Effects of Balanced Versus Saline-based Solutions on Acute Kidney Injury in Off-pump Coronary Artery Bypass Surgery: A Randomized Controlled Trial.

OBJECTIVES: To determine whether balanced solutions can reduce the incidence of acute kidney injury after off-pump coronary artery bypass surgery compared with saline. DESIGN: Randomized controlled trial. SETTING: Single tertiary care center. PARTICIPANTS: Patients who underwent off-pump coronary artery bypass surgery between June 2014 and July 2020. INTERVENTIONS: Balanced solution-based chloride-restrictive intravenous fluid strategy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was acute kidney injury within 7 postoperative days, as defined by the 2012 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline. The incidence of acute kidney injury was 4.4% (8/180) in the balanced group and 7.3% (13/178) in the saline group. The difference was not statistically significant (risk difference, -2.86%; 95% confidence interval [CI], -7.72% to 2.01%; risk ratio, 0.61, 95% CI, 0.26 to 1.43; p = 0.35). Compared with the balanced group, the saline group had higher levels of intraoperative serum chloride and lower base excess, which resulted in a lower pH. CONCLUSIONS: In patients undergoing off-pump bypass surgery with a normal estimated glomerular filtration rate, the intraoperative balanced solution-based chloride-restrictive intravenous fluid administration strategy did not decrease the rate of postoperative acute kidney injury compared with the saline-based chloride-liberal intravenous fluid administration strategy.

Video-based automatic hand hygiene detection for operating rooms using 3D convolutional neural networks.

Hand hygiene among anesthesia personnel is important to prevent hospital-acquired infections in operating rooms; however, an efficient monitoring system remains elusive. In this study, we leverage a deep learning approach based on operating room videos to detect alcohol-based hand hygiene actions of anesthesia providers. Videos were collected over a period of four months from November, 2018 to February, 2019, at a single operating room. Additional data was simulated and added to it. The proposed algorithm utilized a two-dimensional (2D) and three-dimensional (3D) convolutional neural networks (CNNs), sequentially. First, multi-person of the anesthesia personnel appearing in the target OR video were detected per image frame using the pre-trained 2D CNNs. Following this, each image frame detection of multi-person was linked and transmitted to a 3D CNNs to classify hand hygiene action. Optical flow was calculated and utilized as an additional input modality. Accuracy, sensitivity and specificity were evaluated hand hygiene detection. Evaluations of the binary classification of hand-hygiene actions revealed an accuracy of 0.88, a sensitivity of 0.78, a specificity of 0.93, and an area under the operating curve (AUC) of 0.91. A 3D CNN-based algorithm was developed for the detection of hand hygiene action. The deep learning approach has the potential to be applied in practical clinical scenarios providing continuous surveillance in a cost-effective way.

Comparison of preoxygenation with a high-flow nasal cannula and a simple face mask before intubation in Korean patients with head and neck cancer.

BACKGROUND: Although preoxygenation is an essential procedure for safe endotracheal intubation, in some cases securing sufficient time for tracheal intubation may not be possible. Patients with head and neck cancer might have a difficult airway and need a longer time for endotracheal intubation. We hypothesized that the extended apneic period with preoxygenation via a high-flow nasal cannula (HFNC) is beneficial to patients who undergo head and neck surgery compared with preoxygenation with a simple mask. METHODS: The study was conducted as a single-center, single-blinded, prospective, randomized controlled trial. Patients were divided into groups based on one of the two preoxygenation. METHODS: HFNC group or simple facemask (mask group). Preoxygenation was performed for 5 minutes with each method, and endotracheal intubation for all patients was performed using a video laryngoscope. Oxygen partial pressures of the arterial blood were compared at the predefined time points. RESULTS: For the primary outcome, the mean arterial oxygen partial pressure (PaO2 ) immediately after intubation was 454.2 mm Hg (95% confidence interval [CI], 416.9-491.5 mm Hg) in the HFNC group and 370.7 mm Hg (95% CI, 333.7-407.4 mm Hg) in the mask group (P=0.002). The peak PaO2 at 5 minutes after preoxygenation was not statistically different between the groups (P=0.355). CONCLUSIONS: Preoxygenation with a HFNC extending to the apneic period before endotracheal intubation may be beneficial in patients with head and neck cancer.

Optimization of the Operating Room Scheduling Process for Improving Efficiency in a Tertiary Hospital.

Efficient operating room (OR) scheduling can improve OR utilization and reduce costs. We hypothesize that the scheduling office (ORSO) leading the modification scheduling process could increase OR utilization rate. Using retrospective data from a single tertiary hospital in two consecutive calendar years, we compared OR utilization rate, the number of daily cases and cumulative operative time in the pre- and post-implementation of scheduling process alteration. We operated about 100,609 cases in the OR during the study period. Daytime utilization rate increased from 85.6% to 89.4% (P < 0.001); overall OR utilization rate from 115.1% to 117.6% (P = 0.019); daily case numbers from 229.9 ± 7.3 to 239.6 ± 7.6 (P = 0.0.14); and cumulative operation time of total and daytime cases from 611.7 case-hour/day to 624.5 case-hour/day (P = 0.013) and from 510.8 case-hour/day to 533.8 case-hour/day (P < 0.001), respectively. Evening/night time case-hour significantly decreased from 100.9 case-hour/day to 90.7 case-hour/day (P < 0.001). The optimization of the scheduling process and coordination by the office during regular workhours resulted in enhanced OR efficiency. The OR scheduling office can act as a control tower to make OR management more flexible, which can improve efficiency and carry financial benefits in tertiary hospitals.

Patient and haemodynamic factors affecting intraoperative graft flow during coronary artery bypass grafting: an observational pilot study.

Transit-time flow measurement (TTFM) is frequently used to evaluate intraoperative quality control during coronary artery bypass grafting (CABG) and has the ability to assess graft failure intraoperatively. However, perioperative factors affecting TTFM during CABG remain poorly understood. Patients who underwent CABG at a single institution between July 2016 and May 2018 were prospectively evaluated. TTFM and blood viscosity were measured haemodynamically, while mean flow (mL/min), pulsatility index, and diastolic filling were recorded. Arterial blood gas was analysed immediately after left internal mammary artery to left descending artery anastomosis and before sternal closure. Factors associated with TTFM were assessed using multiple linear regression analysis. We evaluated 57 of the 62 patients who underwent CABG during the study period, including 49 who underwent off-pump and 8 who underwent on-pump surgeries. Blood viscosity was not significantly associated with TTFM (p > 0.05). However, TTFM was significantly associated with body mass index, systolic blood pressure, and cardiac index (p < 0.05 each). In conclusion, maintaining the SBP in the perioperative period and maintaining the CI with inotropic support or fluid resuscitation can be important in improving blood flow of graft vessels after surgery.

Comparison of preoxygenation with a high-flow nasal cannula and a simple mask before intubation during induction of general anesthesia in patients undergoing head and neck surgery: Study protocol clinical trial (SPIRIT Compliant).

BACKGROUND: To assess the arterial oxygen partial pressure (PaO2) at defined time points during preoxygenation and to compare high-flow heated humidified nasal oxygenation with standard preoxygenation using oxygen insufflation via a facemask for at least 5 minutes, before intubation during induction of general anesthesia. METHODS: This randomized, single-blinded, prospective study will be conducted in patients undergoing head and neck surgery. After standard monitoring, the artery catheter at the radial artery or dorsalis pedis artery will be placed and arterial blood gas analysis (ABGA) for baseline values will be performed simultaneously. Each group will be subjected to 1 of 2 preoxygenation methods (high-flow nasal cannula or simple facemask) for 5 minutes, and ABGA will be performed twice. After confirming intubation, we will start mechanical ventilation and check the vital signs and perform the final ABGA. DISCUSSION: This trial aims to examine the trajectory of PaO2 levels during the whole preoxygenation procedure and after intubation. We hypothesize that preoxygenation with the high-flow nasal cannula will be superior to that with the face mask. STUDY REGISTRATION: This trial was registered with the Clinical Trial Registry (NCT03896906; ClinicalTrials.gov).

Comparison of recovery profiles in patients with Parkinson's disease for 2 types of neuromuscular blockade reversal agent following deep brain stimulator implantation.

As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.

Age-dependent relationship between preoperative serum aminotransferase and mortality after cardiovascular surgery.

Although serum aminotransferase levels are frequently measured for preoperative evaluation, their prognostic value to postoperative outcomes remain unclear. This study aimed to investigate the relationship between preoperative serum aminotransferase levels and postoperative 90-day mortality in patients undergoing cardiovascular surgery. We included adult patients (n=6264) who underwent cardiovascular surgery between January 2010 and December 2016 at a tertiary academic hospital. Preoperative serum alanine aminotransferase (ALT), serum aspartate aminotransferase (AST), and De Ritis ratio (defined as AST/ALT) were categorized into three groups: low (≤20th percentile), middle (20th-80th percentile), and high (>80th percentile). Of the 6264 patients enrolled (40.4% women; median age, 62 years), 183 (2.9%) died within 90 days postoperatively. Multivariable-adjusted analyses revealed low ALT (hazard ratio 1.58, 95% confidence interval, 1.14-2.18) and high De Ritis ratio (hazard ratio 1.59, 95% confidence interval, 1.15-2.20) were independent predictors of postoperative mortality, but AST did not have a statistically significant association. The association of low ALT and high De Ritis ratio with 90-day mortality was more pronounced in patients older than 60 years (P-values for interaction <0.05). Therefore, preoperative serum aminotransferase levels may be a valuable prognostic marker in patients with cardiovascular surgery, particularly in the elderly.

Effective dose of dobutamine in augmenting free flap blood flow during reconstructive surgery of the lower extremity.

Success of surgical free flap transfer depends on achieving and maintaining adequate perfusion across the microvascular anastomosis. The purpose of this prospective study was to determine the optimal infusion rate of dobutamine to augment duplex ultrasound measured blood flow to the tissue flap during surgery.Twenty-one patients undergoing general anesthesia for lower limb reconstructive surgery were recruited. The optimal dobutamine dose was evaluated using the modified Dixon's up-and-down method, starting at 6 µg·kg·min, and then titrated in increments of 1 µg·kg·min.The optimal dose of dobutamine for improving blood flow to the tissue flap was 3.50 ±â€Š0.57 µg·kg·min in 50% of patients. The 95% effective dose of dobutamine calculated by probit analysis was 4.46 µg·kg·min (95% confidence interval: 3.99-7.00 µg·kg·min).The results of our study suggest that a dobutamine infusion rate less than 5 µg·kg·minprovides significant improvement of blood flow to the tissue flap, while minimizing cardiovascular side effects.

Effect of restrictive fluid therapy with hydroxyethyl starch during esophagectomy on postoperative outcomes: a retrospective cohort study.

BACKGROUND: To improve prognosis after esophageal surgery, intraoperative fluid optimization is important. Herein, we hypothesized that hydroxyethyl starch administration during esophagectomy reduce the total amount of fluid infused and it could have a positive effect on postoperative complication occurrence and mortality. METHODS: All consecutive adult patients who underwent elective esophageal surgery for cancer were studied. The primary outcome was the development of composite complications including death, cardio-cerebrovascular complications, respiratory complications, renal complications, gastrointestinal complications, sepsis, empyema or abscess, and multi-organ failure. The relationship between perioperative variables and composite complication was evaluated using multivariable logistic regression. RESULTS: Of 892 patients analyzed, composite complications developed in 271 (30.4%). The higher hydroxyethyl starch ratio in total fluid had a negative relationship with the total fluid infusion amount (r = - 0.256, P <  0.001). In multivariable analysis, intraoperatively administered total fluid per weight per hour (odds ratio, 1.248; 95% CI, 1.153-1.351; P <  0.001) and HES-to-crystalloid ratio (odds ratio, 2.125; 95% CI, 1.521-2.969; P <  0.001) were associated with increased risks of postoperative composite outcomes. CONCLUSIONS: Although hydroxyethyl starch administration reduces the total fluid infusion amount during esophageal surgery for cancer, intravenous hydroxyethyl starch infusion is associated with an increasing risk of postoperative composite complications.

Preoperative dexamethasone for acute post-thoracotomy analgesia: a randomized, double-blind, placebo-controlled study.

BACKGROUND: The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy. METHODS: Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 µg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. RESULTS: No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h (63.6 [55.9-72.7] vs. 68.5 [60.2-89.0] ml, P = 0.281) and 72 h (199.4 [172.4-225.1] vs. 194.7 [169.1-252.2] ml, P = 0.890). Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay. CONCLUSION: A single intravenous administration of dexamethasone during the preoperative period does not reduce opioid consumption and post-thoracotomy pain. TRIAL REGISTRATION: The study was registered at http://cris.nih.go.kr ( KCT0000359 ) and was conducted from December 2011 to October 2012.

Recurrent ST segment elevations in a patient with asymptomatic early repolarization during head and neck surgery: implications of vasospastic angina.

A 57-year-old woman scheduled for cochlear implant removal exhibited preoperative electrocardiographic findings of early repolarization (ER). Four episodes of transient ST segment elevations during surgery raised suspicion for vasospastic angina (VA). In the post-anesthetic care unit, the patient complained of chest discomfort and received sublingual nitroglycerin with uncertain effect. The patient refused to proceed with postoperative invasive coronary angiography, resulting in inconclusive diagnosis. Intraoperative circumstances limit the diagnosis of VA, which emphasizes the need for further testing to confirm the diagnosis. When VA is suspected in patients with underlying ER, it is reasonable to consider invasive examination to establish the diagnosis and prevent recurrence of VA. If ST changes are observed during surgery in patients with preoperative ER, careful monitoring is recommended. Due to general anesthesia, the absence of patient symptoms limits the definitive diagnosis of those with suspected VA. Therefore, additional postoperative surveillance is recommended.

Pretransplant increases in left ventricular volume and mass are associated with QT prolongation during pediatric liver transplantation.

Structural alterations in the cirrhotic heart may contribute to electromechanical abnormalities, represented by QT prolongation. The aim of this study was to investigate the changes in QTc according to the operative stage during pediatric LT and to identify which baseline echocardiographic parameters were associated with intraoperative QTc prolongation. Data were evaluated from 39 children undergoing LT for chronic liver disease (median age 9 months). In 19 patients (48.7%), baseline QTc was prolonged ≥440 ms (462 ± 19 ms). Through the period of post-reperfusion, QTI, QTc, and JTI progressively increased, although values partially recovered toward the end of surgery. High LVMI (≥82.51 g/m2 ) was associated with baseline QTc ≥ 440 ms (OR = 1.034, P = .032). In the 5 minutes post-reperfusion stage, marked QTc prolongation (defined as QTc ≥ 500 ms; n = 24, 61.5%) was significantly associated with high EDVI (OR = 1.060, P = .027) and SVI (OR = 1.075, P = .026). In children with chronic liver disease, increased ventricular volumes and mass may increase the risk of QTc prolongation during LT, suggesting that repolarization abnormalities might be contributed by structural changes characteristic of cirrhotic cardiomyopathy.

Pulmonary aspiration during intubation in a high-risk patient: A video clip and clinical implications.

We report a case of pulmonary aspiration during induction of general anesthesia in a patient who was status post esophagectomy. Sudden, unexpected aspiration occurred even though the patient had fasted adequately (over 13 hours) and received rapid sequence anesthesia induction. Since during esophagectomy, the lower esophageal sphincter is excised, stomach vagal innervation is lost, and the stomach is flaccid, draining only by gravity, the patient becomes vulnerable to aspiration. As the incidence of perioperative pulmonary aspiration is relatively low, precautions to prevent aspiration tend to be overlooked. We present a video clip showing pulmonary aspiration and discuss the literature concerning the risk of aspiration and its preventive strategies.

Propofol for implantable cardioverter defibrillator implantation in patients with Brugada syndrome.

AIMS: Avoiding propofol in patients with Brugada syndrome has been suggested because of the theoretical risk of provoking ventricular arrhythmias, although propofol may be selected for conscious sedation during electrophysiological procedures in catheterization laboratories. This study aimed to document periprocedural electrocardiographic changes and adverse events in patients with Brugada syndrome undergoing implantable cardioverter defibrillator (ICD) implantation using propofol sedation. METHODS: We reviewed the clinical data of 53 consecutive patients who underwent ICD implantation during 1998-2011. Sedation was achieved by combining propofol with either midazolam or fentanyl, and a bolus propofol dose (0.5-1 mg/kg) was administered to induce deep sedation. Periprocedural events, including arrhythmias, defibrillations, and hyperthermia episodes, were evaluated, and electrocardiogram (ECG) variables were measured. The need for emergency anesthetic support/intubation and incidence of perioperative complications or mortality were analyzed. RESULTS: Procedure time and cumulative propofol dose for each patient was 125.2 (42.8) min and 204.6 (212.7) mg, respectively. During deep sedation, blood pressure, heart rate, and oxygen saturation were significantly decreased (P < 0.001) such that eight (15.1%) patients required manual ventilation and one (1.9%) needed atropine injection. No significant ECG changes were observed. Only two (3.7%) patients showed newly developed ST elevation in the anterior precordial lead, whereas three (5.6%) had isolated premature ventricular contractions. CONCLUSION: ICD implantation without significant ECG changes or adverse outcomes is feasible under propofol sedation in patients with Brugada syndrome. However, because of significant hemodynamic changes and respiratory compromise, close monitoring and meticulous propofol dose titration is warranted.

Prognostic Impacts of Increases in Amino Transaminases Following Coronary Artery Bypass Grafting on Mortality.

OBJECTIVE: To evaluate the prognostic impacts of postoperative increases in serum amino transaminases on 1-year mortality in patients who underwent coronary artery bypass graft. DESIGN: A retrospective analysis. SETTING: A tertiary care university hospital. PARTICIPANTS: A total of 1,950 patients who underwent coronary artery bypass graft. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Aspartate amino transaminase and alanine amino transaminase ratios were calculated as the ratio between the peak aspartate amino transaminase and alanine amino transaminase within the first 5 post-operative days and their respective upper limit of normal values. A ratio of 2.0 was seen to be the minimum for which a difference in 1-year mortality could be detected in univariate analysis, when considering simultaneously both aspartate amino transaminase and alanine amino transaminase ratios. Multivariable analysis showed an association between an aspartate amino transaminase ratio > 2.0 and increased 1-year mortality (hazard ratio [HR] 2.68, 95% confidence interval [CI] 1.42-5.05, P = 0.002), and also between both an aspartate amino transaminase and alanine amino transaminase ratio > 2.0 and increased 1-year mortality (HR 3.90, 95% CI 1.87-8.14, P < 0.001). However, increases in alanine amino transaminase only above the upper limit of normal were not associated with increased 1-year mortality. CONCLUSIONS: Postoperative increases in aspartate amino transaminase only and increases in both aspartate amino transaminase and alanine amino transaminase greater than twice the upper limit of normal were associated with increased 1-year mortality in patients undergoing coronary artery bypass graft.

Impact of anesthetic agents on overall and recurrence-free survival in patients undergoing esophageal cancer surgery: A retrospective observational study.

Given that surgical stress response and surgical excision may increase the likelihood of post-surgery cancer dissemination and metastasis, the appropriate choice of surgical anesthetics may be important for oncologic outcomes. We evaluated the association of anesthetics used for general anesthesia with overall survival and recurrence-free survival in patients who underwent esophageal cancer surgery. Adult patients (922) underwent elective esophageal cancer surgery were included. The patients were divided into two groups according to the anesthetics administered during surgery: volatile anesthesia (VA) or intravenous anesthesia with propofol (TIVA). Propensity score and Cox regression analyses were performed. There were 191 patients in the VA group and 731 in the TIVA group. In the entire cohort, VA was independently associated with worse overall survival (HR 1.58; 95% CI 1.24-2.01; P < 0.001) and recurrence-free survival (HR 1.42; 95% CI 1.12-1.79; P = 0.003) after multivariable analysis adjustment. Similarly, in the propensity score matched cohorts, VA was associated with worse overall survival (HR 1.45; 95% CI 1.11-1.89; P = 0.006) and recurrence-free survival (HR 1.44; 95% CI 1.11-1.87; P = 0.006). TIVA during esophageal cancer surgery was associated with better postoperative survival rates compared with volatile anesthesia.

The photoplethysmographic amplitude to pulse pressure ratio can track sudden changes in vascular compliance and resistance during liver graft reperfusion: A beat-to-beat analysis.

During liver transplantation, the thermodilution cardiac output (CO) technique cannot respond to sudden hemodynamic changes associated with postreperfusion syndrome. Photoplethysmography (PPG) can reflect changes in intravascular volume and thus can be used to assess vasomotor tone and arterial stiffness on the pressure-volume relation. We investigated whether a beat-to-beat analysis of the arterial pressure-PPG relationship can estimate dynamic changes in vascular characteristics immediately after liver graft reperfusion.In 10 recipients, arterial blood pressure and PPG waveforms recorded simultaneously were analyzed from the beginning of fall to nadir in systolic blood pressure immediately after reperfusion. On a beat-to-beat basis, we compared the ratio of the amplitude of PPG to arterial pulse pressure (PPGamp/PP, as relative vascular compliance) to total peripheral resistance (TPR) and Windkessel compliance (Cwk) obtained from the Modelflow CO algorithm.Following graft reperfusion, PPGamp/PP and Cwk increased (median 41.5%; P = .005 and 42.0%; P < .001, respectively), whereas TPR decreased (median -46.4%; P < .001). Beat-to-beat PPGamp/PP was negatively correlated with TPR (median r = -0.80 [95% CI -0.85 to -0.76] on linear regression and r = 0.84 [95% CI 0.73-0.92] on curvilinear regression), and was positively correlated with Cwk (median r = 0.86 [95% CI 0.81-0.91] on linear regression and r = 0.88 [95% CI 0.75-0.96] on curvilinear regression).Our results suggest that relative compliance, obtained from beat-to-beat analysis of PPG and arterial pressure waveforms, can track abrupt changes in vascular characteristics associated with postreperfusion syndrome. This simple index would contribute to differential diagnoses of sudden hypotension.

Effect of Positive End-Expiratory Pressure on the Sonographic Optic Nerve Sheath Diameter as a Surrogate for Intracranial Pressure during Robot-Assisted Laparoscopic Prostatectomy: A Randomized Controlled Trial.

BACKGROUND: Positive end-expiratory pressure (PEEP) can increase intracranial pressure. Pneumoperitoneum and the Trendelenburg position are associated with an increased intracranial pressure. We investigated whether PEEP ventilation could additionally influence the sonographic optic nerve sheath diameter as a surrogate for intracranial pressure during pneumoperitoneum combined with the Trendelenburg position in patients undergoing robot-assisted laparoscopic prostatectomy. METHODS: After anesthetic induction, 38 patients were randomly allocated to a low tidal volume ventilation (8 ml/kg) without PEEP group (zero end-expiratory pressure [ZEEP] group, n = 19) or low tidal volume ventilation with 8 cmH2O PEEP group (PEEP group, n = 19). The sonographic optic nerve sheath diameter was measured prior to skin incision, 5 min and 30 min after pneumoperitoneum and the Trendelenburg position, and at the end of surgery. The study endpoint was the difference in the sonographic optic nerve sheath diameter 5 min after pneumoperitoneum and the Trendelenburg position between the ZEEP and PEEP groups. RESULTS: Optic nerve sheath diameters 5 min after pneumoperitoneum and the Trendelenburg position did not significantly differ between the groups [least square mean (95% confidence interval); 4.8 (4.6-4.9) mm vs 4.8 (4.7-5.0) mm, P = 0.618]. Optic nerve sheath diameters 30 min after pneumoperitoneum and the Trendelenburg position also did not differ between the groups [least square mean (95% confidence interval); 4.5 (4.3-4.6) mm vs 4.5 (4.4-4.6) mm, P = 0.733]. CONCLUSIONS: An 8 cmH2O PEEP application under low tidal volume ventilation does not induce an increase in the optic nerve sheath diameter during pneumoperitoneum combined with the steep Trendelenburg position, suggesting that there might be no detrimental effects of PEEP on the intracranial pressure during robot-assisted laparoscopic prostatectomy. TRIAL REGISTRATION: ClinicalTrial.gov NCT02516566.

Effect of Exogenous Albumin on the Incidence of Postoperative Acute Kidney Injury in Patients Undergoing Off-pump Coronary Artery Bypass Surgery with a Preoperative Albumin Level of Less Than 4.0 g/dl.

BACKGROUND: Hypoalbuminemia may increase the risk of acute kidney injury (AKI). The authors investigated whether the immediate preoperative administration of 20% albumin solution affects the incidence of AKI after off-pump coronary artery bypass surgery. METHODS: In this prospective, single-center, randomized, parallel-arm double-blind trial, 220 patients with preoperative serum albumin levels less than 4.0 g/dl were administered 100, 200, or 300 ml of 20% human albumin according to the preoperative serum albumin level (3.5 to 3.9, 3.0 to 3.4, or less than 3.0 g/dl, respectively) or with an equal volume of saline before surgery. The primary outcome measure was AKI incidence after surgery. Postoperative AKI was defined by maximal AKI Network criteria based on creatinine changes. RESULTS: Patient characteristics and perioperative data except urine output during surgery were similar between the two groups studied, the albumin group and the control group. Urine output (median [interquartile range]) during surgery was higher in the albumin group (550 ml [315 to 980]) than in the control group (370 ml [230 to 670]; P = 0.006). The incidence of postoperative AKI in the albumin group was lower than that in the control group (14 [13.7%] vs. 26 [25.7%]; P = 0.048). There were no significant between-group differences in severe AKI, including renal replacement therapy, 30-day mortality, and other clinical outcomes. There were no significant adverse events. CONCLUSION: Administration of 20% exogenous albumin immediately before surgery increases urine output during surgery and reduces the risk of AKI after off-pump coronary artery bypass surgery in patients with a preoperative serum albumin level of less than 4.0 g/dl.