Impact of a computerised clinical decision support system on vancomycin loading and the risk of nephrotoxicity.

BACKGROUND: A vancomycin loading dose is recommended for the treatment of serious methicillin-resistant Staphylococcus aureus (MRSA) infections. However, clinicians often do not adhere to these recommendations, mainly due to nephrotoxicity risk, unfamiliarity with the guideline, or complexity of calculating an individual dose. Therefore, we introduced a computerised clinical decision support system (CDSS) for vancomycin loading (hereafter Vancomycin CDSS) to promote the use of vancomycin loading dose. METHODS: We describe a quasi-experimental study spanning 6 months before and 18 months after the deployment of a Vancomycin CDSS. The Vancomycin CDSS was integrated into the hospital's electronic medical record system in the form of a vancomycin order set. Our primary endpoint was the incidence of nephrotoxicity; the secondary endpoint was mean initial vancomycin trough levels. We also conducted a survey to evaluate the reasons why clinicians opted not to utilise a vancomycin loading dose. RESULTS: After implementation of Vancomycin CDSS, 363 out of 746 patients (49 %) who were first administered vancomycin received a loading dose. We did not find significant differences in nephrotoxicity between the pre- and post-intervention groups, nor between the loading- and non-loading groups. In the pre-intervention group, the mean initial vancomycin trough level was 7.10 mg/L, which was significantly lower than that in the post-intervention group of 11.11 mg/L. In the vancomycin loading group, the mean initial trough level was 11.95 mg/L, compared to 7.55 mg/L in the non-loading group. The main reason stated for not prescribing a vancomycin loading dose was concern about nephrotoxicity. CONCLUSION: Introduction of the Vancomycin CDSS did not increase nephrotoxicity and increased the mean initial dose and trough level of vancomycin.

Effect of combining a recruitment maneuver with protective ventilation on inflammatory responses in video-assisted thoracoscopic lobectomy: a randomized controlled trial.

BACKGROUND: We hypothesized that the addition of a recruitment maneuver to protective ventilation (PVRM) would result in lower pulmonary and systemic inflammatory responses than traditional ventilation or protective ventilation (PV) alone in patients undergoing lung surgery. METHODS: Sixty patients who underwent scheduled thoracoscopic lobectomy were randomly assigned to three groups: traditional ventilation, PV, or PVRM. Ventilations were performed using a tidal volume of 10 mL/kg for the traditional ventilation group and either 8 mL/kg (two-lung) or 6 mL/kg (one-lung, OLV) with a positive end-expiratory pressure of 5 cm H2O for the PV and PVRM groups. The RM was performed 10 min after the start of OLV. Fiberoptic bronchoalveolar lavage (BAL) was performed twice in dependent and non-dependent lungs: before the start and immediately after the end of OLV. Blood samples were collected at the same time points. The levels of cytokines, including TNF-α, IL-1ß, IL-6, IL-8, and IL-10, were measured. RESULTS: After OLV, the level of TNF-α in the BAL fluid of dependent lungs was significantly higher in the PV than in the PVRM group (P = 0.049), whereas IL-1ß, IL-6, IL-8, and IL-10 levels were not significantly different among the groups. In non-dependent lung BAL fluid, no cytokines were significantly different among the groups. After OLV, IL-10 serum levels were significantly higher in the traditional ventilation than in the PVRM group (P = 0.027). CONCLUSIONS: Lower inflammatory responses in the ventilated lung and serum were observed with PVRM than with traditional ventilation or PV alone. Larger multi-center clinical trials are warranted to confirm the effects of different ventilatory strategies on postoperative outcomes.

Cadaveric Evaluation of Different Approaches for Quadratus Lumborum Blocks.

Background: A quadratus lumborum (QL) block is an abdominal truncal block technique that primarily provides analgesia and anaesthesia to the abdominal wall. This cadaveric study was undertaken to compare the dye spread between different needle approaches for ultrasound-guided QL blocks in soft-embalmed cadavers. Methods: After randomization, an experienced anesthesiologist performed two lateral, three posterior, and five alternative QL blocks on the left or right sides of five cadavers. The target injection point for the alternative approach was the lumbar interfascial triangle, same as that of conventional posterior QL block, with a different needle trajectory. For each block, 20 ml of dye solution was injected. The lumbar region and abdominal flank were dissected. Results: Ten blocks were successfully performed. Regardless of the approach used, the middle thoracolumbar fascia was deeply stained in all blocks, but the anterior layer was less stained. The alternative approach was more associated with spread of injectate to the transversus abdominis and transversalis fascia plane. Despite accurate needle placement, all lateral QL blocks were associated with a certain amount of intramuscular or subcutaneous infiltration. Two posterior QL blocks showed a deeply stained posterior thoracolumbar fascia, and one of them was associated with obvious subcutaneous staining. The subcostal, iliohypogastric, and ilioinguinal nerves were mostly involved, but the thoracic paravertebral space and lumbar plexus were not affected in all blocks. Conclusions: The alternative approach for QL blocks was able to achieve a comparable extent when compared to the conventional approach.

Ultrasonographic optic nerve sheath diameter for predicting elevated intracranial pressure during laparoscopic surgery: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic surgery involves the creation of a carbon dioxide (CO2) pneumoperitoneum to facilitate a clear surgical view, which may result in an elevated intracranial pressure (ICP). Depending on the surgical area, steep Trendelenburg positioning may be used as well, further increasing the ICP. The objective of this study was to assess the effects of laparoscopic surgery on changes in ICP assessed by ultrasonographic measurement of optic nerve sheath diameter (ONSD), which is a generally accepted simple, reliable, and non-invasive ICP measurement technique. METHODS: A computerized literature search was performed in August 2016 to identity prospective studies that measured ONSD to assess ICP changes during laparoscopic surgery. The primary outcome was the change in ONSD during the early (0-30 min) and late (30-120 min) periods after initiating pneumoperitoneum, compared with baseline values measured after anesthesia induction. Mean differences (MDs) with 95% confidence intervals [CIs] were calculated. RESULTS: Nine observational studies and one randomized controlled trial, with a total of 460 subjects, were analyzed. Compared to the baseline value after anesthesia induction, significant increases in ONSD were observed in both the early period (MD 0.46, 95% CI 0.31-0.61, P < 0.001, I 2 = 97.3%) and late period (MD 0.67, 95% CI 0.20-1.14, P = 0.005, I 2 = 99.2%). Comparing the ONSD during the early and late periods revealed no significant differences over time. CONCLUSIONS: The current meta-analysis revealed that ICP elevation during laparoscopy could be anticipated through a significant increase in the ONSD in the early (0-30 min) and late (30-120 min) periods during CO2 pneumoperitoneum.

Skin perfusion pressure as an indicator of tissue perfusion in valvular heart surgery: Preliminary results from a prospective, observational study.

Hemodynamic management aims to provide adequate tissue perfusion, which is often altered during cardiac surgery with cardiopulmonary bypass (CPB). We evaluated whether skin perfusion pressure (SPP) can be used for monitoring of adequacy of tissue perfusion in patients undergoing valvular heart surgery. Seventy-two patients undergoing valve replacement were enrolled. SPP and serum lactate level were assessed after anaesthesia induction (baseline), during CPB, after CPB-off, end of surgery, arrival at intensive care unit, and postoperative 6 h. Lactate was further measured until postoperative 48 h. Association of SPP with lactate and 30-day morbidity comprising myocardial infarction, acute kidney injury, stroke, prolonged intubation, sternal infection, reoperation, and mortality was assessed. Among the lactate levels, postoperative 6 h peak value was most closely linked to composite of 30-day morbidity. The SPP value during CPB and its % change from the baseline value were significantly associated with the postoperative 6 h peak lactate (r = -0.26, P = 0.030 and r = 0.47, P = 0.001, respectively). Optimal cut-off of % decrease in SPP during CPB from baseline value for the postoperative 6 h hyperlactatemia was 48% (area under curve, 0.808; 95% confidence interval (CI), 0.652-0.963; P = 0.001). Decrease in SPP >48% during CPB from baseline value was associated with a 12.8-fold increased risk of composite endpoint of 30-day morbidity (95% CI, 1.48-111.42; P = 0.021) on multivariate logistic regression. Large decrease in SPP during CPB predicts postoperative 6 h hyperlactatemia and 30-day morbidity, which implicates a promising role of SPP monitoring in the achievement of optimal perfusion during CPB.

A randomized comparison of volume- and pressure-controlled ventilation in children with the i-gel: Effects on peak inspiratory pressure, oropharyngeal leak pressure, and gastric insufflation.

BACKGROUND: The i-gel provides good airway sealing but gastric insufflation may occur when peak inspiratory pressure (PIP) exceeds the sealing pressure of the i-gel without a gastric tube. Pressure-controlled ventilation (PCV) provides lower PIP compared with volume-controlled ventilation (VCV) and low PIP may reduce the incidence of gastric insufflation in children during positive pressure ventilation. This study was designed to evaluate PIP, oropharyngeal leak pressure, and gastric insufflation during VCV or PCV in children undergoing general anesthesia with i-gel without a gastric tube in situ. METHODS: A prospective, randomized-controlled study was conducted. Thirty-four children, aged 6 to 84 months, were randomly allocated into the VCV or PCV group. Fiberoptic bronchoscopy was performed to confirm appropriate position of i-gel. Oropharyngeal leak pressure and PIP were measured after i-gel insertion, after caudal block, and after surgery. Ultrasonography was performed to detect gastric insufflation. Gastric tube was not inserted. RESULTS: PIP in cm H2O was significantly lower in the PCV group than in the VCV group after i-gel insertion (10 [9-12] vs 12 [11-15], P = .021), after caudal block (11 [10-12] vs 13 [11-15], P = .014), and after surgery (10 [10-12] vs 13 [11-14], P = .002). There was no difference in the incidence of gastric insufflation between the 2 groups (4/17 in the VCV group and 3/17 in the PCV group) (P > .999). CONCLUSION: When i-gel was used without a gastric tube, gastric insufflation occurred regardless of the ventilation modes, which provided different PIP.

Autoantibodies with mimicking specificity detected by the dilution technique in patients with warm autoantibodies.

BACKGROUND: The aim of this study was to investigate the frequency of autoantibodies with mimicking specificity by using the dilution technique, to assess the usefulness of the combination of the dilution technique and red blood cell (RBC) phenotyping, and to establish a pre-transfusion testing algorithm in patients with warm autoantibodies. METHODS: Serum samples from 71 patients with warm autoantibodies were tested using the dilution technique. Among them, 25 samples were adsorbed with allogeneic ZZAP (a combination of dithiothreitol and enzyme) or polyethylene glycol (PEG) and their RBC phenotypes were determined. Thirty-nine patients were transfused with our pre-transfusion testing algorithm using a combination of dilution technique and RBC phenotyping. RESULTS: Autoantibodies with mimicking specificity were detected by the dilution technique in 26.8% (19/71) of the patients and most of them were directed against Rh system antigens. The agreement of the results obtained with the dilution technique in combination with RBC phenotyping and those from ZZAP or PEG adsorption was 100% (18/18) in patients who have autoantibodies with mimicking specificity and/or alloantibodies. No clinical symptoms indicating severe acute or delayed hemolytic transfusion reactions were reported in the 39 patients transfused with our pre-transfusion testing algorithm. CONCLUSIONS: Autoantibodies with mimicking specificity detected by the dilution technique in patients with warm autoantibodies are relatively frequent, can be discriminated from alloantibodies by employing a combination of dilution technique and RBC phenotyping, and might not appear to cause severe acute or delayed hemolytic transfusion reactions.

Outcome of various treatments for posttransplant hepatitis B virus recurrence.

BACKGROUND: Currently, no treatment guidelines are available for posttransplant hepatitis B virus (HBV) recurrence. We retrospectively evaluated the rate of clearance of hepatitis B surface antigen (HBsAg) from serum according to various treatment regimens in two large Korean liver transplantation centers. METHODS: Between 1996 and 2008, HBV recurred in 59 patients among 933 HBV liver recipients (6.3 %). Patients with HBV recurrence were divided into four groups according to their treatment: group L (lamivudine-based therapy n = 21) and group N [new nucleos(t)ide analogue (NA)-based therapy, n = 38]. Intravenous hepatitis B immunoglobulin (ivHBIG) had been simultaneously administered to 10 patients in group L and 26 patients in group N. The mean posttransplant follow-up duration and time to HBV recurrence were 69 (14-152) months and 37 (3-120) months. RESULTS: Overall, 22 patients (37.3 %) showed seronegative conversion of HBsAg for a median 8 months after treatment (range 1-15 months). The seroclearance rate was significantly higher in group N (n = 20, 52.6 %) than in group L (n = 2, 9.5 %) (p < 0.000). The time to seroconversion did not differ between group L (7 months, range 5-16) and group N (7 months, range 1-15) (p = 0.428). Subgroup analysis showed that the HBsAg seroconversion rate was much higher for patients given combined ivHBIG and new NAs (15/26 patients, 58.0 %) than the others (p = 0.006). CONCLUSIONS: Seroclearance of HBsAg could be achieved using new NAs in half of the patients after posttransplant HBV recurrence. Combined ivHBIG may add a synergistic effect to new NAs for clearing HBsAg.

Comparison of single-incision laparoscopic distal gastrectomy and laparoscopic distal gastrectomy for gastric cancer in a porcine model.

INTRODUCTION: The single-incision laparoscopic approach may be suitable for several intra-abdominal surgical interventions, but its usefulness for treating gastric cancer has not been established. The aim of this study is to compare the perioperative outcomes of single-incision laparoscopic distal gastrectomy (SIDG) and conventional laparoscopic distal gastrectomy (LDG) by using a porcine model. METHODS: Ten pigs were used to compare the perioperative outcomes of SIDG and LDG. All were subjected to the same distal gastrectomy with D1+ß lymph node dissection method. Specimens retrieved during the operation were subjected to manual lymph node picking and counting. To evaluate the inflammatory reactions, white blood cell (WBC) counts and C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor (TNF)-α levels were measured before and 1 hour, 1 day, and 5 days after surgery. The pigs were sacrificed 1 week after surgery. RESULTS: The procedures were successfully performed in all pigs. The SIDG group lost more weight than the LDG group, but this was not statistically significant (3.34±2.36 kg versus 1.94±1.61 kg, P=.305). The SIDG group was associated with a significantly longer operation time (140±14.14 minutes versus 93±4.47 minutes, P<.001), but it had a similar mean number of resected lymph nodes (25±2.45 versus 22±4.87, P=.393). Variance analysis failed to detect significant WBC, CRP, IL-6, or TNF-α differences. At sacrifice, one pig from each group exhibited anastomosis narrowing. CONCLUSIONS: This animal study shows that SIDG can be applicable for treating gastric cancer with similar inflammatory reaction and complication rates when compared with LDG. Comparative human study is necessary to demonstrate the benefits of SIDG compared with standard laparoscopic surgery.

Genital group B Streptococcus carrier rate and serotype distribution in Korean pregnant women: implications for group B streptococcal disease in Korean neonates.

AIMS: We investigated the genital group B streptococcus (GBS) carrier rate in Korean pregnant women and the serotype distribution in face of the recent increase of late-onset GBS disease in Korea. METHODS: GBS screening was performed on 4045 healthy pregnant women at 35-37 weeks' gestation. In case of positive GBS culture, serotyping was performed by using GBS typing antisera. RESULTS: When both vaginal and anorectal culture were performed, the GBS carrier rate was 10.0% (n=121/1205), which is the highest rate ever reported in Korea. Type III was more common (36%), and type Ia (13%) and Ib (7%) were less prevalent. CONCLUSIONS: Increased maternal genital GBS carrier rate and difference in serotype distribution pattern of GBS may be related to the recent increase of late-onset GBS disease in Korea.

Extramedullary peritoneal hematopoiesis combined with tuberculosis in a patient with primary myelofibrosis.

Primary myelofibrosis (PMF) is a myeloproliferative disorder characterized by bone marrow fibrosis or dysmegakaryocytes, extramedullary hematopoiesis, and the presence of JAK2 mutations. We present a 73-year-old man with PMF that had a fulminant clinical course. Peritoneal extramedullary hematopoiesis combined with tuberculosis was found 4 months after the diagnosis. This combination of complications has not been previously reported. These events were followed by rapid leukemic transformation and the patient's death.

Significance of small dense low-density lipoproteins as coronary risk factor in diabetic and non-diabetic Korean populations.

Small dense low-density lipoproteins (LDLs) have been associated with coronary heart disease (CHD) and type 2 diabetes in previous studies. However, the significance of small dense LDLs as a coronary risk factor for subjects with type 2 diabetes remains unclear. We measured mean LDL particle diameter by gradient gel electrophoresis (Quantimetrix Lipoprinttrade mark LDL System) in 44 type 2 diabetes patients, 100 CHD patients, 35 CHD patients with type 2 diabetes and 88 age-matched control subjects. Mean LDL particle sizes were significantly smaller (p < 0.05, Mann-Whitney test) in diabetes mellitus-only patients (25.7 +/- 0.8 nm), CHD-only patients (25.2 +/- 1.4 nm), and CHD patients with diabetes mellitus (24.9 +/- 1.6 nm) than in controls (26.2 +/- 1.4 nm). As for the mean LDL particle size, the prevalence of small dense LDLs (mean diameter < or =25.5 nm) was higher (p < 0.05, chi(2) test) in all disease groups than in controls. Furthermore, the LDL particle size in CHD patients with diabetes mellitus (24.9 nm) was significantly smaller (p = 0.049) than in diabetes mellitus-only patients (25.7 nm). Multiple logistic regression analysis revealed that small dense LDL was independently associated with the incidence of CHD in all subjects [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.2-16.1, and OR 4.5, 95% CI 1.2-17.3, p < 0.05]. In this study the LDL particle size did not further decrease in CHD patients even when they had diabetes. However, the presence of CHD affects the LDL particle size in diabetes patients. These results suggest that identifying LDL size as a routine laboratory test could be used as a marker for CHD risk in both diabetic and non-diabetic Korean populations.