The relationship between preoperative blood pressure during anesthetic examinations and pre-intubation blood pressure.

BACKGROUND: There have been few reports showing the relationship between blood pressure (BP) measured at clinics preoperatively and BP measured before anesthetic intubation/induction. The purpose of this study was to examine the relationship between BP measured at different times and settings preoperatively and BP measured before intubation/induction. METHODS: A total of 182 patients who underwent general anesthesia between March 2021 and April 2022 in a university hospital were examined. In addition to self-reported BP asked on an anesthetic examination sheet completed by each patient, BPs were measured three times, before, during, and after preoperative examination by the anesthesiologist. The derived parameter was compared with BP measured before intubation at the time of general anesthesia induction. RESULTS: The systolic BP in the intra-examination period had the most significant correlation with pre-intubation systolic BP (r = 0.5230, p < 0.0001, 95% CI = 0.4050 to 0.6238). On Bland-Altman analysis, the intra-examination systolic BP seemed to be similar and showed better agreement with pre-intubation systolic BP than other measured BPs, with a mean bias of 2.2 mmHg and the narrowest 95% limits of agreement (-33.7 to + 38.1 mmHg). CONCLUSIONS: The preoperative systolic BP value measured during the examination by the anesthesiologist was found to be closely related to pre-intubation systolic BP measured in the operating room. Higher BP during the preoperative examination may be a result of anxiety-induced stress or white-coat hypertension. Measuring BP during the anesthesiologist's examination may be useful for predicting hypertension in the pre-intubation period.

Adequate Oxygenation State Maintained during Electroconvulsive Therapy in Nonobese Patients Using the Oxygen Reserve Index: A Pilot Study.

Some controversial reports have observed oxygen desaturation (defined as percutaneous oxygen saturation (SpO2) < 90%) during electroconvulsive therapy (ECT). The purpose of this pilot study was to examine oxygenation states in eight patients during ECT. In addition to the usual hemodynamic monitors and pulse oximeter, the oxygen reserve index (ORi) was monitored using a pulse oximeter. Patients received either no preoxygenation or preoxygenation with 100% oxygen via a tight-fitting mask for 1 or 3 min before induction of anesthesia. ORi increased after preoxygenation. ORi differed significantly between 3 min of preoxygenation and the other two methods before restarting mask ventilation. SpO2 was significantly increased with all methods before stopping manual mask ventilation or before restarting manual mask ventilation compared with that before preoxygenation. No oxygen desaturation was observed at any time with any treatment methods. In nonobese patients, the adequate oxygenation state as shown by SpO2 and ORi was maintained during ECT even without preoxygenation.

Pseudo-intestinal obstruction after transsphenoidal surgery for craniopharyngioma.

Craniopharyngioma surgery is frequently associated with the occurrence of central diabetes insipidus, and oral rehydration therapy is reliable for postoperative management if the patient's thirst is normal. A 61-year-old Japanese male patient underwent extended endoscopic transsphenoidal surgery for craniopharyngioma. He was undergoing acute treatment for postoperative central diabetes insipidus and hypopituitarism in the intensive care unit. Two days after the surgery, he started to vomit occasionally, despite receiving oral rehydration therapy for central diabetes insipidus. Despite increasing the dose of parenteral hydrocortisone, the periodic vomiting persisted during fasting periods and progressed to aspiration pneumonia and severe sepsis. Abdominal computed tomography was performed to identify the cause of persistent vomiting and revealed the presence of a pseudo-intestinal obstruction extending from the small to large intestine. When oral rehydration therapy for central diabetes insipidus is accompanied by vomiting symptoms suggestive of hypopituitarism, a holistic evaluation of the gastrointestinal system is advisable.

Severe bradycardia at the termination of seizure during electroconvulsive therapy.

BACKGROUND: Few cases of asystole or severe bradycardia occurring after the termination of seizure in the third phase with the dominance of parasympathetic nervous system activity during electroconvulsive therapy (ECT) have been reported. We describe a case of severe bradycardia occurring at the termination of seizure. CASE PRESENTATION: The patient had been diagnosed with bipolar disorder more than 9 years earlier. No adverse hemodynamic events had been observed in over 100 sessions of ECT performed during a 9-year period. ECT was usually induced by propofol and suxamethonium. On this ECT, the heart rate gradually decreased before seizure termination, and severe bradycardia (5-6 beats/min) was identified lasting 15-20 s. Atropine administration immediately before electrical stimulus prevented any further bradycardia during the next session of ECT. CONCLUSIONS: This case report indicates that attention should be paid to adverse cardiac events related to autonomic nerve activity even before such events occur during ECT.

Hemodynamically adjusted infrahepatic inferior venous cava clamping can reduce postoperative deterioration in renal function: a retrospective observational study.

PURPOSE: Infrahepatic inferior vena cava (IIVC) clamping is beneficial for reducing the amount of bleeding during hepatic surgery, although the associated systemic circulatory deterioration is noticeable. The relationship between changes in the degree of IIVC clamping and postoperative renal function was retrospectively evaluated. METHODS: A total of 59 patients who underwent elective hepatic surgery with surgical IIVC clamping in the two years were analyzed. In 2016, constant 80% clamping of the IIVC was performed (29 cases), and in 2017, hemodynamically adjusted IIVC clamping was performed (30 cases). Intraoperative parameters, including total blood loss and number of blood transfusions, were examined. The use of each vasoactive agents was analyzed. Renal function in the acute postoperative phase was evaluated using serum creatinine (Cr) and estimated glomerular filtration rate (eGFR) values. RESULTS: Comparison of the two groups showed that bolus doses of both ephedrine and phenylephrine were significantly higher in the 2016 group (P = 0.0221, 0.0017). Continuous doses of dopamine were significantly higher in the 2016 group, while those of noradrenaline were not. Postoperative serum Cr levels relative to baseline (%) were significantly higher in the 2016 group immediately after surgery and on postoperative day (POD) 1 (P = 0.0143, 0.0012). Postoperative eGFR relative to baseline (%) was significantly higher in the 2016 group immediately postoperatively and on PODs 1 and 2 (P = 0.0042, 0.0003, 0.0382). CONCLUSION: Hemodynamically adjustable IIVC clamping might be superior to uniformly fixed clamping in preserving renal function without compromising the desired effect on hemostasis.

Effect of Low Dose Remifentanil on Postoperative Pain Relief and Heart Rate Variability in Post-Anaesthesia Care Unit.

OBJECTIVE: Several reports have shown the negligible adverse effects of low-dose remifentanil on the autonomic nervous system. We propose that the administration of low-dose remifentanil would be beneficial without adverse respiratory and hemodynamic effects. This study aimed to examine the effects of low-dose remifentanil on postoperative pain relief and heart rate variability (HRV) after surgery. METHODS: In total, 20 patients, who underwent breast cancer surgery, were analysed for HRV in the post-anaesthesia care unit (PACU). A sedative dose of remifentanil was continuously infused if patients experienced pain while in PACU. The remifentanil infusion dose was determined by achieving analgesia with no adverse effects on hemodynamics and/or respiration. Variables of low-frequency power, high-frequency power and low-frequency power/high-frequency power ratio were measured before and after the administration of remifentanil. Pain score was expressed as the numeric rating scale (NRS) from 0 to 10. RESULTS: The mean dosage of remifentanil administered as a continuous infusion was 0.029±0.0042 µg kg-1 min-1. After remifentanil administration, the value of the NRS decreased from 4.2±2.9 to 2.7±2.6. In addition, the value of high-frequency power increased from 35.6±14.3 to 49.4±3.0. CONCLUSION: The continuous infusion of low-dose remifentanil may reduce post-operative pain scores and trigger the relative activation of the parasympathetic nervous system in post-surgical patients. This indicates that continuous infusion of low-dose remifentanil may be a useful option for postoperative pain relief in cases where postoperative pain control proves inadequate even with the application of regional block technique.

Differences in heart rate variability may be related to the appearance of postoperative pain in patients undergoing breast cancer surgery.

BACKGROUND: Some reports have highlighted the relationship between heart rate variability (HRV) and the degree of postoperative pain experienced. This study retrospectively examined whether differences in heart rate variability may be related to the appearance of postoperative pain in patients undergoing breast cancer surgery. FINDINGS: We retrospectively analyzed 20 postoperative patients who had no pain immediately upon admission to the post-anesthesia care unit (PACU), divided into two groups: group A (n = 16) had no pain on admission to PACU, remaining pain free upon discharge (12 h after surgery); group B (n = 4) comprised patients with no pain on admission to PACU but who experienced increasing pain requiring intervention in PACU 1 h after surgery. HRV was measured immediately on admission to PACU and 2 h after surgery; this included variables of low-frequency power (LF), high-frequency power (HF), and LF/HF. There were significant differences in HF and LF/HF in group A compared with those in group B on admission to PACU (immediately after arrival): HF, group A, 35.4 ± 18.1; group B, 64.2 ± 9.5*; LF/HF group A, 2.7 ± 2.4; group B, 0.6 ± 0.2*, *p < 0.05). There was no significant difference in the Numerical rating scale (NRS) between the two groups immediately after admission to PACU. At 1 h after the surgery, NRS in Group B increased, and there were significant differences in NRS values between the two groups 1 h after surgery prior to the use of analgesic agents (NRS, group A, 1.0 ± 0.9; group B, 4.0 ± 1.4*, *p < 0.01). Patients in group A required no analgesic agents for at least 12 h after surgery. CONCLUSIONS: Lower HF and higher LF/HF values immediately after arrival in PACU were observed in patients remaining pain free for 12 h after surgery compared to patients who experienced increasing postoperative pain 1 h after surgery. The data suggest that differences in HRV may be related to the appearance of postoperative pain.

Comparison between succinylcholine and rocuronium as neuromuscular blocking agents for electroconvulsive therapy in a patient with pseudocholinesterase deficiency.

We report here the anesthetic management of a patient with schizophrenia and pseudocholinesterase deficiency. Electroconvulsive therapy was performed using succinylcholine and rocuronium as the neuromuscular blocking agents in the first seven and latter six treatments, respectively. The recovery time from muscle relaxation after succinylcholine administration was remarkably longer than that after rocuronium-sugammadex administration. Rocuronium and sugammadex appear to be useful in situations in which succinylcholine is contraindicated.

Effects of adding remifentanil to propofol anesthesia on systemic hemodynamics, cardiac output, and middle cerebral artery flow velocity during electroconvulsive therapy: a pilot study.

PURPOSE: The purpose of this study was to examine the effects of adding remifentanil to propofol anesthesia on systemic hemodynamics, cardiac output, and middle cerebral artery (MCA) blood flow velocity during electroconvulsive therapy (ECT). METHODS: Twelve patients undergoing ECT were enrolled in this study. The patients received anesthesia by one of the following 2 methods: either propofol alone at a dose of 1.0 mg/kg, or propofol 0.75 mg/kg with remifentanil 1.0 µg/kg in turn during successive ECT sessions, immediately before the administration of succinylcholine. All patients were monitored for blood pressure, heart rate, cardiac output, and MCA flow velocity by transcranial Doppler sonography. RESULTS: Middle cerebral artery flow velocity increased after ECT in both anesthesia method groups and lasted for 2 minutes after ECT. No difference in MCA flow velocity was observed between the 2 methods at any time point. Seizure duration was longer under propofol with remifentanil than under propofol alone [propofol with remifentanil, 32 (3) seconds; propofol alone, 24 (4) seconds; P < 0.01]. In contrast, no difference in time to awakening (time from the ECT stimulus to the patient's ability to open eyes) was observed between the 2 groups [propofol with remifentanil, 183 (19) seconds; propofol alone, 185 (21) seconds]. CONCLUSIONS: The addition of remifentanil (1 µg/kg) is suitable for reduction of the propofol dose during ECT, without any adverse hemodynamic effects, including on cerebral blood flow.

Optimal dose of landiolol for preventing abrupt changes in both cardiac output and middle cerebral artery flow velocity after electroconvulsive therapy.

The purpose of this study was to examine the dose-dependent effects of landiolol on systemic hemodynamics, cardiac output, and cerebral artery blood flow. Eight patients undergoing electroconvulsive therapy (ECT) received 1 of the 3 drugs/doses (saline, 0.125 mg/kg of landiolol, 0.25 mg/kg of landiolol), in turn, for 3 ECT sessions, immediately after the administration of succinylcholine. In the case of 0.25 mg/kg of landiolol, heart rate, mean arterial pressure, and cardiac output remained unchanged throughout the study period.We believe that 0.25 mg/kg of landiolol may be suitable for preventing the increase in systemic hemodynamics, including cardiac output after ECT.

Comparative effects of flurbiprofen and fentanyl on natural killer cell cytotoxicity, lymphocyte subsets and cytokine concentrations in post-surgical intensive care unit patients: prospective, randomized study.

PURPOSE: The purpose of this study was to compare the effect of the long-term administration of flurbiprofen and fentanyl in the intensive care unit on natural killer cell cytotoxicity (NKCC), lymphocyte subsets and cytokine levels. METHODS: In this prospective study, patients scheduled for at least 48 h sedation after neck surgery were randomly assigned to two groups called group N and group F. Group N patients were sedated with propofol and flurbiprofen after surgery (n = 12), while group F patients were sedated with propofol and fentanyl (n = 13). The NKCC, lymphocyte subsets, and plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-6, and IL-10 were measured before and at the end of surgery, on postoperative day (POD) 1 and POD2. RESULTS: The NKCC was significantly higher on POD1 in group N than in group F (14.5 ± 11.2 versus 6.3 ± 4.1%, p < 0.05), the difference between the groups disappearing on POD2. Lymphocyte subsets and plasma levels of cytokines were not significantly different between the two groups during the study period. CONCLUSIONS: Transient suppressive effects on NKCC were observed in the fentanyl group as compared to the flurbiprofen group. This suggests that when choosing postoperative analgesics, physicians should bear in mind the potential immunosuppressive effects of these agents in patients requiring prolonged sedation in the intensive care unit.

Optimal fentanyl dosage for attenuating systemic hemodynamic changes, hormone release and cardiac output changes during the induction of anesthesia in patients with and without hypertension: a prospective, randomized, double-blinded study.

PURPOSE: The purpose of this study was to compare the dose-related effects of fentanyl on systemic hemodynamics, hormone release and cardiac output in response to endotracheal intubation in patients with and without hypertension. METHODS: Forty-five patients without hypertension and 45 patients with hypertension (total 90 patients) undergoing elective general surgical, urological or gynecological procedures under general anesthesia were studied. The patients were randomly divided into three groups to receive either saline (control), 2.0 µg/kg fentanyl or 4.0 µg/kg fentanyl before tracheal intubation. Anesthesia was induced via intravenous target controlled infusion of propofol (plasma concentration, 4.0 µg/mL) followed by administration of the three drugs. Heart rate, blood pressure, and cardiac output were continuously monitored using Flo Trac/Vigileo system™ and Bispectral index from before anesthetic induction until 10 min after tracheal intubation. RESULTS: In patients without hypertension, there was a significant difference in mean arterial pressure (MAP) among the three groups 2 min after intubation. Cardiac index (CI) in all three groups decreased before intubation compared with that in the awake period, returning to awake values after intubation in all three groups. There was a significant difference in CI between the 4 µg/kg fentanyl group and the other two groups immediately and 1 min after intubation. In patients with hypertension, a differential time course of MAP changes was observed among the three groups after intubation. CI in the three groups decreased after the induction of anesthesia and increased after intubation in control and 2 µg/kg fentanyl groups compared with that in the awake period. CONCLUSIONS: The present study shows that it is preferable to administer 2 µg/kg fentanyl in patients without hypertension and 4 µg/kg fentanyl in patients with hypertension in order to minimize the changes in heart rate, systolic blood pressure and cardiac output associated with tracheal intubation.

Effects of balloon-induced pulsatile perfusion on postoperative short- and long-term cognitive dysfunction in diabetic patients with impaired cerebrovascular carbon dioxide reactivity.

OBJECTIVES: The purpose of this study was to identify whether reduced jugular venous oxygen saturation (SjvO(2)) in diabetic patients with impaired cerebrovascular carbon dioxide (CO(2)) reactivity could be improved by pulsatile perfusion during cardiopulmonary bypass (CPB) and whether improved SjvO(2) could improve postoperative cognitive dysfunction after coronary artery bypass graft surgery. SETTING: A prospective, observational study. PARTICIPANTS: Ninety-nine diabetic patients with impaired CO(2) reactivity (< 3%/mmHg). INTERVENTIONS: Ninety-nine diabetic patients divided into 2 groups: group 1 received an intra-aortic balloon pump (IABP) after the induction of anesthesia and group 2 did not. Group 1 received pulsatile perfusion during CPB, and group 2 received nonpulsatile perfusion during CPB. MEASUREMENTS AND MAIN RESULTS: Hemodynamic data (arterial and jugular venous gas values) were measured during CPB. All patients underwent neurologic and neuropsychologic tests the day before surgery and 7 days and 6 months after surgery. The duration of SjvO(2) ≤50% during CPB was shorter in group 1 (13 ± 5 minutes) than in group 2 (20 ± 6 minutes, p < 0.01). No significant differences in the rate of cognitive dysfunction were observed between groups at 7 days and 6 months postoperatively. CONCLUSIONS: Pulsatile perfusion flow generated by the IABP could reduce the decrease in SjvO(2) values during CPB, but amelioration of SjvO(2) values was not associated with short- or long-term postoperative cognitive dysfunction in diabetic patients with impaired CO(2) reactivity.

Recovery time after sugammadex reversal of rocuronium-induced muscle relaxation for electroconvulsive therapy is independent of cardiac output in both young and elderly patients.

PURPOSE: This study was conducted to (1) compare the recovery times from rocuronium-induced muscle relaxation after reversal with sugammadex between young and elderly patients undergoing electroconvulsive therapy (ECT), and (2) to examine the existence of a correlation between cardiac index and reversibility of rocuronium-induced neuromuscular block with sugammadex after ECT. METHODS: Seventeen patients (young group, 50 years or younger, n = 8; elderly group, 70 years or older, n = 9) who were scheduled to undergo ECT were studied. Anesthesia was induced using propofol (1.0 mg/kg) followed by rocuronium (0.6 mg/kg). Assisted mask ventilation was initiated with 100% oxygen. Cardiac index was monitored noninvasively throughout the procedure. After the first twitch of the train of four (TOF) was assessed as being zero by neuromuscular monitoring, an electroshock stimulus was applied bilaterally. Immediately after the seizure stopped, patients were given 8-mg/kg sugammadex intravenously to reverse the muscle relaxation. Neuromuscular monitoring was continued until recovery of the TOF ratio to 0.9 at the tibial nerve in the leg. The time to recovery of the TOF to 0.1 and 0.9 was compared in both groups. RESULTS: Although no significant difference in return to a TOF of 0.1 was found between the groups, there were significant differences in both recovery to a TOF of 0.9 and the time interval to the first spontaneous breath between groups (time to recovery to a TOF of 0.9, young group, 403 ± 37 seconds; elderly group, 443 ± 36 seconds; P < 0.05). In contrast, there was no relationship between cardiac index after ECT and recovery time to TOF of 0.9. CONCLUSIONS: Although recovery time to TOF of 0.9 after the administration of 8.0-mg/kg sugammadex was longer in the elderly patients than in the young patients, it had no relationship with cardiac output after ECT.