The Impact of Rocuronium and Sugammadex on Length of Stay in Patients Undergoing Open Spine Surgery: A Propensity Score-Matched Analysis.

Enhanced Recovery After Surgery (ERAS), an all-encompassing perioperative care approach, has been demonstrated to enhance surgical results, mitigate postoperative issues, and decrease the length of hospital stay (LOS) in diverse surgical specialties. In this retrospective study, our objective was to examine the influence of muscle relaxant selection on LOS and perioperative results in adult patients undergoing open spine surgery. Specifically, we compared 201 patients who received cisatracurium and neostigmine with 201 patients who received rocuronium and sugammadex, after 1:1 propensity score matching. The utilization of the rocuronium and sugammadex combination in anesthesia for open spinal surgery did not lead to a reduction in the LOS but was associated with a decreased incidence of postoperative chest radiographic abnormalities, including infiltration, consolidation, atelectasis, or pneumonia (p = 0.027). In our secondary analysis, multivariate analysis revealed multiple determinants influencing the prolonged LOS (>7 days) during open spine surgery. Bispectral index-guided anesthesia emerged as a protective factor, while variables such as excessive intraoperative blood loss and fluid administration as well as postoperative chest radiographic abnormalities independently contributed to prolonged LOS.

Density Spectral Array Enables Precise Sedation Control for Supermicrosurgical Lymphaticovenous Anastomosis: A Retrospective Observational Cohort Study.

Supermicrosurgical lymphaticovenous anastomosis (LVA) is a minimally invasive surgical technique that creates bypasses between lymphatic vessels and veins, thereby improving lymphatic drainage and reducing lymphedema. This retrospective single-center study included 137 patients who underwent non-intubated LVA in southern Taiwan. A total of 119 patients were enrolled and assigned to two study groups: the geriatric (age ≥ 75 years, n = 23) and non-geriatric groups (age < 75 years, n = 96). The primary outcome was to investigate and compare the arousal and maintenance of the propofol effect-site concentration (Ce) using an electroencephalographic density spectral array (EEG DSA) in both groups. The results showed that the geriatric group required less propofol (4.05 [3.73-4.77] mg/kg/h vs. 5.01 [4.34-5.92] mg/kg/h, p = 0.001) and alfentanil (4.67 [2.53-5.82] µg/kg/h vs. 6.68 [3.85-8.77] µg/kg/h, p = 0.047). The median arousal Ce of propofol among the geriatric group (0.6 [0.5-0.7] µg/mL) was significantly lower than that in patients aged ≤ 54 years (1.3 [1.2-1.4] µg/mL, p < 0.001), 55-64 years (0.9 [0.8-1.0] µg/mL, p < 0.001), and <75 years (0.9 [0.8-1.2] µg/mL, p < 0.001). In summary, the combined use of EEG DSA provides the objective and depth of adequate sedation for extensive non-intubated anesthesia in late-elderly patients who undergo LVA without perioperative complications.

Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study.

Purpose: Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. Patients and Methods: In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Results: Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Conclusion: Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.

Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis.

BACKGROUND: We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). METHODS: This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. RESULTS: Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005). CONCLUSIONS: During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.

Analgesic and Anesthetic Efficacy of Rocuronium/Sugammadex in Otorhinolaryngologic Surgery: A Propensity Score-Matched Analysis.

The use of rocuronium/sugammadex in otorhinolaryngologic surgery improves intubation conditions and surgical rating scales. This study primarily aimed to evaluate the effect of the combination of rocuronium and sugammadex on intraoperative anesthetic consumption. The secondary outcomes were the intraoperative and postoperative morphine milligram equivalent (MME) consumption, duration of intraoperative hypertension, extubation time, incidence of delayed extubation and postoperative nausea and vomiting, pain score, and length of stay. A total of 2848 patients underwent otorhinolaryngologic surgery at a tertiary medical center in southern Taiwan. After applying the exclusion criteria, 2648 of these cases were included, with 167 and 2481 in the rocuronium/sugammadex and cisatracurium/neostigmine groups, respectively. To reduce potential bias, 119 patients in each group were matched by propensity scores for sex, age, body weight, and type of surgery. We found that the rocuronium/sugammadex group was associated with significant preservation of the intraoperative sevoflurane and MME consumption, with reductions of 14.2% (p = 0.009) and 11.8% (p = 0.035), respectively. The use of the combination of rocuronium and sugammadex also significantly increased the dose of intraoperative labetalol (p = 0.002), although there was no significant difference in intraoperative hypertensive events between both groups. In conclusion, our results may encourage the use of the combination of rocuronium and sugammadex as part of volatile-sparing and opioid-sparing anesthesia in otorhinolaryngologic surgery.

Anesthetic management for intraoperative acute pulmonary embolism during inferior vena cava tumor thrombus surgery: A case report.

BACKGROUND: Acute pulmonary embolism (APE) is a rare and potentially life-threatening condition, even with early detection and prompt management. Intraoperative APE required specific ways for detecting since classic symptoms of APE in the awake patient could not be observed or self-reported by the patient under general anesthesia. CASE SUMMARY: A 44-year-old man with a history of hepatic cell carcinoma was admitted for radical nephrectomy and tumor thrombectomy due to a newly found kidney tumor with inferior vena cava (IVC) tumor thrombus. APE that occurred during tumor thrombectomy with hypercapnia and desaturation. The capnography combined with the transesophageal echocardiography (TEE) provided a crucial differential diagnosis during the operation. The patient was continuously managed with aggressive intravenous fluid resuscitation and blood transfusion under continuous cardiac output monitoring to maintain hemodynamic stability. He completed the surgery under stable hemodynamics and was extubated after percutaneous mechanical thrombectomy by a certified cardiologist. There were no significant symptoms and signs or obvious discomfort in the patient's self-report during visits to the general ward. CONCLUSION: Under general anesthesia for IVC tumor thrombus surgery, a sudden decrease in end-tidal carbon dioxide is the initial indicator of APE, which occurs before hemodynamic changes. When intraoperative APE is suspected, TEE is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram. Timely clinical impression and supportive treatment and intervention should be conducted to obtain a better prognosis.

Are Risk Factors for Postoperative Significant Hemorrhage following Total Knee Arthroplasty Potentially Modifiable? A Retrospective Cohort Study.

Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis (OA) of the knee, because it alleviates pain and restores function of the knee. However, TKA-associated hemorrhage and subsequent anemia remain a concern. Most previous studies have defined meaningful postoperative bleeding as blood loss > 500 mL or hemoglobin (Hb) drop > 20 g/L. Therefore, we defined significant hemorrhage as a postoperative Hb drop more than 20 g/L in this study, and we investigated possible risk factors related to significant hemorrhage in TKA and whether these risk factors are modifiable. This retrospective study was conducted through a comprehensive review of the perioperative records of patients with OA of the knee who underwent TKA between January 2009 and December 2015 at our hospital. Patients were allocated into two groups: patients in Group A had their Hb drop ≤ 20 g/L; patients in Group B had their Hb drop > 20 g/L. Factors analyzed included sex, age, body mass index (BMI), the American Society of Anesthesiologists (ASA) classification, comorbidities, preoperative platelet count, use of tranexamic acid (TXA), operation time, and type of anesthesia. A total of 3350 patients met the criteria for analysis, with 1782 patients allocated to Group A and 1568 patients to Group B. Five independent risk factors for significant hemorrhage were identified: male sex (odds ratio(OR), 1.29; 95% confidence interval(CI), 1.08−1.53; p = 0.005), age (OR, 1.02; 95% CI, 1.01−1.03; p = 0.001), use of TXA (OR, 0.39; 95% CI, 0.34−0.45; p < 0.001), spinal anesthesia versus general anesthesia (OR, 0.71; 95% CI, 0.56−0.90; p = 0.004), and preoperative platelet count (OR, 0.96; 95% CI, 0.93−0.98; p = 0.001). Of these identified risk factors, preoperative platelet count, use of TXA, and spinal anesthesia are modifiable. These potentially modifiable risk factors need to be taken into consideration when making both the perioperative care and anesthesia plan by surgeons and anesthesiologists, especially in patients at risk of significant hemorrhage.

Airway management during left-sided gastrobronchial fistula repair after esophagectomy for esophageal carcinoma: A case report.

RATIONALE: Gastrobronchial fistula (GBF) is a rare but life-threatening complication of esophagectomy with gastric conduit reconstruction, and airway management during fistula repair is challenging. Here, we describe airway management in a patient undergoing left-sided GBF repair using video-assisted thoracoscopic surgery. PATIENT CONCERNS: A 63-year-old man diagnosed with esophageal carcinoma underwent esophagectomy with reconstruction by gastric pull-up and tabularization of the gastric conduit. Subsequently, about 8 weeks later, the patient presented with repeated pneumonia and a 1-week history of cough with significant sputum, dysphagia, and repeated fever. DIAGNOSIS: GBF, a rare postoperative complication, was located on the left main bronchus at 2 cm below the carina and was diagnosed based on findings from gastroscopy, flexible bronchoscopy, and thoracic computed tomography scan with contrast. INTERVENTIONS: We performed left-sided one-lung ventilation (OLV) under total intravenous anesthesia instead of inhalational anesthetics. The left-sided OLV, with positive end-expiratory pressure (PEEP) and nasogastric tube decompression, generated positive pressure across the fistula. It prevented backflow into the left main bronchus. Total intravenous anesthesia preserved hypoxic pulmonary vasoconstriction and prevented adverse effects associated with inhalational anesthetics. A right-sided, double-lumen endotracheal tube was inserted after anesthesia induction, and surgical repair was performed through a right-sided video-assisted thoracoscopic surgery. OUTCOMES: Intraoperative hemodynamics remained relatively stable, except for brief tachycardia at 113 beats/min. Arterial blood gas analysis revealed pH 7.17 and PaO2 89.1 mmHg upon 100% oxygenation, along with hypercapnia (PaCO2 77.1 mmHg), indicating respiratory acidosis. During OLV, pulse oximetry remained higher than 92%. The defect in the left main bronchus was successfully sutured after dissecting the fistula between the left main bronchus and the gastric conduit, and subsequently, OLV resulted in ideal ventilation. LESSONS: A left-sided GBF could lead to leakage from the OLV during surgery. Possible aspiration or alveolar hypoventilation due to this leakage is a major concern during airway management before surgical repair of the main bronchus.

Colorectal Cancer Risk in Patients with Hemorrhoids: A 10-Year Population-Based Retrospective Cohort Study.

Colorectal cancer (CRC) is a common disease and one of the leading causes of cancer deaths worldwide. This retrospective cohort study evaluated the risk of developing CRC in people with hemorrhoids. Using Taiwan's National Health Insurance Research Database, we established three sets of retrospective study cohorts with and without hemorrhoids. The first set of cohorts were matched by sex and age, the second set of cohorts were matched by propensity score without including colonoscopies, and the third set of cohorts were matched by propensity score with colonoscopies, colorectal adenomas, and appendectomies included. In the second set of cohorts, 36,864 persons with hemorrhoids that were diagnosed from 2000 to 2010 and a comparison cohort, with the same size and matched by propensity score, were established and followed up to the end of 2011 to assess the incidence and Cox proportional regression-measured hazard ratio (HR) of CRC. The overall incidence rate of CRC was 2.39 times greater in the hemorrhoid cohort than it was in the comparison cohort (1.29 vs. 0.54 per 1000 person-years), with a multivariable model measured adjusted HR of 2.18 (95% CI = 1.78-2.67) after controlling for sex, age, and comorbidity. Further analysis on the CRC incidence rates among colorectal sites revealed higher incidence rates at the rectum and sigmoid than at other sites, with adjusted HRs 2.20 (95% CI = 1.48-3.28) and 1.79 (95% CI = 1.06-3.02), respectively. The overall incidence rates of both cohorts were similar in the first and second sets of cohorts, whereas the rate was lower in the third set of hemorrhoid cohorts than in the respective comparison cohorts, probably because of overmatching. Our findings suggest that patients with hemorrhoids were at an elevated risk of developing CRC. Colonoscopy may be strongly suggested for identifying CRC among those with hemorrhoids, especially if they have received a positive fecal occult blood test result.