Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy.

BACKGROUND: General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery. METHODS: In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared. RESULTS: Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively. CONCLUSIONS: Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

Positive end-expiratory pressure during one-lung ventilation for preventing atelectasis after video-assisted thoracoscopic surgery: a triple-arm, randomized controlled trial.

BACKGROUND: There is little evidence regarding the benefits of lung-protective ventilation in patients undergoing one-lung ventilation for thoracic surgery. This study aimed to determine the optimal level of positive end-expiratory pressure (PEEP) during one-lung ventilation for minimizing postoperative atelectasis through lung ultrasonography. METHODS: A total of 142 adult patients scheduled for video-assisted thoracoscopic surgery at Seoul National University Hospital between May 2019 and February 2020 were enrolled in this study. Patients were randomly assigned to different groups: 1) PEEP 3 cmH2O group; 2) PEEP 6 cmH2O group; and 3) PEEP 9 cmH2O group during one-lung ventilation. The lung ultrasound score was used to evaluate lung aeration using ultrasonography 1 hour after surgery. RESULTS: The 1-hour post-surgery lung ultrasound scores were 8.1±2.5, 6.8±2.6, and 5.9±2.6 in the PEEP 3, 6, and 9 cmH2O groups, respectively (P<0.001). The PEEP 3 cmH2O group showed significantly higher lung ultrasound scores than the PEEP 6 (adjusted P=0.034) and 9 cmH2O groups (adjusted P<0.001). The PaO2/FiO2 ratio measured at 10 minutes after the end of one-lung ventilation was significantly lower in the PEEP 3 cmH2O group (392 [331 to 469]) than the PEEP 6 cmH2O (458 [384 to 530], adjusted P=0.018) or PEEP 9 cmH2O groups (454 [374 to 522], adjusted P=0.016). CONCLUSIONS: Although the optimal level of PEEP during one-lung ventilation was not determined, the application of higher PEEP can prevent aeration loss in the ventilated lung after video-assisted thoracoscopic surgery under one-lung ventilation.

Genetic landscape and PD-L1 expression in Epstein-Barr virus-associated gastric cancer according to the histological pattern.

Epstein-Barr virus (EBV)-associated gastric cancer (EBVaGC) is a distinct molecular subtype of gastric cancer. This study aims to investigate genomic and clinicopathological characteristics of EBVaGC according to the histological pattern. We retrospectively collected 18 specimens of surgically resected EBVaGCs. Whole-exome sequencing was performed for all cases. Moreover, PD-L1 expression and tumor-infiltrating lymphocyte (TIL) percentage were investigated. Among 18 EBVaGCs, 10 cases were of intestinal histology, 3 were of poorly cohesive histology, and the remaining 5 were of gastric carcinoma with lymphoid stroma histology. Whole-exome sequencing revealed that EBVaGCs with intestinal histology harbored pathogenic mutations known to frequently occur in tubular or papillary adenocarcinoma, including TP53, KRAS, FBXW7, MUC6, ERBB2, CTNNB1, and ERBB2 amplifications. One patient with poorly cohesive carcinoma histology harbored a CDH1 mutation. Patients with EBVaGCs with intestinal or poorly cohesive carcinoma histology frequently harbored driver mutations other than PIK3CA, whereas those with EBVaGCs with gastric carcinoma with lymphoid stroma histology lacked other driver mutations. Moreover, the histological pattern of EBVaGCs was significantly associated with the levels of TILs (P = 0.005) and combined positive score (P = 0.027). In conclusion, patients with EBVaGCs with different histological patterns exhibited distinct genetic alteration, PD-L1 expression, and degree of TILs.

Pleth variability index during preoxygenation could predict anesthesia-induced hypotension: A prospective, observational study.

STUDY OBJECTIVE: To determine whether changes in the pleth variability index (PVi) during preoxygenation with forced ventilation for 1 min could predict anesthesia-induced hypotension. DESIGN: Prospective, observational study. SETTING: A tertiary teaching hospital. PATIENTS: Ninety-six patients who underwent general anesthesia using total intravenous anesthesia were enrolled. INTERVENTIONS: Upon the patient's arrival at the preoperative waiting area, a PVi sensor was affixed to their fourth fingertip. For preoxygenation, forced ventilation of 8 breaths/min in a 1:2 inspiratory-expiratory ratio was conducted using the guidance of an audio file. One minute after preoxygenation, anesthetic administration was initiated. Blood pressure was measured for the next 15 min. MEASUREMENTS: We calculated the difference (dPVi) and percentage of change (%PVi) between the PVi values immediately before and after forced ventilation. Anesthesia-induced hypotension was defined as a mean arterial pressure of <60 mmHg within 15 min after the infusion of anesthetics. MAIN RESULTS: Overall, 87 patients were included in the final analysis. Anesthesia-induced hypotension occurred in 31 (35.6%) of the 87 patients. Receiver operating characteristic curve analyses identified a cut-off value of -2 for dPVi, with an area under the curve of 0.691 (95% confidence interval [CI], 0.564-0.818; P < 0.001) and a cut-off value of -7.6% for %PVi, with an area under the curve of 0.711 (95% CI, 0.589-0.832; P < 0.001). Further, multivariate logistic regression analysis showed that a low %PVi with an odds ratio of 9.856 (95% CI, 3.131-31.032; P < 0.001) was a significant determinant of anesthesia-induced hypotension. CONCLUSIONS: Hypotension frequently occurs during general anesthesia induction and can impact outcomes. Additionally, the percentage change in the PVi before and after preoxygenation using deep breathing can be used to predict anesthesia-induced hypotension.

Neuromuscular blocking agent re-exposure in a retrospective cohort with neuromuscular blocking agent-associated anaphylaxis.

BACKGROUND: Neuromuscular blocking agents (NMBAs) are one of the most common causes of perioperative anaphylaxis. Although skin test positivity may help identify reactive NMBAs, it is unclear whether skin test negativity can guarantee the safety of systemically administered NMBAs. OBJECTIVE: This study aimed to evaluate the real-world safety of alternative NMBAs screened using skin tests in patients with suspected NMBA-induced anaphylaxis. METHODS: A retrospective cohort of suspected NMBA-induced anaphylaxis were recruited among patients at Seoul National University Hospital from June 2009 to May 2021, and their characteristics and outcomes were assessed. RESULTS: A total of 47 cases (0.017%) of suspected anaphylaxis occurred in 282,707 patients who received NMBAs. Cardiovascular manifestations were observed in 95.7%, whereas cutaneous findings were observed in 59.6%. Whereas 83% had a history of undergoing general anesthesia, 17% had no history of NMBA use. In skin tests, the overall positivity to any NMBA was 94.6% (81.1% to culprit NMBAs) and the cross-reactivity was 75.7%, which is related to the chemical structural similarity among NMBAs; the cross-reactivity and chemical structure similarity of rocuronium were 85.3% and 0.814, respectively, with vecuronium; this is in contrast to 50% and 0.015 with cisatracurium and 12.5% and 0.208 with succinylcholine. There were 15 patients who underwent subsequent surgery with a skin test-negative NMBA; whereas 80.0% (12/15) safely completed surgery, 20.0% (3/15) experienced hypotension. CONCLUSION: Similarities in chemical structure may contribute to the cross-reactivity of NMBAs in skin tests. Despite the high negative predictability of skin tests for suspected NMBA-induced anaphylaxis, the potential risk of recurrent anaphylaxis has not been eliminated.

Comparison of the recovery profile of remimazolam with flumazenil and propofol anesthesia for open thyroidectomy.

BACKGROUND: Previous studies have consistently reported a slower recovery of consciousness following remimazolam-based total intravenous anesthesia without flumazenil than with propofol. This study aimed to compare the reversal effect of flumazenil on the recovery of consciousness after remimazolam-based total intravenous anesthesia with the propofol recovery profile. METHODS: This prospective, single-blinded, randomized trial included 57 patients undergoing elective open thyroidectomy at a tertiary university hospital. Patients were randomly allocated to receive either remimazolam- or propofol-based total intravenous anesthesia (remimazolam group: 28 patients, propofol group: 29 patients). The primary outcome was the time from the end of general anesthesia to first eye opening (min). The secondary outcomes were the time from the end of the general anesthesia to extubation (min), initial modified Aldrete score measured at the post-anesthesia care unit, length of stay at the post-anesthesia care unit (min), occurrence of postoperative nausea and vomiting during the first 24 h postoperatively, and Korean version of Quality of Recovery-15 score at 24 h postoperatively. RESULTS: The remimazolam group showed significantly faster first eye opening time (2.3 [interquartile range, IQR: 1.8-3.3] min vs. 5.0 [IQR: 3.5-7.8] min, median difference:-2.7 [95% confidence interval, CI: -3.7 to -1.5] min, P < 0.001) and extubation time (3.2 [IQR: 2.4-4.2] min vs. 5.7 [IQR: 4.7-8.3] min, median difference: -2.7 [97.5% CI: -5.0 to -1.6] min, P < 0.001). There were no significant differences in other postoperative outcomes. CONCLUSIONS: The planned incorporation of flumazenil with remimazolam-based total intravenous anesthesia provided rapid and reliable recovery of consciousness.

Efficacy of high-flow nasal oxygenation compared with tracheal intubation for oxygenation during laryngeal microsurgery: a randomised non-inferiority study.

BACKGROUND: Oxygenation via a high-flow nasal cannula (HFNC) can be an alternative to tracheal intubation during short apnoeic procedures. This randomised, non-inferiority study assessed the efficacy of HFNC compared with tracheal intubation in laryngeal microsurgery. METHODS: Patients (≥20 yr old) undergoing laryngeal microsurgery under general anaesthesia and neuromuscular blockade were randomised to either the HFNC or tracheal intubation groups. The primary endpoint was lowest pulse oxygen saturation (SpO2) during the first 30 min of surgery. Secondary endpoints included incidence of desaturation (SpO2 <95%), hypercarbia (transcutaneous carbon dioxide [CO2] ≥8.7 kPa), and rescue intervention. RESULTS: Amongst 130 patients randomised, 118 were included in the analysis. The lowest SpO2 was 100 (98-100)% in the HFNC group (n=56) and 100 (100-100)% in the tracheal intubation group (n=62), with a mean difference of -1.4% (95% confidence interval: -2.4% and -0.3%), failing to confirm non-inferiority with a non-inferiority margin of 2%. The peak transcutaneous CO2 and end-tidal CO2 at the end of surgery were higher in the HFNC group compared with the tracheal intubation group. Incidences of desaturation, hypercarbia, and rescue intervention were more frequent in patients receiving HFNC compared with tracheal intubation. CONCLUSIONS: HFNC oxygenation was not non-inferior to tracheal intubation for maintaining oxygen saturation during laryngeal microsurgery. Considering more frequent desaturation, hypercarbia, and requirement for rescue intervention compared with tracheal intubation, HFNC should be used with cautious monitoring even for short duration airway surgery. CLINICAL TRIAL REGISTRATION: NCT03629353.

Repeated intermittent hypoxic stimuli to operative lung reduce hypoxemia during subsequent one-lung ventilation for thoracoscopic surgery: A randomized controlled trial.

BACKGROUND: An intervention to potentiate hypoxic pulmonary vasoconstriction may reduce intrapulmonary shunt and hypoxemia during one-lung ventilation. Previous animal studies reported that repeated intermittent hypoxic stimuli potentiated hypoxic pulmonary vasoconstriction, but no clinical study has examined the effects of this intervention on hypoxemia during one-lung ventilation. We thus performed a single-center, parallel-group, double-blind, randomized controlled trial to investigate whether repeated intermittent hypoxic stimuli to the operative lung reduce hypoxemia during the subsequent one-lung ventilation for thoracoscopic surgery. METHODS: Patients undergoing one-lung ventilation were randomized into two groups (n = 68 each). Before one-lung ventilation, in the intermittent hypoxia group, the nondependent lung was not ventilated for 2 min and then ventilated for 2 min while the dependent lung was continuously ventilated. This was repeated five times. In the continuous normoxia group, both lungs were ventilated for 20 min. We measured SpO2, PaO2, FiO2, PaCO2, SaO2, and central venous oxygen saturation during one-lung ventilation. The primary outcome was the number of patients with hypoxemia defined as a SpO2 <95% during one-lung ventilation, which was analyzed with a chi-squared test. RESULTS: Hypoxemia was less frequent in the intermittent hypoxia group than in the continuous normoxia group during OLV [6/68 (8.8%) vs 17/68 (25.0%), risk ratio (95% CI) 0.35 (0.15-0.84), p = 0.012]. The PaO2 (p = 0.008 for 30 min and 0.007 for 60 min) and PaO2/FiO2 (p = 0.008 for both) were higher 30 and 60 min after starting one-lung ventilation, and the alveolar-arterial pressure gradient (p = 0.010) and shunt index (p = 0.008) were lower 30 min after starting one-lung ventilation in the intermittent hypoxia group than in the continuous normoxia group. Postoperative adverse events did not differ significantly between groups. CONCLUSIONS: Repeated intermittent hypoxic stimuli to the operative lung seemed to potentiate hypoxic pulmonary vasoconstriction, and thus reduced hypoxemia during the subsequent one-lung ventilation.

Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Epidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural analgesia before thoracotomy incision reduces acute and chronic post-thoracotomy pain in adults compared with epidural analgesia after incision. METHODS: We searched databases including MEDLINE, Embase, and CENTRAL for randomized controlled trials comparing epidural analgesia initiated before (pre-emptive group) and after (control group) thoracotomy incision in adults. The primary outcomes were the pain intensity during rest and coughing within 72 hours after surgery and the incidence of pain 1 to 6 months after surgery. Data were combined with random-effects meta-analyses. We rated the quality of evidence as high, moderate, low, and very low using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. RESULTS: We included 19 trials with 1062 participants involving 529 in the pre-emptive group and 533 in the control group. The pain intensity was significantly lower at rest within 72 hours after surgery (19 studies, n=1062) and during coughing within 48 hours after surgery (11 studies, n=638), and the incidence of pain was significantly lower 1 to 6 months after surgery (6 studies, n=276) in the pre-emptive group than in the control group. The quality of evidence was moderate or low in the primary outcomes. CONCLUSIONS: Our review provides low-quality evidence that pre-emptive epidural analgesia reduces the intensity of acute pain and the incidence of chronic pain after thoracotomy in adults. PROTOCOL REGISTRATION NUMBER: CRD42019131620.

Establishment of Novel Intraoperative Monitoring and Mapping Method for the Cavernous Nerve During Robot-assisted Radical Prostatectomy: Results of the Phase I/II, First-in-human, Feasibility Study.

BACKGROUND: Potency preservation often does not meet expectation despite nerve-sparing prostatectomy. OBJECTIVE: To set the protocol for intraoperative cavernous nerve monitoring and mapping during robot-assisted radical prostatectomy (RARP), and to evaluate its safety and clinical feasibility. DESIGN, SETTING, AND PARTICIPANTS: A prospective phase I/II, feasibility study was performed. A total of 30 patients with prostate cancer who underwent RARP at a high-volume tertiary academic hospital were enrolled. SURGICAL PROCEDURE: Pudendal somatosensory evoked potential, bulbocavernosus reflex, spontaneous corpus cavernosum electromyography (CC-EMG), median nerve stimulation evoked CC-EMG, and neurovascular bundle (NVB)-triggered CC-EMG with various stimulation protocols were assessed during conventional RARP under total intravenous anesthesia with controlled muscle relaxation. MEASUREMENTS: The primary endpoint was the completion rate of planned surgery and assessment. Adverse events, and erectile and urinary functions were evaluated within 1 yr. CC-EMGs were graded and correlated with functional outcomes. RESULTS AND LIMITATIONS: The completion rate was 100%. Only one patient experienced adverse events, which were not related to study intervention. Grades of CC-EMGs including NVB-triggered CC-EMG before prostate removal were associated with baseline five-item International Index of Erectile Function (IIEF-5) score (grades 0-1, 4.6±2.7; grade 2, 13.2±6.8; grades 3-4, 16.6±5.9; p=0.003). Furthermore, grades of CC-EMGs including NVB-triggered CC-EMG after prostate removal were significantly associated with potency recovery (grade 0, 12.5%; grade 1, 0%; grade 2, 33.3%; grades 3-4, 100% at 12 mo; p=0.005) and postoperative IIEF-5 scores at all evaluation time points (grades 0-1, 2.6±2.8; grade 2, 4.3±5.8; grades 3-4, 15.7±11.0 at 12 mo; p=0.003). CONCLUSIONS: We successfully established the protocol for safe intraoperative cavernous nerve monitoring and mapping using CC-EMG during RARP. Its grades were well correlated with erectile function. PATIENT SUMMARY: In this first-in-human feasibility study, we successfully established the protocol for safe intraoperative cavernous nerve monitoring and mapping method during robot-assisted radical prostatectomy. The results were significantly associated with erectile function. Evaluation of clinical efficacy to preserve potency seems worthy of further optimization and investigation in confirmatory clinical trials.

Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy.

PURPOSE: The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy. MATERIALS AND METHODS: Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10-30 mA intensity, 4 trains, 1,000 µs/train, and 5× frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively. RESULTS: Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed. CONCLUSIONS: Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0000823.

Intravenous Oxycodone Versus Other Intravenous Strong Opioids for Acute Postoperative Pain Control: A Systematic Review of Randomized Controlled Trials.

INTRODUCTION: Optimal pain management is crucial to the postoperative recovery process. We aimed to evaluate the efficacy and safety of intravenous oxycodone with intravenous fentanyl, morphine, sufentanil, pethidine, and hydromorphone for acute postoperative pain. METHODS: A systematic literature search of PubMed, Cochrane Library, and EMBASE databases was performed for randomized controlled trials published from 2008 through 2017 (inclusive) that evaluated the acute postoperative analgesic efficacy of intravenous oxycodone against fentanyl, morphine, sufentanil, pethidine, and hydromorphone in adult patients (age ≥ 18 years). Outcomes examined included analgesic consumption, pain intensity levels, side effects, and patient satisfaction. RESULTS: Eleven studies were included in the review; six compared oxycodone with fentanyl, two compared oxycodone with morphine, and three compared oxycodone with sufentanil. There were no eligible studies comparing oxycodone with pethidine or hydromorphone. Overall, analgesic consumption was lower with oxycodone than with fentanyl or sufentanil. Oxycodone exhibited better analgesic efficacy than fentanyl and sufentanil, and comparable analgesic efficacy to morphine. In terms of safety, there was a tendency towards more side effects with oxycodone than with fentanyl, but the incidence of side effects with oxycodone was comparable to morphine and sufentanil. Where patient satisfaction was evaluated, higher satisfaction levels were observed with oxycodone than with sufentanil and comparable satisfaction was noted when comparing oxycodone with fentanyl. Patient satisfaction was not evaluated in the studies comparing oxycodone with morphine. CONCLUSIONS: Our findings suggest that intravenous oxycodone provides better analgesic efficacy than fentanyl and sufentanil, and comparable efficacy to morphine with less adverse events such as sedation. No studies comparing intravenous oxycodone with pethidine or hydromorphone were identified in this review. Better alignment of study methodologies for future research in this area is recommended to provide the best evidence base for a meta-analysis. FUNDING: Mundipharma Singapore Holding Pte Ltd, Singapore.

Cardiopulmonary Bypass Strategies to Maintain Brain Perfusion during Lung Transplantation in a Patient with Severe Hypercapnia.

Herein, we report a case of lung transplantation in a patient with profound preoperative hypercapnia, focusing on the cardiopulmonary bypass strategy used for brain perfusion during the operation. We applied the pH-stat method for acid-base regulation, and thereby achieved the desired outcome without any neurologic deficit.

Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients With Normal Airways.

BACKGROUND: During induction of general anesthesia, it is common practice to delay neuromuscular blockade until the ability to deliver mask ventilation has been confirmed. However, the benefits of this approach have never been scientifically validated. We thus compared the early and late administration of rocuronium before and after checking mask ventilation to investigate the efficiency of mask ventilation and the time to tracheal intubation in patients with normal airways. METHODS: Patients (n = 114) were randomized to receive IV rocuronium either before (early rocuronium group, n = 58) or after (late rocuronium group, n = 56) checking mask ventilation. Expiratory tidal volumes (VTs) were measured at 10, 20, 30, 40, 50, and 60 seconds after apnea during mask ventilation. We graded the ease of mask ventilation and measured the time from apnea to tracheal intubation. The primary outcome was the average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea. The main secondary outcome was the time from apnea to tracheal intubation. STATA was used for statistical analysis. RESULTS: The average of mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea was larger in the early rocuronium group than in the late rocuronium group (552 mL breath [165 mL breath] vs 393 mL breath [165 mL breath], mean difference, 160 mL breath; 95% CI, 98-221 mL breath; P < .001, unpaired t test). Because the interaction between time and group was significant in mask VTs measured at 10, 20, 30, 40, 50, and 60 seconds after apnea (P < .001, linear mixed effects model), pairwise comparisons were performed at the 6 time points. The differences in VTs between the groups were significant at 10, 20, 30, 40, and 50 seconds after apnea (P < .001 each, contrast statements in STATA). The time from apnea to tracheal intubation was shorter in the early rocuronium group than in the late rocuronium group (116 seconds [42 seconds] vs 195 seconds [41 seconds]; mean difference, -79 seconds; 95% CI, -96 to -64 seconds, P < .001). CONCLUSIONS: The early administration of rocuronium before checking mask ventilation resulted in a larger mask VT and earlier tracheal intubation than the late administration of rocuronium after checking mask ventilation in patients with normal airways.

Augmentation of curved tip of left-sided double-lumen tubes to reduce right bronchial misplacement: A randomized controlled trial.

BACKGROUND: During intubation with a blind technique, a left-sided double-lumen tube (DLT) can be misdirected into the right bronchus even though its curved tip of the bronchial lumen turns to the left. This right bronchial misplacement may be associated with the tip angle of DLTs. We thus performed a randomized trial to test the hypothesis that the DLT with an acute tip angle enters the right bronchus less frequently than the tube with an obtuse tip angle. METHODS: We randomized surgical patients (n = 1427) receiving a polyvinyl chloride left-sided DLT. Before intubation, the curved tip was further bent to an angle of 135° and kept with a stylet inside in the curved-tip group, but not in the control group. After the tip was inserted into the glottis under direct or video laryngoscopy, the stylet was removed and the DLT was advanced into the bronchus with its tip turning to the left. We checked which bronchus was intubated, and the time and number of attempts for intubation. After surgery, we assessed airway injury, sore throat, and hoarseness. The primary outcome was the incidence of right bronchial misplacement of the DLT. RESULTS: DLTs were misdirected into the right bronchus more frequently in the control group than in the curved-tip group: 57/715 (8.0%) vs 17/712 (2.4%), risk ratio (95% CI) 3.3 (2.0-5.7), P < 0.001. The difference was significant in the use of 32 (P = 0.003), 35 (P = 0.007), and 37 (P = 0.012) Fr DLTs. Intubation required longer time (P < 0.001) and more attempts (P = 0.002) in the control group. No differences were found in postoperative airway injury, sore throat and hoarseness. CONCLUSIONS: Before intubation of left-sided DLTs, augmentation of the curved DLT tip reduced the right bronchial misplacement and facilitated intubation without aggravating airway injury.

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.

Tracheal tubes lubricated with water to reduce sore throat after intubation: A randomized non-inferiority trial.

BACKGROUND: Sore throat is common after tracheal intubation. Water can be used to lubricate tracheal tubes, but its benefit has not been validated. We thus did a randomised non-inferiority trial to test the hypothesis that a tube lubricated with water does not reduce sore throat after tracheal intubation. METHODS: We randomized female or male patients (n = 296) undergoing surgery in the ears or eyes to receive either a tube lubricated with water or a tube without lubrication for intubation. We assessed sore throat at 0, 2, 4, and 24 h after surgery; pharyngeal injury at 2 and 24 h after surgery; and respiratory infections within 7 days after surgery. For the incidence of sore throat within 24 h after surgery (primary outcome), the two-sided 90% confidence interval of the risk difference was compared with the prespecified non-inferiority margin of 15%. Other outcomes were analyzed with two-sided superiority tests. RESULTS: The incidence of sore throat within 24 h after surgery was 80/147 (54.4%) in the non-lubricated tube group and 83/149 (55.7%) in the water-lubricated tube group (risk difference -1.3%, 90% confidence interval -10.9% to 8.3%). Because the confidence interval was below the non-inferiority margin, the incidence of sore throat was not higher in the non-lubricated tube group than in the water-lubricated tube group. There was no significant association between groups in the sore throat, pharyngeal injury, and respiratory infection at each assessment time. CONCLUSIONS: The tube lubricated with water did not reduce sore throat and pharyngeal injury after tracheal intubation compared to the tube without lubrication.