Comparative study on the impact of remimazolam and sevoflurane on quality of recovery after transurethral resection of bladder tumor: A randomized controlled noninferiority study.

BACKGROUND: Remimazolam is manifested by rapid action, hemodynamic stability, and fast recovery. Our study aimed to investigate whether the quality of recovery (QoR) after remimazolam anesthesia in patients undergoing transurethral resection of bladder tumor, which is predominantly performed in the elderly population, is not inferior to that after conventional anesthesia using sevoflurane. METHODS: Thirty-four patients were randomly allocated into either of group S (n = 17, receiving sevoflurane anesthesia), or group R (n = 17, receiving remimazolam anesthesia). The QoR was assessed by Korean version of QoR-15 questionnaire, on the day before and after the surgery. Scores acquired for each individual item, QoR-15 scores categorized into 5 dimensions (physical comfort, physical independence, psychological support, emotional state, and pain), and overall global score were subjected to comparative analysis. The primary outcome was postoperative global QoR-15, and a noninferiority delta value of 8.0 was employed. RESULTS: The postoperative global QoR-15 in the group S was 141 (134-146), and in the groups R was 133 (128-142) (P = .152). The mean difference of global QoR-15 (group S-group R) was 1.471 (95% confidence interval of -10.204 to 13.146), and the lower 95% confidence interval margin was lower than the noninferiority margin of -8.0. When comparing the QoR-15 sorted by 5 dimensions, pain scored higher in the group S (20 [18-20]) compared to the group R (15 [15-20], P = .032). CONCLUSION: The postoperative QoR following transurethral resection of bladder tumor was found to be lower in patients anesthetized with remimazolam in comparison to those anesthetized with sevoflurane.

Nefopam as a multimodal analgesia in thoracoscopic surgery: a randomized controlled trial.

Background: Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure. However, some patients still experience severe pain after VATS. Pain after VATS can disturb deep breathing and coughing, and can increase postoperative pulmonary complications. Therefore, multidisciplinary pain management is emphasized for enhanced recovery after VATS. Nefopam is a centrally-acting, non-opioid, non-steroidal analgesic drug, and its pain reduction effect in many surgeries has been reported. We sought to determine whether administration of nefopam is effective as multimodal analgesia in VATS. Methods: This study enrolled patients aged 19 years or older, and scheduled for elective VATS lobectomy with American Society of Anesthesiologists (ASA) physical class I-III. Forty-six participants were randomly divided into a group receiving nefopam (group N), and a control group (group O) in a 1:1 ratio. The study participants, and the researcher collecting the data were blinded to the group allocation. For the group N, nefopam 20 mg was administered before surgical incision and also at the end of surgery while chest tube was inserted. For the group O, normal saline 100 mL was administered. The primary outcome of this study was the pain score, by verbal numerical rating scale, at rest and upon coughing. Results: Forty-five participants (group N =22, group O =23) were involved in the statistical analysis. Nefopam reduced pain at rest at 0 h [8 (IQR, 5-10) vs. 4 (IQR, 2-7), P=0.01], and at 0-1 h [5 (IQR, 5-8) vs. 3 (IQR, 2-5), P=0.001]. Pain upon coughing decreased with nefopam at 0 h [9 (IQR, 6-10) vs. 6 (IQR, 2-8), P=0.009], 0-1 h [6 (IQR, 5-8) vs. 5 (IQR, 2-6), P=0.001], and at 12-24 h [4 (IQR, 3-7) vs. 3 (IQR, 1-4), P=0.03]. Injection of 20 mg of nefopam before incision and at the end of surgery relieved postoperative pain at 0 h, 1 h at rest and at 0 h, 1 h, 12-24 h with coughing after VATS. Conclusions: Therefore, nefopam can serve as a useful component of multimodal analgesia for pain management after VATS. Trial Registration: ClinicalTrials.gov (NCT05173337).

A comparative study using gastric ultrasound to evaluate the safety of shortening the fasting time before pediatric echocardiography: a randomized controlled non-inferiority study.

PURPOSE: The objective of this study was to demonstrate that the gastric cross-sectional area (CSA) in the right lateral decubitus position (RLDP) during a 2-h fasting period is not larger than that during a conventional 4-h fasting period prior to pediatric echocardiography. METHODS: 93 patients aged under 3 years scheduled for echocardiography under sedation were enrolled and randomly allocated into two groups; 2-h fasting vs 4-h fasting. For group 4 h (n = 46), the patients were asked to be fasted for all types of liquid for more than 4 h, while group 2 h (n = 47) were asked to be fasted for all types of liquid for 2 h before echocardiography. Gastric ultrasound was performed before echocardiography, and CSARLDP was measured. We compared CSARLDP, incidence of at-risk stomach, fasting duration, and the incidence of major (pulmonary aspiration, aspiration pneumonia) and minor complications (nausea, retching, and vomiting, apnea, and bradycardia) between two groups. RESULTS: The mean difference of CSARLDP (group 2 h-group 4 h) was 0.49 (- 0.18 to 1.17) cm2, and it was within the non-inferiority margin (Δ = 2.1 cm2). There was no difference in the incidence of at-risk stomach (P = 0.514). There was no significant difference in the incidence of major and minor complications between the two groups. CONCLUSION: Two-hour fasting in pediatric patients who need an echocardiography did not increase major and minor complications and CSA significantly.

Dynamic Arterial Elastance as a Predictor of Supine-to-Prone Hypotension (SuProne Study): An Observational Study.

Background and Objectives: Supine-to-prone hypotension is caused by increased intrathoracic pressure and decreased venous return in the prone position. Dynamic arterial elastance (Eadyn) indicates fluid responsiveness and can be used to predict hypotension. This study aimed to investigate whether Eadyn can predict supine-to-prone hypotension. Materials and Methods: In this prospective, observational study, 47 patients who underwent elective spine surgery in the prone position were enrolled. Supine-to-prone hypotension is defined as a decrease in Mean Arterial Pressure (MAP) by more than 20% in the prone position compared to the supine position. Hemodynamic parameters, including systolic blood pressure (SAP), diastolic blood pressure, MAP, stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index, cardiac index, dP/dt, and hypotension prediction index (HPI), were collected in the supine and prone positions. Supine-to-prone hypotension was also assessed using two different definitions: MAPprone < 65 mmHg and SAPprone < 100 mmHg. Hemodynamic parameters were analyzed to determine the predictability of supine-to-prone hypotension. Results: Supine-to-prone hypotension occurred in 13 (27.7%) patients. Eadyn did not predict supine-to-prone hypotension [Area under the curve (AUC), 0.569; p = 0.440]. SAPsupine > 139 mmHg (AUC, 0.760; p = 0.003) and dP/dtsupine > 981 mmHg/s (AUC, 0.765; p = 0.002) predicted supine-to-prone hypotension. MAPsupine, SAPsupine, PPVsupine, and HPIsupine predicted MAPprone <65 mm Hg. MAPsupine, SAPsupine, SVVsupine, PPVsupine, and HPIsupine predicted SAPprone < 100 mm Hg. Conclusions: Dynamic arterial elastance did not predict supine-to-prone hypotension in patients undergoing spine surgery. Systolic arterial pressure > 139 mmHg and dP/dt > 981 mmHg/s in the supine position were predictors for supine-to-prone hypotension. When different definitions were employed (mean arterial pressure < 65 mmHg in the prone position or systolic arterial pressure < 100 mmHg in the prone position), low blood pressures in the supine position were related to supine-to-prone hypotension.

Association between body composition and chronic low back pain in Korean adults aged over 50 years: The Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2011.

Background The relationship between overweight or obesity and low back pain (LBP) has previously been investigated. Several recent studies have focused on the relationship between other indicators of obesity, particularly indicators of fat and the risk of LBP. However, the results of body composition and LBP have been inconsistent. Methods All data for the present retrospective, cross-sectional study was extracted from the Korea National Health and Nutrition Examination Survey (KNHANES) versions V-1 and 2 conducted in 2010 and 2011 by the Korean Centers for Disease Control and Prevention. In KNHANES V-1 (2010) and V-2 (2011), those over 50 years of age completed the surveys on LBP, body weight, and body composition assessed using dual-energy X-ray absorptiometry (DXA) were included. The multivariable logistic regression analysis was used to examine the relationship between the presence of chronic LBP and body composition adjusting for confounders. Results We analyzed 3,579 persons who completed the question. In the multivariable analyses adjusting for age and sex, none of the variables, including fat mass and fat-free mass, remained positively or negatively associated with LBP. Additionally, when depression, smoking, alcohol intake, physical activity, diabetes mellitus, and fat or lean tissue mass were included in the multivariable logistic model, no significant associations were found between all measures of fat mass, fat-free mass, and LBP Conclusion This study is contrary to previous studies that concluded that there is a correlation between obesity and fat mass and LBP. LBP is not associated with increased levels of obesity and fat mass.

Differences in preoperative gastric ultrasound findings in elderly compared to the mid-aged surgical patients: A retrospective observational study.

This study aimed to compare gastric ultrasound assessments between young and elderly patients, to determine whether the cross-section area (CSA) cutoff values for elderly and young patients should be different, and to suggest CSA cutoff values for elderly patients. This study evaluated the data of 120 patients who underwent elective surgery under general anesthesia between July 2019 and August 2020. Demographic and gastric ultrasound assessment data were retrieved. Patients were divided into the elderly group (n = 58, age: ≥65 years) and young group (n = 62, age: <65 years). The CSAs in the supine and right lateral decubitus positions (RLDP), semiquantitative 3-point Perlas grade (grades 0, 1, and 2), and gastric volume (GV) were determined. CSAs according to different Perlas grades were compared between the 2 groups. To compare normally and non-normally distributed continuous data, Student t test and the Mann-Whitney U test were used, respectively. Categorical data were compared using the chi-square test or Fisher exact test, as appropriate. The receiver operating characteristic (ROC) curves were built for the CSAs to predict pulmonary aspiration. The CSA cutoff values for predicting a high risk of pulmonary aspiration in both the groups were determined. Among patients with Perlas grade 0, the CSAsupine (P = .002) and CSARLDP (P = .002) were greater in the elderly group than in the young group. The specificity, positive predictive value, and accuracy of the CSA decreased when the CSA cutoff value for the young group was applied to the elderly group. The CSA cutoff values for the elderly group were: CSAsupine, 6.92 cm2 and CSARLDP, 10.65 cm2. The CSA of the empty stomach was greater in elderly patients than in young patients. We suggest that the following CSA cutoff values should be used for predicting pulmonary aspiration risk in elderly patients: CSAsupine, 6.92 cm2 and CSARLDP, 10.65 cm2.

Machine learning for prediction of postoperative nausea and vomiting in patients with intravenous patient-controlled analgesia.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a still highly relevant problem and is known to be a distressing side effect in patients. The aim of this study was to develop a machine learning model to predict PONV up to 24 h with fentanyl-based intravenous patient-controlled analgesia (IV-PCA). METHODS: From July 2019 and July 2020, data from 2,149 patients who received fentanyl-based IV-PCA for analgesia after non-cardiac surgery under general anesthesia were applied to develop predictive models. The rates of PONV at 1 day after surgery were measured according to patient characteristics as well as anesthetic, surgical, or PCA-related factors. All statistical analyses and computations were performed using the R software. RESULTS: A total of 2,149 patients were enrolled in this study, 337 of whom (15.7%) experienced PONV. After applying the machine-learning algorithm and Apfel model to the test dataset to predict PONV, we found that the area under the receiver operating characteristic curve using logistic regression was 0.576 (95% confidence interval [CI], 0.520-0.633), k-nearest neighbor was 0.597 (95% CI, 0.537-0.656), decision tree was 0.561 (95% CI, 0.498-0.625), random forest was 0.610 (95% CI, 0.552-0.668), gradient boosting machine was 0.580 (95% CI, 0.520-0.639), support vector machine was 0.649 (95% CI, 0.592-0.707), artificial neural network was 0.686 (95% CI, 0.630-0.742), and Apfel model was 0.643 (95% CI, 0.596-0.690). CONCLUSIONS: We developed and validated machine learning models for predicting PONV in the first 24 h. The machine learning model showed better performance than the Apfel model in predicting PONV.

Oxygen reserve index guided fraction of inspired oxygen titration to reduce hyperoxemia during laparoscopic gastrectomy: A randomized controlled trial.

BACKGROUND: The usefulness of the oxygen reserve index (ORi) in reducing hyperoxemia remains unclear. We designed this study to investigate whether fraction of inspired oxygen (FiO2) adjustment under a combination of ORi and peripheral oxygen saturation (SpO2) guidance can reduce intraoperative hyperoxemia compared to SpO2 alone. METHODS: In this prospective, double-blind, randomized controlled study, we allocated patients scheduled for laparoscopic gastrectomy to the SpO2 group (FiO2 adjusted to target SpO2 ≥ 98%) or the ORi-SpO2 group (FiO2 adjusted to target 0 < 0 ORi < .3 and SpO2 ≥ 98%). The ORi, SpO2, FiO2, arterial partial pressure of oxygen (PaO2), and incidence of severe hyperoxemia (PaO2 ≥ 200 mm Hg) were recorded before and 1, 2, and 3 hours after surgical incision. Data from 32 and 30 subjects in the SpO2 and ORi-SpO2 groups, respectively, were analyzed. RESULTS: PaO2 was higher in the SpO2 group (250.31 ± 57.39 mm Hg) than in the ORi-SpO2 group (170.07 ± 49.39 mm Hg) 1 hour after incision (P < .001). PaO2 was consistently higher in the SpO2 group than in the ORi-SpO2 group, over time (P = .045). The incidence of severe hyperoxemia was higher in the SpO2 group (84.4%) than in the ORi-SpO2 group (16.7%, P < .001) 1 hour after incision. Higher FiO2 was administered to the SpO2 group [52.5 (50-60)] than the ORi-SpO2 group [40 (35-50), P < .001] 1 hour after incision. SpO2 was not different between the 2 groups. CONCLUSION: The combination of ORi and SpO2 guided FiO2 adjustment reduced hyperoxemia compared to SpO2 alone during laparoscopic gastrectomy.

Machine Learning Approaches to Predict Chronic Lower Back Pain in People Aged over 50 Years.

Background and Objectives: Chronic lower back pain (LBP) is a common clinical disorder. The early identification of patients who will develop chronic LBP would help develop preventive measures and treatment. We aimed to develop machine learning models that can accurately predict the risk of chronic LBP. Materials and Methods: Data from the Sixth Korea National Health and Nutrition Examination Survey conducted in 2014 and 2015 (KNHANES VI-2, 3) were screened for selecting patients with chronic LBP. LBP lasting >30 days in the past 3 months was defined as chronic LBP in the survey. The following classification models with machine learning algorithms were developed and validated to predict chronic LBP: logistic regression (LR), k-nearest neighbors (KNN), naïve Bayes (NB), decision tree (DT), random forest (RF), gradient boosting machine (GBM), support vector machine (SVM), and artificial neural network (ANN). The performance of these models was compared with respect to the area under the receiver operating characteristic curve (AUROC). Results: A total of 6119 patients were analyzed in this study, of which 1394 had LBP. The feature selected data consisted of 13 variables. The LR, KNN, NB, DT, RF, GBM, SVM, and ANN models showed performances (in terms of AUROCs) of 0.656, 0.656, 0.712, 0.671, 0.699, 0.660, 0.707, and 0.716, respectively, with ten-fold cross-validation. Conclusions: In this study, the ANN model was identified as the best machine learning classification model for predicting the occurrence of chronic LBP. Therefore, machine learning could be effectively applied in the identification of populations at high risk of chronic LBP.

Gastric emptying of preoperative carbohydrate in elderly assessed using gastric ultrasonography: A randomized controlled study.

BACKGROUND: Preoperative carbohydrate loading enhances postoperative recovery and reduces patient discomfort. However, gastric emptying of liquids can be delayed in elderly populations. Therefore, this study aimed to evaluate the gastric emptying of 400 mL of a carbohydrate drink ingested 2 hours before surgery in elderly patients. METHODS: In this prospective, randomized controlled study, patients aged >65 years were allocated to either fast from midnight (nil per os [NPO] group, n = 29) or drink 400 mL of a carbohydrate drink 2 hours before surgery (carbohydrate group, n = 29). The gastric antrum was assessed using ultrasonography in the supine position, followed by the right lateral decubitus (RLD) position. The gastric antrum was graded as grade 0 (fluid not seen in both positions), grade 1 (fluid only seen in the RLD position), and grade 2 (fluid seen in both positions). The gastric antral cross-sectional area (CSA) and aspirated residual gastric volume were measured. RESULTS: In 58 patients, the incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). The gastric antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72-5.18] cm2 vs 5.31 [4.35-6.92] cm2, P = .018). The gastric antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [0-7.5] vs 3 [0-13.4], P = .331) in NPO group versus carbohydrate group. CONCLUSION: The incidence of grade 2 stomach was not different between NPO group and carbohydrate group in elderly patients.