Nonintubated bronchoscopic interventions with high-flow nasal oxygen: A retrospective observational study.

ABSTRACT: To determine the feasibility on maintaining oxygenation of high-flow nasal oxygenation (HFNO) with bispectral index-guided intravenous anesthesia for nonintubated interventional bronchoscopy (NIIB). If desaturation happens, the factors influencing intraprocedural desaturation were also analyzed.This is a single-center retrospective study on patients receiving NIIB with HFNO and intravenous anesthesia guided by bispectral index levels to the depth of general anesthesia, which were between 40 and 60. Intraprocedural desaturation (SPO2 < 90%) and complications (bleeding, delayed discharge, unexpected admission) were collected. Factors affecting desaturation and complications were analyzed including patients' factors (age, American Society of Anesthesiologists classification, body mass index [BMI]), procedural factors (procedural time, with or without use of cryoprobe), and setting (outpatient or hospitalized).Records of 223 patients receiving NIIB were collected. The NIIB procedures time was 56.1 ±â€Š26.8 minute. Sixty patients (26.9%) presented desaturation events. Higher BMI, but not procedure time or setting, was significantly associated with desaturation. The desaturation were resolved after relieving upper airway obstruction but 1 patient required bag-valve-mask ventilation to restore oxygenation. Accidental massive bleeding and intraprocedural desaturation during tracheal and bronchial recannulation with cryoprobes happened in 2 patients and 1 of them was admitted to intensive care unit.HFNO is feasible to maintain oxygenation during NIIB only if there is effective upper airway management especially for patients with higher BMI. Longer procedural time and different setting did not affect the desaturation rate. Complications and unexpected admission were associated with the use of cryoprobes.

Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial.

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter-incision incongruent for cesarean delivery. METHODS: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. RESULTS: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). CONCLUSIONS: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

mTOR Inhibitors Can Enhance the Anti-Tumor Effects of DNA Vaccines through Modulating Dendritic Cell Function in the Tumor Microenvironment.

The life span of dendritic cells (DCs) can become short following induced activation, which is associated with metabolic transition due to the regulation of mechanistic target of rapamycin (mTOR). The purpose of this study was to investigate the potential of inhibiting mTOR to modulate DC functions for elevating the anti-tumor effects of DNA vaccines. Therefore, the influences of various inhibitors of mTOR (mTORi) on the expressions of DC maturation markers, the abilities of antigen presenting and processing of BMM-derived DCs and the tumor killing effects of E7-specific CD8+ T lymphocytes activated by BMM-derived DCs were in vitro examined. The anti-tumor effects of connective tissue growth factor (CTGF)/E7 DNA vaccine and/or mTORi were also in vivo analyzed. In our study, suppressive effects of mTORi on the DC maturation markers expressed on BMMCs could be reversed. The mTORi-treated mature BMM-derived DCs tended to be non-apoptotic. These mTORi-treated BMM-derived DCs could have better antigen presenting and processing abilities. The E7-specific cytotoxic CD8+ T lymphocytes could have more potent tumoricidal activity following activation of mTORi-treated BMM-derived DCs. For tumor-bearing mice, those treated with CTGF/E7 DNA vaccine and mTORi indeed can have higher percentages of mature DCs in the TME, better disease control and longer survivals. Consequently, application of mTORi can be a pharmacological approach for temporally increasing life span, antigen presenting and antigen processing of DCs to strengthen the therapeutic outcome of cancer immunotherapy.

Mirtazapine, in orodispersible form, for patients with preoperative psychological distress: A pilot study.

BACKGROUND: Perioperative psychological distress is associated with preoperative anxiety, depression, and postoperative pain. Mirtazapine is effective as an antidepressant, anxiolytic agent, and sleep enhancer. Moreover, mirtazapine can be made as orodispersible tablets with a fast onset for patients in nil per os status. This study is to determine whether mirtazapine can help psychologically distressed patients reduce perioperative anxiety, depression, and postoperative pain. MATERIALS AND METHODS: Patients with preoperative psychological distress, undergoing major abdominal surgery, were inquired and assigned to two groups according to their own choice. In the treatment group, patients could choose to take orodispersible mirtazapine 30 mg at each night from Preoperative Day 0 to Postoperative Day 3. There was no other intervention in the nontreatment group. Hospital Anxiety and Depression Scale (HADS), Athens Insomnia Scale (AIS), and pain scores were accessed on the day before operation (Day 0), and on the 1(st) day (Day 2) and 3(rd) day (Day 4) after operation. We compared the HADS, AIS, and pain scores, and morphine consumptions between the two groups on a daily basis. Marginal regression models were fitted to our correlated longitudinal data alone with the generalized estimating equations method to estimate the population average effects of time-varying mirtazapine usage on the mean values of HADS, AIS, and pain scores, and daily morphine consumptions. RESULTS: From September 2007 to December 2008, 86 patients agreed to be enrolled and 79 of them completed the study. Propensity scores and multivariate analysis showed that mirtazapine reduced HADS scores of patients in 2 days. Trial results indicated that mirtazapine lowered the AIS day index and tended to decrease night index as well. Mirtazapine may reduce patients' morphine consumption, but this effect was not statistically significant (p = 0.2). CONCLUSION: Mirtazapine helps reduce anxiety, depression, and insomnia scores for patients with perioperative psychological distress.

Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation.

OBJECTIVES: Thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation without endotracheal intubation is a promising technique for selected patients, but little is known about its feasibility and safety. METHODS: We evaluated 109 patients with lung (105), mediastinal (3) or pleural (1) tumours treated using non-intubated thoracoscopic surgery. Internal, intercostal nerve block was performed at the T3-T8 intercostal level and vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. RESULTS: Thoracoscopic lobectomy was performed in 43 patients, wedge resection in 50, segmentectomy in 12 and mediastinal or pleural tumour excision in 4. Three patients (2.8%) required conversion to intubated one-lung ventilation because of vigorous mediastinal movement and dense diaphragmatic adhesions. Anaesthetic induction and operation had a median duration of 10.0 and 127.0 min, respectively. Operative complications developed in 13 patients with air leaks for more than 3 days and 1 patient required transfusion of blood products. The median postoperative chest drainage and hospital stay were 2.0 and 4.0 days, respectively. CONCLUSIONS: Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation is technically feasible and safe in surgical treatment of lung, mediastinal and pleural tumours in selected patients.

Patient-controlled analgesia (PCA) following video-assisted thoracoscopic lobectomy: comparison of epidural PCA and intravenous PCA.

OBJECTIVES: To compare the efficacy and side effects of epidural patient-controlled analgesia (EPCA) with those of intravenous patient-controlled analgesia (IVPCA) in fast-track video-assisted thoracoscopic (VATS) lobectomy. PATIENTS AND METHODS: EPCA or IVPCA was chosen by patients and was started immediately following tracheal extubation in the wake of completion of VATS lobectomy. EPCA analgesia was carried out with the PCA device programmed to deliver a bolus dose of 3 mL of 0.1% bupivacaine combined with 1.2 µg/mL fentanyl, and continuous epidural infusion at a rate of 4 mL/hour through an epidural catheter placed at the T(6-7) or T(7-8) level. IVPCA was made possible by a patient controlled infusion pump programmed to deliver 0.1% morphine with a loading dose of 3 mg, and the controlled bolus of 1 mg, at a lockout interval of 5 minutes. A rescue dose of 5 mg intravenous morphine was available for all patients in postoperative care unit. Pain management was assessed with visual analog scale at rest (VAS-R) and during motion (VAS-M); side effects including nausea, vomiting, pruritus, dizziness and sleepiness were recorded and analyzed from postoperative Day 1 (POD1) to Day 3 (POD3). RESULTS: This study included 105 patients. Satisfactory pain control was achieved, although 9/70 patients in the EPCA group and 5/35 patients in the IVPCA group needed rescue morphine in the recovery room. The VAS-R was significantly higher on POD1 than on POD2 or POD3 in both groups (p < 0.001). The VAS-R and VAS-M were comparable in both groups on POD1 and POD3 but significant lower VAS-M was seen in the EPCA group on POD2 (p = 0.008). Higher incidence of dizziness was found in the IVPCA group on POD1 (p = 0.044) but the EPCA group had a higher incidence of pruritus on POD2 (p = 0.024) and POD3 (p = 0.03). CONCLUSION: Our results indicated that the necessity of pain control was higher on POD1 for VATS lobectomy. Both EPCA and IVPCA can provide an adequate, continuous and effective means for postoperative pain management and a lower VAS-M was found in EPCA on POD2.