Effect of Robot-assisted Surgery on Anesthetic and Perioperative Management for Minimally Invasive Radical Prostatectomy under Combined General and Epidural Anesthesia.

BACKGROUND: Robot-assisted surgery and pure laparoscopic surgery are available for minimally invasive radical prostatectomy (MIRP). The differences in anesthetic management between these two MIRPs under combined general and epidural anesthesia (CGEA) remain unknown. This study therefore aimed to determine the effects of robot-assisted surgery on anesthetic and perioperative management for MIRP under CGEA. METHODS: This retrospective observational study analyzed data from patients' electronic medical records. Data on demographics, intraoperative variables, postoperative complications, and hospital stays after MIRPs were compared between patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) and those treated by pure laparoscopic radical prostatectomy (LRP). RESULTS: There were no differences in background data between the 102 who underwent RALP and 112 who underwent LRP. Anesthesia and surgical times were shorter in the RALP group than in the LRP group. Doses of anesthetics, including intravenous opioids, and epidural ropivacaine, were lower in the RALP group. Although estimated blood loss and volume of colloid infusion were lower in the RALP group, the volume of crystalloid infusion was larger. Intraoperative allogeneic transfusion was not required in either group. There was no difference between groups in the incidences of postoperative cardiopulmonary complications or postoperative nausea and vomiting. Hospital stays after the procedure were shorter in the RALP group. CONCLUSIONS: Robot-assisted surgery required varied consumption of anesthetics and infusion management during MIRP under GCEA. It also shortened postoperative hospital stays, without increasing rates of postoperative complications.

Pregabalin prescription for terminally ill cancer patients receiving specialist palliative care in an acute hospital.

BACKGROUND: Pregabalin is recommended as an adjuvant analgesic for neuropathic cancer-related pain, and may be taken at all steps of the World Health Organization analgesic ladder. However, unlike opioids, pregabalin treatments are limited to an oral administration route. If patients have oral feeding difficulties, it is not possible to administer any drug as an adjuvant analgesic for neuropathic cancer-related pain. Therefore, the aim of the present study was to clarify the problems of pain control after pregabalin discontinuation in terminally ill cancer patients. METHODS: Our subjects comprised cancer patients who died during their hospital stay and were referred between April 2013 and October 2015 to the palliative care team of the 899-bed Cancer Hospital at the Nippon Medical School Hospital in Japan. The medical records of each patient were retrospectively reviewed, and patient characteristics were recorded. RESULTS: We obtained data on 183 patients during the study period. Thirty-eight (20.8 %) patients were treated with pregabalin. Thirty-three (86.8 %) out of 38 patients were prescribed pregabalin for neuropathic cancer-related pain. The incidence of bony metastases was significantly higher in patients administered pregabalin than in those not taking the drug (non-pregabalin group 32.4 % vs pregabalin group 57.9 %). Pregabalin was ultimately discontinued in all patients, with the main reason being oral feeding difficulties (81.6 %). After the discontinuation of pregabalin, the amount of opioid drugs administered was increased in 56.5 % of patients with oral feeding difficulties. CONCLUSION: Our results demonstrated that the amount of opioid drugs administered was increased in more than 50 % of patients following the discontinuation of pregabalin, and was repeatedly increased for some patients. A new administration route is required for cancer patients unable to take oral medication. TRIAL REGISTRATION: UMIN000022507. May 28, 2016 retrospectively registered.

[Anesthetic Management for Cervicomedullary Decompression in a Patient with Achondroplasia--A Case Report].

This is a case report of a 42-year-old man who underwent suboccipital craniectomy and C-1 laminoplasty under general anesthesia. His weight and height were 32 kg and 110 cm, respectively. The patient had short limbs, a protruding forehead, a large tongue, and a short neck. Preoperative magnetic resonance imaging showed marked stenosis of the foramen magnum and cervicomedullary compression and malacia, with the smallest anteroposterior diameter of 4.5 mm. Mask ventilation and tracheal intubation were not feasible; therefore, an Airtraq® laryngoscope and a bronchial fiberscope were used. Anesthesia was maintained with propofol, remifentanil, and fentanyl. After intubation and postural change, the patient was awakened, and we confirmed the absence of any limb movement disorder. Intraoperative motor evoked potentials were normal. After extubation, he experienced numbness of the limbs. Postoperative magnetic resonance imaging revealed an enlargement of the foramen magnum and the foramen of the atlas. However, the cervicomedullary malacia remained unchanged. The cause of numbness was unknown. After rehabilitation, he became ambulatory and could walk continuously for about 300 m at a slow pace.

Safety and efficacy of oral rehydration therapy until 2 h before surgery: a multicenter randomized controlled trial.

PURPOSE: In many countries, patients are generally allowed to have clear fluids until 2-3 h before surgery. In Japan, long preoperative fasting is still common practice. To shorten the preoperative fasting period in Japan, we tested the safety and efficacy of oral rehydration therapy until 2 h before surgery. METHODS: Three hundred low-risk patients scheduled for morning surgery in six university-affiliated hospitals were randomly assigned to an oral rehydration solution (ORS) group or to a fasting group. Patients in the ORS group consumed up to 1,000 ml of ORS containing balanced glucose and electrolytes: 500 ml between 2100 the night before surgery and the time they woke up the next morning and 500 ml during the morning of surgery until 2 h before surgery. Patients in the fasting group started fasting at 2100 the night before surgery. Primary endpoints were gastric fluid volume and pH immediately after anesthesia induction. Several physiological measures of hydration and electrolytes including the fractional excretion of sodium (FENa) and the fractional excretion of urea nitrogen (FEUN) were also evaluated. RESULTS: Mean (SD) gastric fluid volume immediately after anesthesia induction was 15.1 (14.0) ml in the ORS group and 17.5 (23.2) ml in the fasting group (P = 0.30). The mean difference between the ORS group and fasting group was -2.5 ml. The 95% confidence interval ranged from -7.1 to +2.2 ml and did not include the noninferior limit of +8 ml. Mean (SD) gastric fluid pH was 2.1 (1.9) in the ORS group and 2.2 (2.0) in the fasting group (P = 0.59). In the ORS group, mean FENa and FEUN immediately after anesthesia induction were both significantly greater than those in the fasting group (P < 0.001 for both variables). The ORS group reported they had been less thirsty and hungry before surgery (P < 0.001, 0.01). CONCLUSIONS: Oral rehydration therapy until 2 h before surgery is safe and feasible in the low-risk Japanese surgical population. Physicians are encouraged to use this practice to maintain the amount of water in the body and electrolytes and to improve the patient's comfort.

Effect of L-canavanine, an Inhibitor of inducible nitric oxide synthase, on myocardial dysfunction during septic shock.

Overproduction of nitric oxide (NO) by inducible NO synthase (iNOS) plays a role in the pathophysiology of septic shock. The depression of cardiac contractility in such situations is mediated by proinflammatory cytokines, including interleukin-1beta (IL-1beta), and tumor necrosis factor-alpha (TNF-alpha). The effects of two NOS inhibitors with different isoform selectivity were compared in isolated working rat hearts. The depression of contractility by IL-1beta and TNF-alpha was prevented by administration of a nonselective nitric oxide synthase inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME) or an inhibitor of inducible nitric oxide synthase, L-canavanine. In contrast, when L-NAME was administered in the absence of IL-1beta and TNF-alpha, it depressed contractility over the 2h perfusion period by significantly reducing coronary flow. These results support current thinking that the depression of myocardial function by IL-1beta and TNF-alpha is mediated, at least in part, by an intracardiac increase in inducible nitric oxide synthase, and that in contrast to L-NAME, the decline in coronary conductance seen in cytokine-treated is not prevented by L-canavanine hearts. L-canavanine shows selective inhibition of inducible nitric oxide synthase unlike the vasopressor action of L-NAME in cytokine-treated hearts.