Estimation of the Risk of Postoperative Hypertension Following Minor to Moderate Surgery Using an Echocardiogram and Biomarkers.

This study aimed to determine independent factors for developing postoperative hypertension using 4 biomarkers in patients receiving oral and maxillofacial surgery under general anesthesia. Brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity myocardial troponin T (hs-TnT), and high-sensitivity myocardial troponin I (hs-TnI) were measured and preoperative echocardiograms were examined. Episodes of systolic blood pressure (SBP) ≥ 170 mmHg or diastolic blood pressure ≥ 100 mmHg within 1 week after surgery were considered postoperative hypertension. We analyzed 213 (130 men; 83 women) patients, who were divided into a postoperative hypertension group (HT group, n = 32) and a normal group (N group, n = 181). The HT group showed a higher LVMI (113.5 versus 100.1), higher E/e' of the lateral wall (9.1 versus 7.7), and higher BNP (39.2 versus 22.9 pg/mL), NT-proBNP (400.1 versus 143.9 pg/mL), and hs-TnT (15.6 versus 10.3 ng/L) concentrations compared to the N group. NT-proBNP and hs-TnT concentrations positively associated with E/e', but BNP and hs-TnI did not. NT-proBNP (AUC = 0.64, cutoff value: 117.0 pg/mL) and hs-TnT (AUC = 0.61, cutoff value: 11.0 ng/L) concentrations were effective for discriminating E/e' ≥ 12. Multivariate logistic regression analyses showed that risk factors responsible for developing postoperative hypertension were NT-proBNP and hs-TnT using biomarkers and E/e' as independent variables, and NT-proBNP and SBP at admission using biomarkers and SBP at admission as independent variables. These findings suggest that NT-proBNP and hs-TnT concentrations, and SBP at admission, are useful to predict postoperative hypertension after minor to moderate surgery, and that left ventricular filling pressure is a primary factor associated with postoperative hypertension.

General Anesthesia During Lip Repair and Palatoplasty After Glenn Surgery.

We performed general anesthesia for a lip repair and palatoplasty in a patient with left ventricular hypoplasia following a Glenn procedure. Preoperative examination revealed hemorrhagic diathesis, hypoxemia, and secondary polycythemia. After completion of the palatoplasty, hypoxemia and intraoral bleeding were observed, and reintubation was required. The bleeding risk was likely increased in this patient due to several factors including the surgical procedure and concurrent antithrombotic therapy. In conclusion, the risks associated with hypoxemia and increased bleeding must be considered for the safe provision of general anesthesia during palatoplasty procedures in patients with cyanotic heart disease.

The State Anxiety Inventory Is Useful for Predicting the Autonomic Nervous System State of Patients Before the Extraction of an Impacted Mandibular Third Molar.

PURPOSE: Dental anxiety about extraction of impacted mandibular third molars changes the activity of the autonomic nervous system. Thus, to provide safe dental treatment, it is important that a surgeon be aware of a patient's pretreatment anxiety and autonomic nervous system state. Therefore, we analyzed how a scheduled treatment to extract mandibular third molars affects the pretreatment electroencephalogram (EEG), autonomic nervous system, and psychological state of patients. We compared their findings with those of volunteers not scheduled to undergo dental treatment. PATIENTS AND METHODS: The study enrolled 30 patients who were scheduled to undergo impacted mandibular third molar extraction (ie, pretreatment group) and 30 volunteers who were not (ie, control group). Heart rate variability and an EEG were recorded during the experiment. The State Anxiety Inventory-State Anxiety scale (STAI-S) scores were recorded before the procedure. For the statistical analysis, P < .05 was deemed statistically significant. RESULTS: High-frequency (HF) variability was significantly decreased and the STAI-S score was significantly increased in the pretreatment group compared with the control group (P < .01 for both). The low frequency (LF)/HF ratio and alpha-wave activity showed a significant negative correlation on both sides in the control group (P < .01); however, no correlation existed in the pretreatment group. The LF/HF ratio and STAI-S score showed a significant positive correlation in the pretreatment group (P < .05); however, no correlation existed in the control group. CONCLUSIONS: Predicting a patient's autonomic nervous system state before dental treatment based on the EEG was difficult. The STAI-S psychological test was a useful method.

Difference in the Effects of Lidocaine With Epinephrine and Prilocaine With Felypressin on the Autonomic Nervous System During Extraction of the Impacted Mandibular Third Molar: A Randomized Controlled Trial.

PURPOSE: Complications during local anesthesia include increased blood pressure and vasovagal reflex, which are caused by changes in the autonomic nervous system. The commonly used local anesthetic preparations are lidocaine to which the vasoconstrictor epinephrine is added (lidocaine-epinephrine) and prilocaine to which the vasoconstrictor felypressin is added (prilocaine-felypressin); however, their effects during dental treatment are unclear. We examined the effects of these 2 different local anesthetic preparations on the autonomic nervous system and circulation during extraction of the impacted mandibular third molar. MATERIALS AND METHODS: In this randomized controlled trial, 40 female patients scheduled for extraction of an impacted mandibular third molar were randomized to the lidocaine-epinephrine group or prilocaine-felypressin group. Heart rate variability, heart rate, and systolic blood pressure were recorded during the experiment. Descriptive and bivariate statistics were computed, and the P value was set at .05. RESULTS: The low frequency-high frequency ratio was significantly increased in the prilocaine-felypressin group during extraction compared with that in the lidocaine-epinephrine group (P < .05). In the lidocaine-epinephrine group, a significant decrease in the high-frequency component was observed during bone removal and extraction compared with that at rest (P < .05). In both groups, a significant increase in systolic blood pressure was observed during local anesthesia, incision and reflection of the flap, bone removal, separation of the tooth crown, extraction, and suturing compared with that at rest (P < .01). CONCLUSIONS: This study is the first to investigate the differences in the influence of 2 different local anesthetic preparations on the autonomic nervous system during extraction of the mandibular third molar. Changes in circulatory dynamics during tooth extraction with the 2 different local anesthetic preparations were the result of a decrease in parasympathetic nervous activity with lidocaine-epinephrine and an increase in sympathetic nervous activity with prilocaine-felypressin.

The Effects of Music Listening During Extraction of the Impacted Mandibular Third Molar on the Autonomic Nervous System and Psychological State.

PURPOSE: Pain, anxiety, and nervousness related to dental procedures can cause acute changes in the autonomic nervous system. Music is widely accepted as a relaxation method during dental treatment; however, its effects during dental treatment are unclear. The authors explored the effects of listening to music during extraction of the impacted mandibular third molar on the autonomic nervous system and the psychological state and hypothesized that listening to music would suppress sympathetic nervous activity and decrease anxiety. MATERIALS AND METHODS: In this prospective study, 40 patients scheduled for extraction of an impacted mandibular third molar were randomized into 2 groups: extraction without music (control group) and extraction while listening to music (music group). Heart rate variability was recorded during the experiment, and Modified Dental Anxiety Scale and State-Trait Anxiety Inventory (STAI) scores were recorded before and after the procedure. Descriptive and bivariate statistics were computed and the P value was set at .05. RESULTS: An increased low-to-high frequency ratio was observed in the control group during incision and flap reflection, bone removal, and separation of the tooth crown; the ratio was significantly decreased in the music group during these time points (P < .05). Compared with the control group, the music group had a significantly greater decrease in postoperative STAI State Anxiety scores from preoperative levels (P < .05). CONCLUSIONS: This study suggested that listening to music while undergoing extraction of the impacted mandibular third molar suppresses activity of the sympathetic nerves during incision, flap reflection, bone removal, and separation of the tooth crown and relieves anxiety after treatment. Future studies will focus on the mechanisms involved and methods to prevent the onset of systemic incidents.

Predictive Factors of Postoperative Blood Pressure Abnormalities Following a Minor-to-Moderate Surgery.

Myocardial ischemic events after non-cardiac surgery is still a serious problem, especially in older, high-risk patients. However, the prevalence and risk factors of blood pressure (BP) abnormalities, which may possibly lead to myocardial ischemic attack, have not been reported. Our aim is to elucidate predictive factors of postoperative BP abnormalities following a minor-to-moderate surgery, employing preoperative left ventricular diastolic function. Patients who underwent cardiac echocardiogram examination and received oral and maxillofacial surgery under general anesthesia were enrolled. The echocardiographic parameters of diastolic function were compared between patients who had postoperative BP abnormalities (hypertension-systolic blood pressure [SBP] ≥ 170 mmHg-or hypotension-SBP < 80 mmHg-episode) that required therapeutic interventions until 7 days after surgery and those who had no BP abnormalities. Of the 173 patients analyzed, 25 (14.4%) had BP abnormalities. BP abnormalities patients were older, having a larger proportion of diabetes mellitus, lower E/A ratio and e', and larger E/e' and left atrial dimension than those without BP abnormalities. Subanalyses revealed that the independent risk factors responsible for hypertension episodes (14 patients) were the mean e' (odd ratio [OR]: 0.434; 95% confidence interval [CI]: 0.229-0.824), diabetes mellitus (OR: 5.018; 95% CI: 1.030-24.436), SBP at hospitalization (OR: 1.099; 95% CI: 1.036-1.165), and operation time (hour; OR: 1.326; 95%CI: 1.109-1.586), while hypotension episodes (11 patients) were associated solely with operation time (OR: 1.206; 95% CI: 1.046-1.391). In conclusion, left ventricular diastolic dysfunction, increased insulin resistance, boosted SBP at hospitalization, and prolonged operation should be taken into consideration as risk factors of postoperative BP abnormalities, especially hypertension, following minor-to-moderate surgery.

The dopamine D1 receptor is expressed and induces CREB phosphorylation and MUC5AC expression in human airway epithelium.

Background: Dopamine receptors comprise two subgroups, Gs protein-coupled "D1-like" receptors (D1, D5) and Gicoupled "D2-like" receptors (D2, D3, D4). In airways, both dopamine D1 and D2 receptors are expressed on airway smooth muscle and regulate airway smooth muscle force. However, functional expression of the dopamine D1 receptor has never been identified on airway epithelium. Activation of Gs-coupled receptors stimulate adenylyl cyclase leading to cyclic AMP (cAMP) production, which is known to induce mucus overproduction through the cAMP response element binding protein (CREB) in airway epithelial cells. We questioned whether the dopamine D1 receptor is expressed on airway epithelium, and whether it promotes CREB phosphorylation and MUC5AC expression. Methods: We evaluated the protein expression of the dopamine D1 receptor on native human airway epithelium and three sources of cultured human airway epithelial cells including primary cultured airway epithelial cells, the bronchial epithelial cell line (16HBE14o-), and the pulmonary mucoepidermoid carcinoma cell line (NCI-H292) using immunohistochemistry and immunoblotting. To characterize the stimulation of cAMP through the dopamine D1 receptor, 16HBE14o- cells and NCI-H292 cells were treated with dopamine or the dopamine D1 receptor agonists (SKF38393 or A68930) before cAMP measurements. The phosphorylation of CREB by A68930 in both 16HBE14o- and NCI-H292 cells was measured by immunoblot. The effect of dopamine or A68930 on the expression of MUC5AC mRNA and protein in NCI-H292 cells was evaluated by real-time PCR and immunofluorescence staining, respectively. Results: The dopamine D1 receptor protein was detected in native human airway epithelium and three sources of cultured human airway epithelial cells. Dopamine or the dopamine D1-like receptor agonists stimulated cAMP production in 16HBE14o- cells and NCI-H292 cells, which was reversed by the selective dopamine D1-like receptor antagonists (SCH23390 or SCH39166). A68930 significantly increased phosphorylation of CREB in both 16HBE14o- and NCI-H292 cells, which was attenuated by the inhibitors of PKA (H89) and MEK (U0126). Expression of MUC5AC mRNA and protein were also increased by either dopamine or A68930 in NCI-H292 cells. Conclusions: These results suggest that the activation of the dopamine D1 receptor on human airway epithelium could induce mucus overproduction, which could worsen airway obstructive symptoms.

Recovery of Endothelial Function after Minor-to-Moderate Surgery Is Impaired by Diabetes Mellitus, Obesity, Hyperuricemia and Sevoflurane-Based Anesthesia.

Endothelial dysfunction is observed in several cardiovascular diseases, where endothelium-dependent vasodilation is impaired by oxidative stress. However, the time course of endothelial function during the perioperative period of a minor-to-moderate surgery, and the effects of atherosclerotic risk factors and employed general anesthetics on recovery of endothelial function, are unknown. Endothelial function of 30 patients was evaluated as the reactive hyperemia index (RHI) of reactive hyperemia peripheral arterial tonometry. RHI was measured on day before surgery (control), immediately after surgery (Day 0), day after surgery (Day 1), and day 4 after surgery (Day 4) in patients with no functional limitations who were scheduled for oral and maxillofacial surgery of around 3 hours. Sevoflurane- or propofol-based anesthesia supplemented with an opioid analgesic remifentanil was employed. The control RHI was 2.26 ± 0.64. The RHI significantly decreased to the lowest level on Day 0 (1.52 ± 0.28), recovered on Day 1 (2.07 ± 0.58), and improved further on Day 4 (2.55 ± 0.83). Multiple linear regression analysis revealed that recovery of the RHI from Day 0 to Day 4 was impaired by diabetes mellitus (P = 0.0313), obesity (BMI ≥ 25; P = 0.0166), hyperuricemia (uric acid ≥ 6.0 mg/dL; P = 0.0416) and sevoflurane-based anesthesia (P = 0.0308). These findings suggest that endothelial function as evaluated by the RHI is severely suppressed on the day of a minor-to-moderate surgery, and that it improves until the 4th postoperative day on average. Recovery of endothelial function is impaired by diabetes mellitus, obesity, hyperuricemia, and sevoflurane-based anesthesia.

Effects of glucose-insulin infusion during major oral and maxillofacial surgery on postoperative complications and outcomes.

BACKGROUND: Secretion of hormones, which antagonize the action of insulin, is facilitated in response to surgery, and acute resistance to the action of insulin develops. Our aim is to elucidate the effects of intraoperative glycemic control by glucose-insulin (GI) infusion on postoperative complications and outcomes in major oral and maxillofacial surgery. FINDINGS: Thirty patients aged ≥ 60 years undergoing a radical operation of oral malignant tumors with tissue reconstruction (≥ 8 h) were analyzed. In the GI group, regular insulin was continuously applied with glucose-added acetate Ringer's solution (5-10 g glucose per 500 mL). Blood glucose was adjusted within the target concentration of 80-120 mg/dL. In the control group, combination of acetate Ringer's solution containing 1% (W/V) glucose and lactate Ringer's solution, which contains no glucose, was employed. Perioperative clinical parameters, incidence of hypoalbuminemia, and postoperative complications, i.e., surgical site infection, necrosis of a reconstructed flap, bacteremia, hypotension, or pneumonia, were compared. Both serum total protein and albumin concentrations (postoperative day 1 [Day1]) were higher in the GI group. The mean infusion rate of glucose during surgery (mg/kg/h) was independently associated with the decrease in both serum total protein and albumin concentrations from the control to Day1. No difference was found between the groups in the incidence of postoperative complications and the days required until discharge, except less incidence of hypoalbuminemia in the GI group. CONCLUSIONS: Application of additional glucose during major oral and maxillofacial surgery preserved serum albumin concentration. However, it did not lead to less postoperative complications and less days until discharge.

Associations between blood pressure responses to acute stress and impaired renal function and serum uric acid level.

The study aimed to examine correlations between blood pressure (BP) responses to direct laryngoscopy and tracheal intubation and parameters of renal function, serum uric acid (SUA) level, and mean preoperative BP. Fifty-four patients (≥ 40 years) who were scheduled for oral surgery were analyzed. General anesthesia was induced by the rapid sequence method without opioid analgesics. Systolic and diastolic BP (SBP, DBP) in the operation room were measured when an electrocardiogram, a BP cuff, and a pulse oximetry probe were attached to the patients (T1) and immediately after the trachea was intubated (T2). The ΔSBP was defined as the difference between SBP at T2 and T1. The increasing rate of SBP (ΔSBPr) was defined as ΔSBP/SBP at T1. SBP at T2 was associated with increasing age (R = 0.44), serum creatinine (R = 0.32), SUA (R = 0.30), mean preoperative SBP and DBP (R = 0.54 and 0.37, respectively), and reduced estimated glomerular filtration rate (eGFR) (R = -0.44). Serum creatinine and SUA were positively associated, and eGFR was negatively associated with ΔSBP (R = 0.36, 0.34, and -0.29) and ΔSBPr (R = 0.39, 0.37, and -0.29). Multivariate regression analysis revealed that age and mean preoperative SBP was independently associated with SBP at T2, and serum creatinine was independently associated with ΔSBP and ΔSBPr. These findings suggested that elevated serum creatinine level, as well as elevated preoperative BP level, was associated with enhanced BP responses to acute stress in middle-aged to elderly patients.

Chronic orofacial pain in dental patients: retrospective investigation over 12 years.

Orofacial pain is often difficult to diagnose and treat. However, there have been few reports on the clinical observation of dental patients with orofacial pain. We retrospectively investigated the characteristics of 221 dental patients who had suffered from persistent orofacial pain. Data were collected from the outpatient medical records in our clinic over the past 12 years. More than half of the patients (53.8%) had suffered with pain for more than 6 months from pain onset until the first visit to our clinic. The main diagnoses were neuropathic pain (30.3%), myofascial pain (23.5%), psychogenic pain (20.4%), odontogenic toothache (17.2%), and others (7.7%) such as temporomandibular disorders and glossitis. The treatments included pharmacotherapy, splint therapy, and others such as nerve block, dental treatment, physiotherapy, and/or psychotherapy. Excluding the patients (52 of 221 initially enrolled patients) with unknown responses to treatment, 65.7% showed remission or a significant improvement in pain in response to treatment. Although only a small group of patients had odontogenic toothache, the rate of improvement was highest for this disorder. In conclusion, early consultation with a dentist is useful to prevent chronicity of odontogenic pain and to make a differential diagnosis in patients with orofacial pain.

A styletted tracheal tube with a posterior-facing bevel reduces epistaxis during nasal intubation: a randomized trial.

PURPOSE: Epistaxis is a common complication of nasal intubation. Ease of insertion of the tracheal tube may be influenced by bevel orientation and tip bending. We examined ease of insertion and epistaxis with two tubes with different orientations and with or without a stylet to modify tip bending. METHODS: Two hundred patients scheduled to undergo oral or maxillofacial surgery were randomized into four groups according to method of nasal intubation used after induction of anesthesia. In one group, a Portex(®) tracheal tube was inserted with bevel facing left (Portex Group). In the second group, a Parker Flex-Tip(®) tube (Parker Group) was inserted with the bevel facing posteriorly, and in the last two groups, a stylet bent at 60° anteriorly was used with the Portex tube (Stylet-Portex Group) or Parker tube (Stylet-Parker Group). When the tube advanced without resistance, insertion was defined as "smooth", and when resistance was encountered, insertion was defined as "impinged". Severity of epistaxis was evaluated as none, mild, moderate, or severe. RESULTS: Smooth insertion was observed in 60% of patients in the Portex Group; 80% in the Parker Group; 100% in the Stylet-Portex Group; and 100% in the Stylet-Parker Group. Epistaxis was found in 50%, 24%, 20%, and 4% of patients, respectively. The styletted tip (difference: 30%; 95% confidence interval [CI]: 20.3 to 38.5; P < 0.0001) was found to improve ease of insertion. Both the posterior-facing bevel (difference: 21%; 95% CI: 9.0 to 32.1; P = 0.0005) and stylet (difference: 25%; 95% CI: 13.1 to 35.9; P < 0.0001) contributed significantly to absence of epistaxis. CONCLUSIONS: Using a styletted tracheal tube with a posterior-facing bevel improves ease of insertion through the nasopharynx and decreases the severity of epistaxis during nasal intubation. CLINICAL TRIAL REGISTRATION NUMBER: UMIN Clinical Trials Registry (UMIN-CTR), UMIN000011327.

Associations between the autonomic nervous system and the second derivative of the finger photoplethysmogram indices.

AIM: The indices of the second derivative of the finger photoplethysmogram(SDPTG) denote stiffness of large arteries, peripheral vascular resistance and vascular aging. However, the association between the autonomic nervous activity and the SDPTG indices has not yet been elucidated. METHODS: The SDPTG and heart rate variability(HRV) were consecutively measured in the sitting position on the day before surgery in 168 patients 18-89 years of age. The relationships between the SDPTG indices(b/a, c/a, d/a and e/a) and HRV indices(power spectral analysis and time domain analysis parameters) were analyzed. The relationships between c/a and atherosclerosis-based conditions and risk factors for atherosclerosis were also evaluated. RESULTS: The SDPTG index b/a was negatively associated and the d/a index was positively associated with the low-frequency(LF)(R=-0.44 and 0.42, respectively) and high-frequency(HF) components(R=-0.31 and 0.35, respectively). The SDPTG index c/a was also positively associated with the LF(R=0.40) and HF(R=0.44) components. A multivariate regression analysis showed that the LF, HF and heart rate were independent determinants of the c/a. Furthermore, the c/a values were significantly lower in the patients with hypertension, diabetes mellitus and hyperlipidemia than in those without these diseases, and a reduced c/a was significantly associated with increased serum triglyceride and total cholesterol concentrations. CONCLUSIONS: These findings suggest that a decrease in c/a is associated with a reduced baroreflex response of the peripheral vasomotor activity and a decreased cardiac parasympathetic activity. Furthermore, a decrease in c/a was found to be associated with atherosclerosis-based conditions, such as hypertension, diabetes mellitus and hyperlipidemia.

Features of lateral cephalograms associated with difficult laryngoscopy in Japanese children undergoing oral and maxillofacial surgery.

BACKGROUND: Difficult laryngoscopy and tracheal intubation are occasionally encountered in children with congenital anomalies or micrognathia. However, no study has elucidated anatomical etiology in relation to craniofacial development. METHODS: Two hundred ten patients aged 8 months-18 years were analyzed. We analyzed the lateral cephalograms of: (i) eight patients in whom laryngoscopy was anticipated as difficult before anesthesia and who were unable to be intubated by direct laryngoscopy and needed fiberoptic bronchoscopy (group A); (ii) 11 patients in whom laryngoscopy was anticipated as difficult before anesthesia but who were able to be intubated by direct laryngoscopy (group B); and (iii) 191 patients in whom laryngoscopy was anticipated as easy before anesthesia and was actually found to be easy (group C). Eight cephalometric parameters were measured and age-parameter relationships were plotted. Logistic regression analysis was performed to characterize group A children for each of the cephalometric variables. RESULTS: Apparently insufficient growth of the mandible was observed in the group A children. Furthermore, the group A children of aged <4 years had undeveloped maxilla, longer mandibular plane-hyoid distances (≥1.3 cm), and deeper depth of the oropharynx; those of aged ≥4 years showed increased inclination of the mandible (sella-nasion plane to mandibular plane angle of ≥46.5°). CONCLUSIONS: Difficult laryngoscopy and tracheal intubation are expected in children aged <4 years with lower-positioned hyoid bone caused by caudal larynx as well as undeveloped maxilla and mandible, and in those aged ≥4 years with increased inclination of the mandible as well as undeveloped mandible.

Cholesterol sulfate induces expression of the skin barrier protein filaggrin in normal human epidermal keratinocytes through induction of RORα.

Cholesterol sulfate is abundant in the human epidermis and is a putative natural ligand for retinoic acid receptor-related orphan receptor alpha (RORα). Although direct binding of cholesterol sulfate is expected to activate RORα, cholesterol sulfate can also induce RORα expression and increase RORα target gene expression. The purpose of this study was to determine whether cholesterol sulfate induces profilaggrin expression, a precursor of the barrier protein filaggrin in the epidermis, through activation of RORα by directly binding to RORα, or through increased RORα expression. Immunohistochemical and polymerase chain reaction (PCR) analyses showed that RORα was expressed in normal human epidermal keratinocytes (NHEKs) and that its expression increased during keratinocyte differentiation in parallel with that of profilaggrin and cholesterol sulfotransferase, which catalyzes the synthesis of cholesterol sulfate. Exogenous cholesterol sulfate significantly increased both RORα and profilaggrin expression in NHEKs, whereas no effect on profilaggrin expression was observed in cells in which RORα was knocked down with small interfering RNA (siRNA). Additionally, a luciferase reporter gene assay revealed that exogenous RORα dose-dependently increased the activity of the profilaggrin gene promoter even in the absence of cholesterol sulfate, and that this response involves activator protein-1. In conclusion, the results of this study indicate that cholesterol sulfate induces filaggrin expression through increased RORα expression. Further studies are required to fully elucidate the mechanisms involved.

Unrecognized bronchial intubation associated with the uncuffed pediatric tracheal tube with bilateral Murphy eyes.

BACKGROUND: Unreliability of breath sounds auscultation after intubation is reportedly mainly related to the presence of the Murphy eye. This study was performed to ascertain whether an uncuffed pediatric tracheal tube with bilateral Murphy eyes increases the risk of unrecognized bronchial intubation, compared to an uncuffed tube without eyes. METHODS: Following induction of anesthesia in 50 toddlers, either an uncuffed tube without eyes or an uncuffed tube with bilateral eyes was inserted into the trachea. The tube was then slowly advanced while breath sounds were auscultated using a stethoscope. In study 1, when breath sounds changed and disappeared, the distance from the carina to the tube tip was measured using a fiberoptic bronchoscope. In study 2, when breath sounds changed, the tracheal tube was withdrawn 5, 10, 15 and 20 mm while using a fiberoptic bronchoscope to ascertain whether bronchial intubation had occurred. RESULTS: When breath sounds changed and disappeared, the tip of the tube with bilateral eyes was positioned more deeply below the carina than that of the tube without eyes. When the tube was withdrawn 10 mm from the point at which breath sounds changed, frequencies of bronchial intubation were 13% and 80% in the no eyes and double eyes groups, respectively. CONCLUSION: An uncuffed pediatric tracheal tube with bilateral Murphy eyes reduces the ability of breath sounds auscultation to detect bronchial intubation and may increase the risk of unrecognized bronchial intubation compared to an uncuffed tube without eyes.

Preoperative autologous blood donation and acute normovolemic hemodilution affect intraoperative blood loss during sagittal split ramus osteotomy.

INTRODUCTION: This study aimed to determine the effects of acute normovolemic hemodilution (ANH) using low-molecular-weight hydroxyethyl starch (LMW-HES) on intraoperative blood loss in patients who had received preoperative autologous blood donation (PABD) and had undergone sagittal split ramus osteotomy (SSRO). METHODS: Patients who had undergone SSRO were analyzed. All 250 patients received PABD of 400-800 mL until 2 weeks before surgery. ANH was performed by withdrawing whole blood, which was replaced by the same volume of LMW-HES. ANH was performed in 197 cases for 200 mL replacement (ANH-200) and in 5 cases for 400 mL replacement (ANH-400); it was not performed in 48 cases (ANH-0). RESULTS: Blood loss in ANH-200 was greater than that in ANH-0, despite no differences in hemoglobin concentrations at pre- and post-PABD, prothrombin time, activated partial thromboplastin time, fibrinogen and platelet counts between the groups before surgery. Blood loss increased as the total withdrawn blood (sum of PABD and ANH) increased. CONCLUSION: Increased intraoperative blood loss was associated with total withdrawn blood before the operation as well as ANH.

Responses of the second derivative of the finger photoplethysmogram indices and hemodynamic parameters to anesthesia induction.

The finger photoplethysmogram (PTG) is a non-invasive method for pulse-wave analysis. The second derivative wave of the PTG (SDPTG) enables evaluation of atherosclerosis and cardiovascular aging. Responses of SDPTG indices and hemodynamic parameters to anesthesia induction are unknown. A total of 42 patients aged 40 years, who may have had atherosclerotic change, and who underwent elective oral surgery, were analyzed. Patients were divided into sevoflurane (S group; N=22) and sevoflurane with remifentanil (R group; N=20) groups. Systolic and diastolic blood pressure (SBP, DBP), heart rate (HR) and SDPTG were measured at four time points: before induction, after loss of consciousness, after tracheal intubation and 30 min after induction. At postintubation, b/a was elevated (that is, large arterial stiffness was increased), and d/a was reduced (that is, peripheral vascular resistance was increased) in the S group compared with the R group. SBP, DBP and HR were increased in the S group compared with those in the R group. In the S group, preanesthetic b/a and the aging index (AGI) were positively correlated with SBP at immediate postintubation, and preanesthetic d/a was negatively correlated with SBP and DBP at immediate postintubation. It is suggested that usage of remifentanil, a potent µ-opioid analgesic, with sevoflurane anesthesia prevented an increase in blood pressure and HR in response to laryngoscopy and tracheal intubation, which was accompanied by suppression of both elevation of b/a and the AGI and reduction of d/a. SDPTG indices are useful for predicting hypertension during induction of sevoflurane anesthesia, regardless of a history of hypertension or hypertensive factors.