Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery.

Introduction: Excessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period. Methods: Patients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM-PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR. Results: Of 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66-0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%). Conclusions: ΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.

Effectiveness of securing central venous catheters with topical tissue adhesive in patients undergoing cardiac surgery: a randomized controlled pilot study.

BACKGROUND: Central venous catheters (CVCs) play an important role during cardiac surgery. Topical tissue adhesives form a thin film of coating that becomes bound to keratin in the epidermis. The advantage of this "super glue" lies in its antimicrobial activity. This study aimed to evaluate fixation of CVCs with topical tissue adhesive in patients (prone to bleed) undergoing cardiac surgery regarding its ability to reduce the incidence of pericatheter leakage. METHODS: This randomized controlled trial included 150 patients > 15 years of age who were (1) scheduled to undergo elective cardiac surgery, (2) required CVC insertion at the internal jugular vein, and (3) scheduled for transfer postoperatively to the cardiac intensive care unit. We randomly assigned patients to a topical tissue adhesive group (TA) or a standard control group (SC). The primary outcome was a change in dressing immediately postoperatively due to pericatheter blood oozing. Secondary outcomes were the number of dressings, total dressings per catheter day, and composite outcome of catheter failure within 3 days. Both intention-to-treat and per-protocol analyses were performed. Seven patients violated the protocol (three TA patients and four SC patients). RESULTS: Regarding the primary outcome, the SC group exhibited a significantly increased incidence of dressing change immediately postoperatively due to pericatheter leakage compared with the TA group in both the intention-to-treat analysis (5.33% vs 18.67%, RR 0.25 [95% CI 0.08 to 0.79], P = 0.012) and the per-protocol analysis (5.56% vs 16.90%, RR 0.289 [95% CI 0.09 to 0.95], P = 0.031). No significant differences were noted in the number of dressings, total dressings per catheter day, or composite outcome of catheter failure within 3 days between the two groups. Multiple logistic regression analysis was performed to adjust baseline characteristics that were different in the per-protocol analysis. The results showed that the risk ratio of immediate postoperative dressing change in TA patients was 0.25 compared to the SC group ([95% CI 0.07 to 0.87], P = 0.029) in the per-protocol analysis. CONCLUSION: The use of a topical tissue adhesive can reduce the incidence of immediate postoperative pericatheter blood oozing. TRIAL REGISTRATION: TCTR20180608004 , retrospectively registered on June 06, 2018.

A comparison of dexmedetomidine and propofol in Patients undergoing electrophysiology study.

BACKGROUND: Dexmedetomidine provides profound levels of sedation without affecting cardiovascular and respiratory stability based on its pharmacological profile. It may be a valuable sedative for procedures with minimal to mild pain. Electrophysiology study (EP study) is a mildly painful procedure that requires conscious sedation. The authors hypothesized that dexmedetomidine would cause lower respiratory and cardiovascular depression than propofol during equal sedation level in an electrophysiology study. MATERIAL AND METHOD: The present study protocol was approved by the clinical research ethics committee at Ramathibodi Hospital. Thirty-four patients were randomly allocated into two groups to receive either dexmedetomidine or propofol for an electrophysiology study. Patients in the dexmedetomidine group received a loading dose of dexmedetomidine (0.5 mcg/kg) infused over 10 minutes followed by 0.4 mcg/kg/h. Each patient in the propofol group received propofol 1 mg/kg over 10 minutes followed by 3 mg/kg/h. All patients received pethidine (0.5 mg/kg) before the initiation of EP study. Sedation was determined using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S). The Modified Observer's Assessment of Alertness/Sedation scores, hemodynamic and respiratory variables were recorded regularly during the EP study. RESULTS: Thirty-four patients were enrolled in the present study. The Modified Observer's Assessment Alertness/Sedation values were similar in both groups. Respiratory rate values with dexmedetomidine were significantly higher than those in the propofol group (p = 0.048) and the oxygen supplement in the dexmedetomidine group were significantly lower than those in the propofol group (p < 0.001). Moreover mean arterial blood pressure values of dexmedetomidine at the five and 15-minute were significantly higher than those of the propofol group (p = 0.024). No incidence of severe bradycardia or hypotension was found in both groups. CONCLUSION: The present study demonstrated that comparable sedation could be achieved by a combination of pethidine with either dexmedetomidine or propofol during EP study. Dexmedetomidine group provided more hemodynamic and respiratory stability than propofol group.

The post-operative analgesic efficacy of celecoxib compared with placebo and parecoxib after total hip or knee arthroplasty.

BACKGROUND: Nonsteroidal antiinflammatory drugs (NSAIDs) in combination with opioids is a model of multimodal analgesia. NSAIDs have the oral and parenteral forms. OBJECTIVE: The aim of the present study was to evaluate the efficacy of celecoxib compared with placebo and parecoxib after total hip or knee arthroplasty. MATERIAL AND METHOD: A total of 120, ASA 1-2, aged 18-75 years, patients were randomly assigned to receive one of the three groups: Group I (control) received placebo (n=40), group II received 400 mg celecoxib orally (n=40) and group III received 40 mg parecoxib intravenously (n=40). The present study medication was administered I hour before surgery. All patients had access to patient-controlled analgesia (PCA) with intravenous morphine. Patients were studied at 0, 1, 6, 12 and 24 hours postoperatively for verbal numerical rating scale (VNRS), morphine consumption, satisfaction score and side effects. RESULTS: The intraoperatively fentayl requirement were similar among the three groups (p < 0.00). Celecoxib and parecoxib significantly decreased the amount of morphine requirement after total hip or knee arthroplasty compared to placebo at 1, 6, 12 and 24 hours (p < 0.00). The celecoxib group required more morphine than the parecoxib group at 1, 6, 12 and 24 hours (p < 0.00). The VNRS score in parecoxib group was significantly lower than the celecoxib and control groups at 1, 6, 12 but not at 24 hours. The VNRS score was lower in the celecoxib group compared to the control group at I and 6 hours postoperatively (p = 0.01, p < 0. 01 respectively). The placebo group had a higher sedation score (p = 0.008) but not for nausea vomiting (p = 0.36) and pruritus (p = 0.12) compared to the treatment groups. CONCLUSION: Within 12 hours after total hip and knee arthroplasty, pre-operative administration of parenteral parecoxib 40 mg was more effective than oral celecoxib 400 mg and placebo in terms of morphine consumption and VNRS score.

Bispectral index in assessment of 3% and 4.5% desflurane in 50% N2O for caesarean section.

BACKGROUND: To prevent awareness and uterine atony among parturients during general anesthesia for caesarean section, volatile anesthetic agents have been limited to 0.5 MAC in 50% N2O. This technique appeared to be inadequate to produce BIS values less than 60 in isoflurane and sevoflurane. OBJECTIVE: To assess BIS value during general anesthesia with 3% and 4.5% desflurane in 50% N2O before delivery. MATERIAL AND METHOD: The parturients were blinded and randomized in opaque envelopes to one of the two study groups. Seventy-two elective caesarean section ASA I - II parturients were induced and intubated with thiopental 4 mg/kg, succinylcholine 1.5 mg/kg and were received either 3% or 4.5% desflurane in 50% N2O to maintain general anesthesia. Both groups received rocuronium 0.6 mg/kg for muscle relaxation. Morphine 0.1 mg/kg and midazolam 0.06 mg/kg were administered after delivery. RESULTS: There were no differences in demographic data in both groups. The incidences of patients with a satisfactory BIS score (< 60) in the 4.5% desflurane group was 81% that was significantly more than 42% in the 3% desflurane group (p < 0.000). Mean BIS values at neonatal delivery were 62 +/- 8 in the 3% desflurane group, versus 49 +/- 12 in the 4.5% desflurane group. Indices of maternal and neonatal outcome were similar between the two groups. CONCLUSION: General anesthesia for caesarean section with 4.5% desflurane in 50% N2O maintained BIS < 60 more significantly than 3% of desflurane in 50% N2O without maternal and neonatal adverse effects in healthy paturients.