Impact of warm saline irrigation, hyperthermic intraperitoneal chemotherapy on postoperative pain in primary ovarian cancer from the KOV-HIPEC-01 randomized trial.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a treatment option at the time of cytoreductive surgery after neoadjuvant chemotherapy. The effect of active warming of HIPEC on postoperative pain needs to be investigated. This study aimed to investigate whether HIPEC reduces postoperative pain. METHODS: From the KOV-HIPEC-01 trial, a randomized controlled trial of HIPEC for advanced primary ovarian cancer, 184 patients with a residual tumor size <1 cm were randomly assigned to the HIPEC and control groups at a 1:1 ratio. The consumption of analgesics and pain scales were analyzed. Hyperthermic intraperitoneal chemotherapy was administered after cytoreductive surgery. The primary objective was to compare the consumption of opioids measured in morphine milligram equivalents and non-opioids measured as the maximum daily dose between the HIPEC and control groups. The secondary objective was to compare the minimum and maximum pain intensities on numeric rating scales between the two groups using a linear mixed model. RESULTS: Lesser consumption of non-opioids, with a lower mean maximum daily dose on postoperative days 1 and 2, was observed. The HIPEC group also experienced lower maximum pain intensities on postoperative day 1. No overall differences in the minimum or maximum pain intensities were observed on postoperative day 7. CONCLUSION: The addition of HIPEC to cytoreductive surgery did not lead to increased postoperative pain, as demonstrated by a reduction in the use of analgesics and lower scores on postoperative pain scales during the early postoperative period.

Arytenoid dislocation after uneventful endotracheal intubation: a case report.

Arytenoid dislocation is an unusual complication of endotracheal intubation. We reported a case of a 48-year-old female with arytenoid dislocation after uneventful endotracheal intubation, which was successfully treated with arytenoid reduction. The patient complained of persistent hoarseness until the fourth day after an uneventful gynecologic surgery under general anesthesia. On laryngoscopic examination, paralyzed left vocal cord with minimal arytenoid movement was observed. An anteromedial dislocation of the left arytenoid cartilage was suspected and surgical reduction was performed by the laryngologist. The hoarseness was immediately resolved after surgical intervention. Anesthesiologists should be careful not to cause laryngeal trauma in anesthetized patients. In addition, early diagnosis and prompt surgical reduction are essential for a better prognosis for arytenoid dislocation.

Improved Postoperative Pain Control for Cytoreductive Surgery in Women With Ovarian Cancer Using Patient-Controlled Epidural Analgesia.

OBJECTIVE: Many studies have compared different methods of postoperative pain management in abdominal laparotomy patients; however, the conclusions have been inconsistent and controversial. This study aimed to compare the pain scores and complications of patients who underwent cytoreductive surgery for ovarian cancer and used either patient-controlled epidural analgesia (PCEA) or patient-controlled intravenous analgesia (PCA) for postoperative pain management. We hypothesized that PCEA would be superior to PCA for postoperative pain management in ovarian cancer surgery. MATERIALS AND METHODS: The medical records of women who underwent ovarian cancer surgery in 2014 were reviewed retrospectively. Pain scores for postoperative days (PODs) 0 to 5 days and the incidence of complications were examined and compared in patients who received PCEA and PCA. Means were compared using an independent sample t test or Wilcoxon rank sum test, and proportions were compared using Fisher exact test or a χ(2) test at each time point. A mixed-effects model was applied to determine correlations among repeated measurements. A P value less than 0.05 was considered significant. RESULTS: Of the 105 study patients, 38 received PCEA and 67 received PCA. Pain scores were significantly lower in the PCEA group than the PCA group at POD 0 (2.47 ± 1.75 vs 4.39 ± 1.17; P < 0.001), 1 (2.65 ± 1.02 vs 3.32 ± 1.09; P < 0.001), and 3 (2.17 ± 1.13 vs 2.79 ± 1.08; P = 0.011), and tended to be lower in the PCEA group at PODs 2, 4, and 5. Patient-controlled epidural analgesia provided significantly better pain relief as analyzed by a mixed-effect model. Complications were not significantly different between both groups. There was no significant difference in pain relief between both groups at PODs 4 and 5. CONCLUSIONS: Patient-controlled epidural analgesia was more effective for postoperative pain management compared with PCA from POD 0 to POD 3 in patients with ovarian cancer who underwent cytoreductive surgery, without increasing the morbidity.

Comparison of the central venous pressure from internal jugular vein and the pressure measured from the peripherally inserted antecubital central catheter (PICCP) in liver transplantation recipients.

BACKGROUND: Unlike its use during stable conditions, central venous pressure (CVP) monitoring from a peripherally inserted central venous catheter (PICC) has not often been used in surgeries with significant hemodynamic alterations. The aim of this study was to evaluate the feasibility of measuring PICC pressure (PICCP) as an alternative to measuring centrally inserted central catheter pressure (CICCP) in adult liver transplantation (LT) patients. METHODS: We measured PICCP and CICCP simultaneously during each main surgical period in adult LT. Statistical analysis was performed using simple linear regression analysis to observe whether changes in PICCP paralleled by simultaneous changes in CICCP. Correlation analysis and Bland-Altman analysis were used to determine the degree of agreement between the two devices. Differences were considered statistically significant when P values were less than 0.05. RESULTS: A total of 1342 data pairs were collected from 35 patients. The PICCPs and CICCPs were highly correlated overall (r = 0.970, P < 0.001) as well as at each period measured. The differences among each period were not clinically significant (0.33 mmHg for pre-anhepatic, 0.32 mmHg for anhepatic, -0.15 mmHg for reperfusion, and -0.10 mmHg for neohepatic periods). The overall mean difference was 0.14 mmHg (95% confidence interval: 0.09-0.19) and PICCP tended to give a higher reading by between 0.09 and 0.19 mmHg overall. The limit of agreement was -1.74 to 2.02 overall. CONCLUSIONS: These findings suggest that PICCP can be a reasonable alternative to CICCP in situations of dynamic systemic compliance and preload, as well as under stable hemodynamic conditions.

Unpredicted tachycardia and hypotension in a patient with medullary thyroid cancer and undiagnosed pheochromocytoma: A case report.

A 35 year old woman with hypercalcitoninemia was scheduled for an operation to treat her medullary thyroid cancer (MTC). TIVA with propofol and remifentanil was planned, and about 3 minutes after the infusion of anesthetics, her heart rate was suddenly elevated to 180/min and the systolic blood pressure was lowered to nearly 50 mmHg. The blood pressure returned to normal after the injection of phenylephrine 100 microgram and a rapid infusion of 700 ml crystalloid solution. After the operation, bilateral pheochromocytoma and a RET proto-oncogene mutation related with multiple endocrine neoplasia 2A (MEN-2A) were found. Patients with MTC can present with peripheral vasodilation and relative hypovolemia that are related with hypercalcitoninemia. Patients with MEN-2A can be anesthetized for a MTC operation without the appropriate preparation for their pheochromocytoma. Therefore, we suggest that patients with MTC and hypercalcitoninemia should be cautiously anesthetized with TIVA. They also should be screened for pheochromocytoma and the RET proto-oncogene mutation to prevent deleterious hemodynamic events during anesthesia.

Propofol reverses oxidative stress-attenuated glutamate transporter EAAT3 activity: evidence of protein kinase C involvement.

The authors investigated the effects of propofol on EAAT3 (excitatory amino acid transporter 3) activity under oxidative stress induced by tert-butyl hydroperoxide (t-BHP), and the mediation of these effects by protein kinase C (PKC). Rat EAAT3 was expressed in Xenopus oocytes and L-glutamate (30 microM)-induced membrane currents were measured using the two-electrode voltage clamp technique. Exposure of these oocytes to t-BHP (1-20 mM) for 10 min dose-dependently decreased EAAT3 activity, and t-BHP (5 mM) significantly decreased the Vmax, but not the Km of EAAT3 for glutamate, and propofol (1-100 microM) dose-dependently reversed this t-BHP-attenuated EAAT3 activity. Phorbol-12-myristate-13-acetate (a PKC activator), also abolished this t-BHP-induced reduction in EAAT3 activity, whereas staurosporine (a PKC inhibitor), significantly decreased EAAT3 activity. However, as compared with staurosporine or t-BHP alone, t-BHP and staurosporine in combination did not further reduce EAAT3 activity. A similar pattern was observed for chelerythrine (also a PKC inhibitor). In oocytes pretreated with combinations of t-BHP and PMA (or staurosporine), propofol failed to change EAAT3 activity. Our results suggest that propofol restores oxidative stress-reduced EAAT3 activity and that these effects of propofol may be PKC-mediated.

Effects of intravenous anesthetics on the activity of glutamate transporter EAAT3 expressed in Xenopus oocytes: evidence for protein kinase C involvement.

We investigated the effects of the intravenous anesthetics, thiopental, etomidate and ketamine, on the activity of one type of glutamate transporters, EAAT3 (excitatory amino acid transporter type 3). Rat EAAT3 was expressed in Xenopus oocytes by injection of its mRNA. Using two-electrode voltage clamp, membrane currents were recorded after the application of L-glutamate (30 microM) in the presence or absence of various concentrations of the anesthetics. Thiopental (0.3-30 microM) and ketamine (3-1000 microM) did not affect EAAT3 activity. Etomidate decreased EAAT3 activity in a concentration-dependent manner (0.10-10 microM). Etomidate at 1 microM significantly decreased the Vmax, but not the Km of EAAT3 for glutamate. Chelerythrine, a protein kinase C (PKC) inhibitor, significantly decreased EAAT3 activity, however, there were no statistical differences among the chelerythrine, etomidate or chelerythrine plus etomidate groups. Likewise, the combination of staurosporine, another PKC inhibitor, and etomidate did not decrease the responses further compared with staurosporine or etomidate alone. Phorbol-12-myrisate-13-acetate, a PKC activator, abolished etomidate-induced decrease in EAAT3 activity. Since our results showed that thiopental and ketamine did not affect EAAT3 activity significantly, EAAT3 may not be a target for their anesthetic effects. Our results also suggest that etomidate, possibly via PKC, decreased EAAT3 activity at clinically relevant concentrations.