Effect of Dexmedetomidine Preconditioning on Hepatic Ischemia-Reperfusion Injury in Acute Hyperglycemic Rats.

BACKGROUND: Acute hyperglycemia frequently occurs in stressful situations, including liver transplantation or hepatic surgery, which may affect the protective effects of dexmedetomidine preconditioning and increase postoperative mortality. Therefore, this study aimed to investigate the effects of dexmedetomidine on hepatic ischemia-reperfusion injury in acute hyperglycemia. METHODS: Thirty-six Sprague-Dawley rats were randomly assigned to 6 groups, including a combination between 2 glycemic (normo- and hyperglycemia) and 3 ischemia-reperfusion conditions (sham, ischemia-reperfusion only, and dexmedetomidine plus ischemia-reperfusion). Dexmedetomidine 70 µg/kg was preconditioned 30 minutes before ischemic injury. After 6 hours of reperfusion, serum aminotransferase levels were measured to confirm the hepatic tissue injury. Furthermore, inflammatory (nuclear factor-κb, tumor necrosis factor-α, and interleukin-6) and oxidative stress markers (malondialdehyde and superoxide dismutase) were detected. RESULTS: Ischemia-reperfusion injury significantly increased the serum levels of aminotransferase and inflammatory and oxidative stress markers. These ischemia-reperfusion-induced changes were further exacerbated in hyperglycemia and were significantly attenuated by dexmedetomidine preconditioning. However, the effects of dexmedetomidine in hyperglycemia were lesser than those in normoglycemia (P < .05 for aminotransferases, inflammatory markers, malondialdehyde, and superoxide dismutase). CONCLUSIONS: These findings suggest that the protective effects of dexmedetomidine preconditioning may be intact against hepatic ischemia-reperfusion injury in acute hyperglycemia. Although its effects appeared to be relatively reduced, this may be because of the increase in oxidative stress and inflammatory response caused by acute hyperglycemia. To determine whether the effects of dexmedetomidine itself would be impaired in hyperglycemia, further study is needed.

Suspected Malignant Hyperthermia in a Brain-Dead Donor During Anesthesia for Organ Procurement Surgery: A Case Report.

We report an unusual case of highly suspected malignant hyperthermia after inducing anesthesia in a brain-dead 18-year-old male patient undergoing organ procurement surgery. The patient was administered desflurane (3 vol%) and rocuronium bromide (50 mg) to induce and maintain general anesthesia. He experienced hypercapnia and tachycardia within 5 minutes of anesthesia induction; however, his body temperature rapidly rose only after 15 minutes. The volatile anesthetic was discontinued, and dantrolene was administered at a low dose (1 mg/kg) to avert possible hepatotoxic effects on the donor liver. Fortunately, the clinical course of the brain-dead donor until the organs were harvested and the liver transplantation outcome of the recipient was favorable. A comprehensive understanding of the pathophysiology of brain death, organ transplantation, and malignant hyperthermia is essential to respond promptly and appropriately. Based on our experience, low-dose dantrolene may be clinically used in brain-dead donors while accounting for its potential hepatotoxic effects.

Anesthetic management for inhibiting sympathetic activation in an adolescent patient diagnosed with catecholaminergic polymorphic ventricular tachycardia and undergoing left cardiac sympathetic denervation: A case report.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder in which catecholamine release during exercise or emotional stress cause fatal tachyarrhythmias. In this paper, we discuss methods to minimize the sympathetic stimulation that can occur during the perioperative period in patients undergoing left cardiac sympathetic denervation to surgically treat CPVT.

Effect of Minimum Bronchial Cuff Volume of Left-Sided Double-Lumen Tube for One-Lung Ventilation on the Change in Bronchial Cuff Pressure during Lateral Positioning in Thoracic Surgery: A Prospective Observational Study.

The minimum bronchial cuff volume (BCVmin) of a double-lumen tube (DLT) without air leaks during lung isolation may vary among individuals, and lateral positioning could increase the bronchial cuff pressure (BCP). We investigated the effect of initially established BCVmin (BCVi) on the change in BCP by lateral positioning. Seventy patients who underwent elective lung surgery were recruited and divided into two groups according to the BCVi obtained during anesthetic induction in each patient. Outcome analysis was conducted using data from 39 patients with a BCVi greater than 0 (BCVi > 0 group) and 27 with a BCVi of 0 (BCVi = 0 group). The primary outcome was a change in the value measured in the supine and lateral positions of the initially established BCP (BCPi; BCP at the time of BCVi injection), which was significantly larger in the BCVi > 0 group than in the BCVi = 0 group (1.5 (0.5-6.0) cmH2O vs. 0.0 (0.0-1.0) cmH2O; p < 0.001). BCVi was related to the left main bronchus (LMB) diameter (Spearman's rho = 0.676, p < 0.001) and the gap between the LMB diameter and the outer diameter of the bronchial cuff (Spearman's rho = 0.553, p < 0.001). Therefore, selecting a DLT size with a bronchial cuff that fits each patient's LMB may be useful in minimizing the change in BCP when performing lateral positioning during thoracic surgery. If the bronchial cuff requires unavoidable initial inflation, it is necessary to be aware that BCP may increase during lateral positioning and to monitor the BCP regularly if possible.

Effects of remote ischemic postconditioning on hepatic injury in lipopolysaccharide-induced endotoxemic rats.

BACKGROUND: Remote ischemic postconditioning (RIPoC) is induced by several cycles of brief, reversible, mechanical blood flow occlusion, and reperfusion of the distal organs thereby protecting target organs. We investigated if RIPoC ameliorated liver injury in a lipopolysaccharide (LPS)-induced endotoxemic rats. METHODS: Protocol 1) Rats were administered LPS and samples collected at 0, 2, 6, 12, and 18 h. 2) After RIPoC at 2, 6, and 12 h (L+2R+18H, L+6R+18H, and L+12R+18H), samples were analyzed at 18 h. 3) RIPoC was performed at 2 h, analysis samples at 6, 12, 18 h (L+2R+6H, L+2R+12H, L+2R+18H), and RIPoC at 6 h, analysis at 12 h (L+6R+12H). 4) Rats were assigned to a control group while in the RIPoC group, RIPoC was performed at 2, 6, 10, and 14 h, with samples analyzed at 18 h. RESULTS: Protocol 1) Liver enzyme, malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), and nuclear factor-κB (NF-κB) levels increased while superoxide dismutase (SOD) levels decreased over time. 2) Liver enzyme and MDA levels were lower while SOD levels were higher in L+12R+18H and L+6R+18H groups when compared with L+2R+18H group. 3) Liver enzyme and MDA levels were lower while SOD levels were higher in L+2R+6H and L+6R+12H groups when compared with L+2R+12H and L+2R+18H groups. 4) Liver enzyme, MDA, TNF-α, and NF-κB levels were lower while SOD levels were higher in RIPoC group when compared with control group. CONCLUSIONS: RIPoC attenuated liver injury in the LPS-induced sepsis model by modifying inflammatory and oxidative stress response for a limited period.

Infection prevention measures and outcomes for surgical patients during a COVID-19 outbreak in a tertiary hospital in Daegu, South Korea: a retrospective observational study.

BACKGRUOUND: The first large coronavirus disease 2019 (COVID-19) outbreak outside China occurred in Daegu. In response, we developed infection prevention measures for surgical patients during the outbreak at our hospital and retrospectively reviewed the outcomes of COVID-19-related surgical patients. METHODS: We reviewed the medical records of 118 COVID-19-related surgical patients and monitored their clinical outcomes until March 31, 2021. We also interviewed healthcare workers who participated in their perioperative care at Kyungpook National University Chilgok Hospital. The perioperative management guidelines for COVID-19-related patients were prepared through multidisciplinary discussions, including the infection control department, surgical departments, and anesthesiology department before and during the COVID-19 outbreak. RESULTS: One standard operating room was temporarily converted to a negative-pressure room by increasing the exhaust air volume, creating a relative pressure of -11.3 Pa. The healthcare workers were equipped with personal protective equipment according to the patient's classification of the risk of COVID-19 transmission. The 118 COVID-19-related patients underwent emergent surgery in the negative-pressure room, including three COVID-19-confirmed patients and five COVID-19-exposed patients. CONCLUSION: All surgeries of the COVID-19-related patients were performed without specific adverse events or perioperative COVID-19 transmission. Our experience setting up a negative-pressure operating room and conservative perioperative protocol to prevent COVID-19 transmission will help plan and execute infection control measures in the future.

The Role of Dexmedetomidine in Hepatic Ischemia-Reperfusion Injury Via a Nitric Oxide-Dependent Mechanism in Rats.

BACKGROUND: Dexmedetomidine is known to protect against ischemia-reperfusion (IR) in various organs; however, the mechanisms of dexmedetomidine in the liver remain unclear. We investigated whether dexmedetomidine preconditioning leads to hepatic protection and whether nitric oxide was associated with this protective mechanism by employing N-nitro-l-arginine methyl ester (l-NAME), a nitrous oxide synthase inhibitor. METHODS: Experiment 1 included 24 rats in 4 groups: sham, IR, 30 µg/kg of dexmedetomidine, and 50 µg/kg of dexmedetomidine. Experiment 2 included 36 rats in 6 groups: IR, 50 µg/kg of dexmedetomidine, 10 mg/kg of l-NAME, 10 mg/kg of l-NAME + 50 µg/kg of dexmedetomidine, 30 of mg/kg l-NAME, and 30 mg/kg of l-NAME + 50 µg/kg of dexmedetomidine. All drugs were administered intraperitoneally. The levels of serum transaminases, malondialdehyde, superoxide dismutase, tumor necrosis factor-α, nuclear factor-κB, and c-Jun N-terminal kinase were measured 6 hours after hepatic surgery. RESULTS: Dexmedetomidine demonstrated a dose-dependent decrease in serum transaminase levels. The 50-µg/kg dexmedetomidine group showed a significant decrease in malondialdehyde levels (P = .002), increase in superoxide dismutase levels (P = .002), and a significantly lower level of phosphorylated tumor necrosis factor-α, nuclear factor-κB, and c-Jun N-terminal kinase (P = .002, respectively) compared with the IR injury group. These protective effects of dexmedetomidine were partially reversed by pretreatment with l-NAME (P < .01 for 20 and 30 mg/kg of l-NAME). CONCLUSION: In hepatic IR injury, dexmedetomidine might protect the liver via antioxidative and anti-inflammatory responses, and nitric oxide production could play a role in these protective mechanisms.

Posterior wall penetration of the internal jugular vein during central venous catheter insertion using real-time ultrasound: Two case reports.

RATIONALE: Because central venous catheters (CVCs) are placed at the great vessels, mechanical complications can be fatal. Using the landmark method alone can make CVC difficult to access, depending on the skill of the operator and various patient conditions, such as anatomical variations of the vessels, young age, hypovolemic state, obesity, and short neck. Therefore, ultrasound (US)-guided techniques, including visualization of the vein and needle in the lumen of the vessel, are recommended. Nevertheless, our experience demonstrated that CVC malposition or vascular penetration cannot be prevented completely, even with real-time US guidance. PATIENT CONCERNS: The first patient was a 19-year-old woman (weight = 58 kg, height = 155 cm) who underwent CVC cannulation in the right internal jugular vein (IJV) under general anesthesia using real-time US. The second patient, a 50-year-old woman (weight = 51.6 kg, height = 155.7 cm), underwent CVC insertion in the right IJV using real-time US. DIAGNOSES: During guidewire insertion in the first case, the posterior wall of IJV was penetrated, and a break in the core body of the guidewire was detected. In the case of second patient, CVC was embedded in the posterior wall of IJV and misplaced in the interpleural space in the right thorax. In both cases, an out-of-plane US approach was used. INTERVENTIONS: In the first case, the broken guidewire was completely removed with real-time US guidance. In the second case, all fluid injected through CVC was aspirated, and then CVC was removed. OUTCOMES: In both cases, surgeries were completed successfully and all the patients were discharged without any complications. LESSONS: Even if the needle tip is located in the lumen of IJV and blood aspiration is confirmed on real-time US, vascular penetration or CVC malposition during the procedure cannot be completely prevented because of the limitation of the US imaging field. These results suggest that care must be exercised even during US-guided CVC placement and that alternative US-guided techniques or supplementary monitoring should be considered to confirm proper CVC position.

Role of Remote Ischemic Preconditioning in Hepatic Ischemic Reperfusion Injury.

The effect of remote ischemic preconditioning (RIPC) has been proposed that mediates the protective response in ischemia reperfusion injury (IRI) of various organs. In this study, we investigated the effect of RIPC in hepatic IRI, by assessing biomarker of oxidative stress and inflammatory cytokines. Moreover, we intended to demonstrate any such protective effect through nitric oxide (NO). Twenty-five rats were divided into the 5 groups: (1) Sham; (2) RIPC; (3) hepatic IRI; (4) RIPC + hepatic IRI; (5) C-PTIO, 2-(4-carboxyphenyl)-4,5dihydro-4,4,5,5-tetramethyl-1H-imidazolyl-1-oxy-3oxide, + RIPC + hepatic IRI. RIPC downregulated the level of aspartate aminotransferase (AST), alanine aminotransferase (ALT), histologic damage, and activity of Malondialdehyde (MDA). However, there was no significant reduction in the level of tumor necrosis factor-alpha (TNF-α) and nuclear factor kappa B (NF-κB). AST and ALT levels, and hepatic tissue morphology in the C-PTIO group showed a significant improvement compared to those of the RIPC + hepatic IRI group. The application of RIPC before hepatic ischemia downregulated the oxidative stress, not the inflammatory cytokines. Moreover, these protective effect of RIPC would be mediated through the activation of NO as well as anti-oxidant effect.

Analgesic Effect of Ultrasound-Guided Preoperative Unilateral Lateral Quadratus Lumborum Block for Laparoscopic Nephrectomy: A Randomized, Double-Blinded, Controlled Trial.

PURPOSE: The quadratus lumborum block (QLB) is a relatively new regional analgesic technique that could provide analgesia to the abdominal wall and reduce postoperative opioid consumption. We investigated the opioid-sparing effect of a unilateral lateral QLB in laparoscopic nephrectomy. PATIENTS AND METHODS: A total of 60 patients undergoing laparoscopic nephrectomy were included in the study. Patients were randomized into two groups as QLB and control group. QLB group received QLB with 25mL 0.25% ropivacaine, and the control group received 25mL 0.9% saline at anterolateral border of quadratus lumborum muscle preoperatively. Opioid consumption and the pain intensity at rest and on movement were measured at 2nd, 6th, 24th, and 48th hour postoperatively. We also assessed the time to first flatus to measure the extent of paralytic ileus and the quality of recovery-15 (QoR-15) questionnaire. RESULTS: Postoperative opioid consumption was significantly lower in the QLB group than in the control group at 6, 24, and 48h after surgery (P < 0.05). The pain intensity at rest and on movement was significantly lower in the QLB group than in the control group during the first 24 hours after surgery (P < 0.05). The incidence of postoperative nausea and vomiting, time to first flatus, and QoR-15 score did not show significant differences. CONCLUSION: Preoperative unilateral QLB successfully decreased postoperative pain and opioid consumption after laparoscopic nephrectomy and could be an option for analgesia after laparoscopic nephrectomy.

The Effect of Nitric Oxide on Remote Ischemic Preconditioning in Renal Ischemia Reperfusion Injury in Rats.

Although remote ischemic preconditioning (RIPC) is an organ-protective maneuver from subsequent ischemia reperfusion injury (IRI) by application of brief ischemia and reperfusion to other organs, its mechanism remains unclear. However, it is known that RIPC reduces the heart, brain, and liver IRI, and that nitric oxide (NO) is involved in the mechanism of this effect. To identify the role of NO in the protective effect of RIPC in renal IRI, this study examined renal function, oxidative status, and histopathological changes using N-nitro-L-arginine methyl ester (L-NAME), an NO synthase inhibitor. Remote ischemic preconditioning was produced by 3 cycles of 5 minutes ischemia and 5 minutes reperfusion. Blood urea nitrogen, creatinine (Cr), and renal tissue malondialdehyde levels were lower, histopathological damage was less severe, and superoxide dismutase level was higher in the RIPC + IRI group than in the IRI group. The renoprotective effect was reversed by L-NAME. Obtained results suggest that RIPC before renal IRI contributes to improvement of renal function, increases antioxidative marker levels, and decreases oxidative stress marker levels and histopathological damage. Moreover, NO is likely to play an important role in this protective effect of RIPC on renal IRI.

Sodium Nitrite Attenuates Hepatic Ischemia-Reperfusion Injury in Rats.

OBJECTIVES: Nitrite as an alternative source of nitric oxide has been proposed, as it can mediate the protective response in the presence of ischemia or hypoxic conditions and inorganic nitrite can be reduced to nitric oxide by xanthine oxidoreductase. Here, we investigated whether pretreatment with sodium nitrite can attenuate liver damage in hepatic ischemia-reperfusion injury and identified the possible mechanism of nitrite reduction using 2-(4-carboxyphenyl)-4,5dihydro-4,4,5,5-tetramethyl-1H-imidazolyl-1-oxy-3oxide (C-PTIO), a nitric oxide scavenger, and allopurinol, a xanthine oxidoreductase inhibitor. MATERIALS AND METHODS: In experiment 1, 30 male Sprague-Dawley rats were divided into 5 groups: (1) sham-operated; (2) hepatic ischemia-reperfusion injury; and (3-5) sodium nitrite administered intra-peritoneally 30 minutes before ischemia at 2.5, 25, and 250 µmol/kg, respectively. In experiment 2, 24 male Sprague-Dawley rats were divided into 4 groups: (1) hepatic ischemia-reperfusion injury; (2) sodium nitrite + hepatic ischemia-reperfusion injury; (3) C-PTIO + sodium nitrite + hepatic ischemia-reperfusion injury; and (4) allopurinol + sodium nitrite + hepatic ischemia-reperfusion injury. Sodium nitrite (25 µmol/kg) was then administered 30 minutes before hepatic ischemia, and C-PTIO or allopurinol was administered 5 minutes before sodium nitrite administration. Blood aspartate aminotransferase, alanine aminotransferase, hepatic tissue malondialdehyde, histologic changes, and expression of mitogen-activated protein kinase family members were evaluated. RESULTS: Sodium nitrite limited serum elevation of alanine aminotransferase and aspartate aminotransferase induced by hepatic ischemia-reperfusion with a peak effect occurring at 25 µmol/kg sodium nitrite. Pre-treatment with allopurinol abolished the protective effect of sodium nitrite, and C-PTIO treatment attenuated the hepatoprotection of sodium nitrite in rats with hepatic ischemia-reperfusion injury. Liver malondialdehyde activity after ischemia-reperfusion decreased in sodium nitrite-treated rats. Sodium nitrite also prevented hepatic ischemia-reperfusion-induced c-Jun N-terminal kinase and extracellular signal-regulated kinase phosphorylation. CONCLUSIONS: Exogenous sodium nitrite had protective effects against hepatic ischemia-reperfusion injury. Catalytic reduction to nitric oxide and attenuation of hepatic ischemia-reperfusion is dependent on xanthine oxidoreductase.

Postoperative emergence agitation and intraoperative sevoflurane sedation under caudal block in children: a randomized comparison of two sevoflurane doses.

BACKGROUND: Sub-umbilical surgery under caudal block in conjunction with sevoflurane sedation may be safe in terms of maintaining spontaneous breathing and avoiding complications associated with general anesthesia. However, sevoflurane-induced emergence agitation (EA) continues to be a clinically important phenomenon in children. To compare the incidence of EA in children undergoing sub-umbilical surgery under caudal block with two different doses of sevoflurane. METHODS: Forty children (aged 1-5 years) scheduled to undergo inguinal hernia repair under caudal block with sevoflurane sedation via a face mask were randomized into either the low-dose (1.0%) end-tidal sevoflurane concentration group (Group LS) or the high-dose (2.5%) end-tidal sevoflurane concentration group (Group HS). We monitored EA episodes at 5 and 30 min in the post-anesthetic care unit (PACU) by using the fourpoint agitation scale and the Pediatric Anesthesia Emergence Delirium (PAED) scale. RESULTS: The four-point agitation scale scores and PAED scores were not different between the groups at 5 min. However, the agitation score was higher in Group HS than in Group LS at 30 min after arriving in the PACU. The time required to recover from sedation was longer in Group HS than in Group LS. CONCLUSIONS: Face-mask sedation with 1.0% sevoflurane in conjunction with caudal block may be more effective than that with 2.5% sevoflurane in preventing EA.

Comparison of oncological benefits of deep neuromuscular block in obese patients with gastric cancer (DEBLOQS_GC study): A study protocol for a double-blind, randomized controlled trial.

PURPOSE: Many studies have demonstrated the advantage of maintaining intraoperative deep neuromuscular block (NMB) with sugammadex. This trial is designed to evaluate the impact of muscle relaxation during laparoscopic subtotal gastrectomy on the oncological benefits, particularly in obese patients with gastric cancer. MATERIALS AND METHODS: This is a double-blind, randomized controlled multicenter prospective trial. Patients with clinical stage I-II gastric cancer with a body mass index of 25 and over, who undergo laparoscopic subtotal gastrectomy will be eligible for trial inclusion. The patients will be randomized into a deep NMB group or a moderate NMB group with a 1:1 ratio. A total of 196 patients (98 per group) are required. The primary endpoint is the number of harvested lymph nodes, which is a critical index of the quality of surgery in gastric cancer treatment. The secondary endpoints are surgeon's surgical condition score, patient's sedation score, and surgical outcomes including peak inspiratory pressure, operation time, postoperative pain, and morbidity. DISCUSSION: This is the first study that compares deep NMB with moderate NMB during laparoscopic gastrectomy in obese patients with gastric cancer. We hope to show the oncologic benefits of deep NMB compared with moderate NMB during subtotal gastrectomy. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT03196791), date of registration: October 10, 2017.

Beneficial Role of Hydrogen Sulfide in Renal Ischemia Reperfusion Injury in Rats.

PURPOSE: Hydrogen sulfide (H2S) is an endogenous gaseous molecule with important physiological roles. It is synthesized from cysteine by cystathionine γ-lyase (CGL) and cystathionine ß-synthase (CBS). The present study examined the benefits of exogenous H2S on renal ischemia reperfusion (IR) injury, as well as the effects of CGL or CBS inhibition. Furthermore, we elucidated the mechanism underlying the action of H2S in the kidneys. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats were randomly assigned to five groups: a sham, renal IR control, sodium hydrosulfide (NaHS) treatment, H2S donor, and CGL or CBS inhibitor administration group. Levels of blood urea nitrogen (BUN), serum creatinine (Cr), renal tissue malondialdehyde (MDA), and superoxide dismutase (SOD) were estimated. Histological changes, apoptosis, and expression of mitogen-activated protein kinase (MAPK) family members (extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38) were also evaluated. RESULTS: NaHS attenuated serum BUN and Cr levels, as well as histological damage caused by renal IR injury. Administration of NaHS also reduced oxidative stress as evident from decreased MDA, preserved SOD, and reduced apoptotic cells. Additionally, NaHS prevented renal IR-induced MAPK phosphorylation. The CGL or CBS group showed increased MAPK family activity; however, there was no significant difference in the IR control group. CONCLUSION: Exogenous H2S can mitigate IR injury-led renal damage. The proposed beneficial effect of H2S is, in part, because of the anti-oxidative stress associated with modulation of the MAPK signaling pathways.

A liver transplant recipient with possible bupivacaine-induced liver injury caused by intra-articular injection after total knee arthroplasty: A case report.

RATIONALE: Although the survival period of patients who undergo liver transplantation is improving due to advances in surgical techniques and medical treatment, there is a lack of detailed, sufficient data that compare the choice of anesthetic agent in post-liver transplant surgery to avoid liver injury. PATIENT CONCERNS: The authors describe acute liver injury observed in a 61-year-old man who underwent liver transplantation surgery 13 years previously and who was on immunosuppressive therapy. The patient underwent bilateral total knee arthroplasty under general anesthesia, for which a total of 200 mg bupivacaine was injected into each knee after wound closure. Liver enzyme levels increased to more than 10 times the upper limit of normal after the conclusion of surgery and remained extremely high on postoperative day 1. DIAGNOSES: Clinical and laboratory findings were consistent with bupivacaine-induced liver injury. Intra-articular administration of bupivacaine after total knee arthroplasty is a widely used intraoperative analgesic method and complications are rare; nevertheless, the risk for inadvertent delivery into the systemic circulation remains. INTERVENTIONS: Clinical presentations and hepatobiliary ultrasound examination allowed a conservative management. OUTCOMES: Serum liver enzyme levels normalized 12 days after surgery, and the patient was discharged 22 days after surgery. LESSONS: Acute liver injury can lead to graft failure from late death after liver transplantation. Transplant recipients with long-term survival have the highest risk for anesthesia because of post-transplant complications, including diabetes, hypertension, and renal insufficiency. Clinicians should be aware that analgesic techniques and anesthetics may affect graft function.

A case report of Tapia's syndrome after mastectomy and breast reconstruction under general anesthesia.

RATIONALE: Tapia's syndrome is a rare and potentially anesthesia-related complication that may cause considerable distress to the patient. Here we describe a case of unilateral Tapia's syndrome in a patient undergoing a skin sparing mastectomy and immediate breast reconstruction which, to the best of our knowledge, has not been reported in the literature. PATIENT CONCERNS: A 41-years old female underwent right skin sparing total mastectomy and breast reconstruction with latissimus dorsi flap under general anesthesia. On the first postoperative day, she complained left sided tongue deviation, subtle hoarseness and swallowing difficulty. DIAGNOSIS: Tapia's syndrome, a combined paralysis of ipsilateral vocal cord and tongue due to injury to the hypoglossal and recurrent laryngeal nerves, in this case, resulting potentially from head and neck position changes INTERVENTIONS:: The patient was closely observed with the administration of empirical prednisolone 5 mg/day for 3 weeks. OUTCOMES: One month after the surgery, functions of the tongue and vocal cord were completely resolved. LESSONS: Particular attention should be paid to the maintenance of adequate cuff pressure, proper position of endotracheal tube and correct neck positioning, especially when procedures taking a long operation time under endotracheal anesthesia and requiring frequent position changes of the patient's head and neck.

The effect of preoperative nefopam treatment on postoperative catheter-related bladder discomfort in patients undergoing transurethral bladder tumor resection: a randomized double-blind study.

BACKGROUND: Catheter-related bladder discomfort (C.R.B.D.) is a risk factor for emergence agitation and delirium in postoperative phase. It may be resistant to conventional analgesic therapy such as opioids. This study evaluated the role of preoperative treatment using intravenous 20 mg nefopam in reducing the incidence and severity of C.R.B.D. during the first postoperative 24 h after urinary catheterization when compared with placebo. METHODS: Seventy adult males undergoing elective transurethral resection of bladder tumor requiring urinary bladder catheterization intraoperatively were randomly divided into two groups of 35 patients. In the intervention group (Group N), intravenous 20 mg nefopam in 100 mL normal saline was administered before spinal anesthesia. The placebo group (Group P) received intravenous normal saline 100 mL instead. The incidence and severity of side-effects, including C.R.B.D. at 1, 2, 6, and 24 h after surgery, was evaluated. RESULTS: The incidence of C.R.B.D. was reduced in Group N compared with Group P during the first postoperative 24 h (6/33 [18.2%] vs 22/35 [62.9%], Group N vs Group P, p = .000). The severity of C.R.B.D. also varied significantly at postoperative 1, 2, and 6 h. The use of postoperative analgesics was reduced in Group N compared with Group P (8/33 [24.2%] vs 25/35 [71.4%], Group N vs Group P, p = .000). CONCLUSIONS: The preoperative administration of single-dose intravenous nefopam reduced the incidence and severity of C.R.B.D. in the early postoperative period in patients undergoing T.U.R.-B. under spinal anesthesia.