorrência de curarização residual pós-operatória na sala de recuperação pós-anestésica, avaliaram-se a capacidade do paciente de passar do leito cirúrgico para o de transporte, a adequação da oxigenação, o padrão respiratório, a habilidade para deglutir saliva e a clareza de visão. Resultados: Os grupos foram homogêneos quanto a gênero, idade, peso corporal total, peso corporal ideal, índice de massa corporal, tipo e tempo de cirurgia. Os tempos de reversão (segundos) foram (média ± desvio-padrão) 225,2 ± 81,2, 173,9 ± 86,8 e 174,1 ± 74,9, respectivamente, nos grupos PI, PC20 e PC40 (p = 0,087). Conclusões: Não foram observadas diferenças entre os grupos quanto ao tempo de reversão do bloqueio neuromuscular e frequência de curarização residual pós-operatória. Concluímos que o peso corporal ideal pode ser usado para calcular a dose de sugamadex para reverter o bloqueio neuromuscular moderado em pacientes com obesidade mórbida.

Use of protocol and evaluation of postoperative residual curarization incidence in the absence of intraoperative acceleromyography - Randomized clinical trial / Aplicação de protocolo e avaliação da incidência de curarização residual pós-operatória na ausência de aceleromiografia intraoperatória - Ensaio clínico randomizado

Abstract Objective Evaluate the incidence of postoperative residual curarization (PORC) in the post-anesthesia care unit (PACU) after the use of protocol and absence of intraoperative acceleromyography (AMG). Methods Randomized clinical trial with 122 patients allocated into two groups (protocol and control). Protocol group received initial and additional doses of rocuronium (0.6 mg·kg-1 and 10 mg, respectively); the use of rocuronium was avoided in the final 45 min; blockade reversal with neostigmine (50 µg·kg-1); time ≥15 min between reversion and extubation. Control: initial and additional doses of rocuronium, blockade reversal, neostigmine dose, and extubation time, all at the discretion of the anesthesiologist. AMG was used in the PACU and PORC considered at T4/T1 ratio <1.0. Results The incidence of PORC was lower in protocol group than in control group (25% vs. 45.2%, p = 0.02). In control group, total dose of rocuronium was higher in patients with PORC than without PORC (0.43 vs. 0.35 mg·kg-1·h-1, p = 0.03) and the time interval between the last administration of rocuronium and neostigmine was lower (75.0 vs. 101.0 min, p < 0.01). In protocol group, there was no difference regarding the analyzed parameters (with PORC vs. without PORC). Considering the entire study population and the presence or absence of PORC, total dose of rocuronium was higher in patients with PORC (0.42 vs. 0.31 mg·kg-1·h-1, p = 0.01), while the time interval between the last administration of rocuronium and neostigmine was lower (72.5 vs. 99.0 min, p ≤ 0.01). Conclusion The proposed systematization reduced PORC incidence in PACU in the absence of intraoperative AMG.

Resumo Objetivo Avaliou-se a incidência de curarização residual pós-operatória (CRPO) na sala de recuperação pós-anestésica (SRPA) após emprego de protocolo e ausência de aceleromiografia (AMG) intraoperatória. Métodos Ensaio clínico, aleatório, com 122 pacientes, distribuídas em dois grupos: protocolo e controle. Protocolo: dose inicial e adicionais de rocurônio foram de 0,6 mg.kg-1 e 10 mg, respectivamente; evitou-se o uso de rocurônio nos 45 minutos finais; reversão do bloqueio com neostigmina (50 µg.kg-1); tempo ≥ 15 minutos entre reversão e extubação. Controle: doses inicial e adicional de rocurônio, reversão do bloqueio, dose de neostigmina e momento da extubação decididos pelo anestesiologista. Foi usada AMG na SRPA e considerado CRPO razão T4/T1 < 1,0. Resultados A incidência de CRPO foi menor no grupo protocolo em relação ao controle (25% vs. 45,2%; p = 0,02). No grupo controle, a dose total de rocurônio foi maior em pacientes com CRPO em relação àqueles sem CRPO (0,43 vs. 0,35 mg.kg-1.h-1; p = 0,03) e o intervalo entre a última administração de rocurônio e a neostigmina foi menor (75,0 vs. 101,0 min; p < 0,01). No grupo protocolo não houve diferença dos parâmetros analisados (com CRPO vs. sem CRPO). Considerando toda a população de estudo e a presença ou não de CRPO, a dose total de rocurônio foi maior em pacientes com CRPO (0,42 vs. 0,31 mg.kg-1.h-1; p = 0,01), enquanto o intervalo entre a última administração de rocurônio e a neostigmina foi menor (72,5 vs. 99,0 min; p ≤ 0,01). Conclusão A sistematização proposta reduziu a incidência de CRPO na SRPA na ausência de AMG intraoperatória.

What anesthesiologists ask to know and should know about the neuromuscular monitoring: an updated review

The increase in mortality and morbidity associated with the use of muscle relaxants, is associated with a lack of clinical pharmacological knowledge of the drugs, and a lack of understanding the risk of postoperative residual curarization. This is due to the absence of standards for neuromuscular monitoring. Clinicians experienced in neuromuscular monitoring and using muscle relaxants in the clinic may have some queries regarding the monitoring: Why should neuromuscular monitoring be done? Are clinical tests really not effective? Why is it not good when I actually perform neuromuscular monitoring? Would using sugammadex not require neuromuscular monitoring? This review answers most of the questions that many clinicians have, and also forwards the knowledge required of clinicians.

Incidence and risk factors of postoperative residual curarization in patients with breast cancer: Prospective cohort study / 解放军医学杂志

Objective To determine the incidence and risk factors of postoperative residual curarization (PORC) in patients with breast cancer after total intravenous anesthesia (TIVA) with vecuronium. Methods Two hundred and fiftyseven female patients with breast cancer undergoing breast-cancer surgery were enrolled into the present study. Anesthesia was induced with target-controlled infusion of propofol (Cp 3-4µg/ml) and remifentanil (2-3 ng/ml). A bolus of vecuronium 0.1mg/ kg was administered intravenously over 5-10s as soon as the patient lost consciousness, and laryngeal mask was placed 3min later. Mechanical ventilation and TIVA were performed for maintaining anesthesia and keeping bispectral index (BIS) between 40 to 60 during the operation. According to the duration of operation, 0.02mg/kg of vecuronium was administrated intermittently. Extubation of the laryngeal tube was performed according to clinical criteria. Train-of-four ratios (TOFr) were immediately measured with Veryark-TOF (Guangzhou Weilifangzhou Technology Ltd, China) in the recovery room. The patients were divided into two groups (Group N and Group R) according to the value of TOFr at the time of extubation. N denoted the non-residual neuromuscular blockade group (TOF=0.7), and R denoted the residual neuromuscular blockade group (TOF0.05). In group R, age and hemoglobin level were lower (P0.05). More patients in Group R received neoadjuvant chemotherapy and multiple boluses of vecuronium administration, and the duration between last dose of vecuronium to extubation was also prolonged compared with Group N (P<0.05). Multivariate logistic regression analysis identified that age, neoadjuvant chemotherapy and multiple boluses of vecuronium administration were not associated with increased risk of PORC. Duration from last dose of vecuronium to extubation was associated with increased risk of PORC (OR=0.970, 95%CI 0.956-0.984, P<0.001). Conclusions PORC is commonly used in patients with breast cancer. Duration from last dose of vecuronium to extubation is associated with increased risk of PORC.

The risk factors of residual stones after single channel percutaneous nephrolithotomy / 重庆医学

Objective To investigate the risk factors and countermeasure of residual stones after single‐channel percutaneous nephrolithotomy for higher stone‐free rate and better operation result .Methods All patients who underwent single‐channel percu‐taneous nephrolithotomy in our hospital from June 2011 to December 2013 were retrospected and the cause of residual stones were analyzed .Results There were 42 patients who had residual stones after operation among total 262 patients undergone single‐chan‐nel PCNL .21 patients had residual stones because the stones they burdened were too complex .7 patients were concerned with com‐plications such as intraoperative hemorrhage .The stone fragments scattered into the calices in 7 patients with overlarge stone during fragmentation .The other causes concerned with stone residue included anatomic structural abnormalities of the kidneys(3 patients) , operation itself inherent limitations(3 patients) ,insufficient practice and experience in operation(1 patients) .Conclusion The main causes concerned with residual stones of single‐channel PCNL are complexity of urinary calculi ,bleeding ,scattering of stone frag‐ments and anatomic structural abnormalities of the kidney .

Comparison of recovery times from deep neuromuscular blockade between single bolus and continuous infusion of rocuronium

BACKGROUND: To prevent sudden unexpected movement of patients during surgery, muscle relaxants are used to maintain intense neuromuscular blockade.They are administered by intermittent bolus or continuous infusion.Rocuronium is often used for continuous infusion because it is known to lack cumulative effects. The purpose of this study was to compare recovery times from intense neuromuscular block to reappearance of muscle twitches after 0.1 Hz single twitch stimulation. MATERIALS AND METHODS: Seventy five patients were randomized to one of 3 groups.Patients in group 1 were administered a single bolus of rocuronium; groups 2 and 3 were given continuous infusion of rocuronium for 1 and 2 h, respectively.During anesthesia, neuromuscular blockade was monitored by TOF-watch(R) and regulated so as not to exceed more than 5 (PTC) during the infusion. After infusion, PTC was counted every 5 min until single twitch heights had reappeared and the time till the twitch reappeared was calculated. RESULTS: There was a good correlation between the time it took to observe a PTC and the first response of TOF time in each group.In a parallelism test, there were no significant differences. There were also no significant differences in recovery times from PTC to the reappearance of a single twitch between groups. CONCLUSIONS: There are no significant differences in recovery times-from deep neuromuscular blockade to reappearance of single twitch-regardless of the infusion time.When a PTC occurs during deep neuromuscular blockade, it may predict the remaining time of reappearance of a single twitch response.