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Correlation of Bedside Airway Screening Tests With Airway Obstruction During Drug-Induced Sleep Endoscopy

Objective: Obstructive sleep apnoea hypopnoea syndrome associated with obesity poses major perioperative airway challenge. Drug-induced sleep endoscopy (DISE), is a real-time upper airway flexible fiberoptic nasoendoscopy in awake and sedation/anaesthesia-induced sleep. The aim of current study was to assess the correlation of bedside airway screening tests with level of obstruction during DISE. Methods: Study was performed in endoscopy suite. Parameters calculated in 40 study group patients were Berlin questionnaire responses, Apnea hypopnea index (AHI), interincisor distance, Mallampati classification (MPC), neck circumference (NC), thyromental distance (TMD), NC/TMD ratio, sternomental distance (SMD), upper lip bite test, lateral cephalometry derived gonial angle and mentohyoid distance (MHD), Muller's manoeuvre during awake nasoendoscopy, Croft-Pringle grade of airway obstruction during DISE and effect of jaw thrust. Results: All patients were American Society of Anesthesiologists physical status 1 and 2 with AHI ＞ 30. Positive responses to Berlin questionnaire, body mass index and AHI increased with increasing grade of DISE. DISE grades 1-5 were observed in 0% (0), 5% (2), 37.5% (15), 27.5% (11) and 30% (12) patients respectively. Muller's manoeuvre showed lateral wall collapse in 40% (16) patients and concentric collapse in 40% (16) patients. Airway patency improved with jaw thrust in 60% (24) patients. Significant association of DISE was found with MPC (p = 0.028), TMD (p = 0.003), MHD (p = 0.008) and NC/TMD ratio (p = 0.002), effect of Muller's manoeuvre (p =0.002), and effect of jaw thrust (p = 0.000). Conclusions: Bedside screening tests MPC, TMD, NC/TMD ratio and MHD correlate significantly with level of obstruction during DISE.

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Pharmacological Approach for the Prevention of Postoperative Shivering: A Systematic Review of Prospective Randomized Controlled Trials

Shivering is a common postoperative complication that occurs after both general and regional anesthesia even in the cases when hypothermia during surgery has been averted. Patients describe it as a highly unpleasant experience, while clinicians are concerned due to its adverse effects such as increased oxygen consumption. In this article, we present a summary of the pathophysiological mechanisms involved in postoperative shivering (POS), risk factors, and inadvertent effects. The major objective of this article was to review the existing literature on the efficiency of various drug interventions as a prophylactic measure against POS. Since α2-adrenergic, opioid, anticholinergic, and serotonergic pathways are thought to play a role in the pathogenesis of POS, a wide variety of drugs has been investigated in this regard. Although the methodological diversity of the study designs and regimens does not support drawing definite conclusions, there is evidence indicating a beneficial effect of dexmedetomidine, ketamine, tramadol, meperidine, dexamethasone, nefopam, granisetron, and ondansetron in the prevention of POS. The purpose of this review is to provide a thorough insight on various drug options and to serve as an aid for clinicians for careful analysis of the advantages and disadvantages of each regimen to decide which regimen will be ideally suited for the medical profile of each patient.

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Percutaneous Cervical Cordotomy for Managing Pain in Terminal Malignant Sarcoma and the Accompanied Shared Decision-Making: A Case Report

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A Comparison Between Thiopental Sodium and Propofol for Induction of Anesthesia in Elective Cesarean Section Using Bispectral Index and Isolated Forearm Technique: A Randomized, Double-Blind Study

Objective: Although regional anesthesia is the most frequently used method for selected surgical approaches, general anesthesia (GA) is still common. Awareness and recall of events are among the main hazards during GA, particularly in Caesarean Section (C/S). In this study, we decided to compare depth of anesthesia, that was measured by Bispectral index (BIS) and isolated forearm technique (IFT) in GA, induced by propofol vs. thiopental for elective C/S. We also aimed to determine the incidence of postoperative recall using these two anesthetic medications. Methods: Ninety parturient were allocated to receive either thiopental (group T) or propofol (group P) with blocking on a 1:1 ratio. All patients underwent standard GA. BIS and IFT were used to monitor depth of anesthesia at different predetermined perioperative events. All patients were evaluated for recall of the events. Results: No patient recalled the perioperative events during the follow up period. BIS scores were significantly lower in group P compared with group T after induction of GA until discontinuation of volatile anesthetics (p ＜ 0.001). IFT values were significantly higher in thiopental group in time interval of induction to skin incision comparing to propofol group (p ＜ 0.050). Conclusion: The current study suggests regarding better effect of propofol on decreasing of awareness during anesthesia and surgery, it seems to be better to use propofol in cases where we are forced to use GA in cesarean section.

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Burnout in Anesthesiology, Critical Care, and Perioperative Care Clinicians in Asia: A Developing Picture

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Risk Factors and Mechanisms of Postoperative Delirium After Intracranial Neurosurgical Procedures

Postoperative delirium (POD) is a condition characterized by cerebral dysfunction or failure and associated with high morbidity and mortality, prolonged intensive care unit and hospital stay, increased costs and long-term disability. The risk factors can be divided into three categories: preoperative, intraoperative, and postoperative. POD is underrecognized, underdiagnosed, and undertreated condition which can also lead to potentially life-threatening conditions. Prevention and treatment of POD include adequate perioperative pain control, maintenance of optimal blood pressure, water-electrolyte balance, hypo- and hyperglycemia, sleep hygiene. Despite POD has been extensively studied in various types of surgery, there is not enough evidence on POD in intracranial neurosurgery. Patients undergoing open craniotomy might be at particular risk because on top of the above-mentioned factors, they also might have a direct neurosurgical brain injury. Future research on the POD in neurosurgical patients after intracranial interventions is needed. A bibliographic search was performed in the MEDLINE and PubMed virtual library. The following descriptors were used: POD, neurosurgery, anesthesia, and POD, postoperative pain management and POD, water and electrolyte imbalance and POD, neurochemistry of POD. We included in this review original and review articles in the English language. Majority of non-neurosurgical patients have multiple risk factors for POD (preoperative, intraoperative, and postoperative); patients undergoing intracranial neurosurgery on top of that might have additional risks associated with neurosurgical pathology (brain tumor, cerebral hemorrhage, and severe traumatic injury) as well as neurosurgery-induced brain injury can also appear to be a contributing factor.

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Increase in Intraoperative Urine Output During Tympanoplasty: A Retrospective Cohort Study

Objective: We sometimes encounter cases with unexpected increase in intraoperative urine output during tympanoplasty. However, no previous study has evaluated whether intraoperative urine output during tympanoplasty is higher than that during other surgeries. Thus, this study aimed to evaluate the association between tympanoplasty and intraoperative urine output. Methods: This single-center retrospective cohort study was conducted by assessing the records of patients who underwent tympanoplasty, sinus surgery, or thyroidectomy under general anesthesia between April 2013 and March 2017. We defined intraoperative polyuria as a urine output rate of ≥ 2.5 mL/kg/h. The factors associated with high urine output were investigated using multivariable analysis. The influence of tympanoplasty on intraoperative urine output was evaluated after propensity score matching that excluded confounding factors, except the surgical procedure. Results: Intraoperative polyuria occurred in 48 of 173 patients (27.7%) who underwent tympanoplasty. Multivariable analysis revealed that tympanoplasty (p = 0.001), operative time of ≥ 3 h (p = 0.010), and fluid infusion volume of ≥ 5 mL/kg/h (p = 0.029) were risk factors for polyuria. Among the study patients, 100 who underwent tympanoplasty (tympanoplasty group) and 100 who underwent sinus surgery or thyroidectomy (control group) were matched by propensity score analysis. The intraoperative urine output rate was significantly higher in the tympanoplasty group than in the control group (1.2 [0.51-2.20] mL/ kg/h vs. 0.70 [0.32-1.60] mL/kg/h, p = 0.010). Conclusion: Our findings indicate that intraoperative urine output is higher during tympanoplasty than that during other otologic surgeries.

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The Effect of Melatonin on the Serum Level of Interleukin 6 and Interleukin 9 in Coronary Artery Bypass Grafting Surgery

Objective: Cardiopulmonary bypass has been recognized as one of the main causes of systemic inflammatory response syndrome, leading to post-operative complications. The aim of this study was to investigate the effect of melatonin on the serum levels of interleukin 6 (IL-6) and interleukin 9 (IL-9) in patients undergoing coronary artery bypass grafting surgery. Methods: Forty-four patients undergoing elective coronary artery bypass surgery were randomly allocated into two study groups of melatonin (n = 23) and placebo (n = 21). Patients in the melatonin group received two melatonin tablet, 5 mg daily for three days before surgery, 10 mg tablet (two doses of 5 mg) 1 h before induction of anesthesia and finally, 10 mg melatonin tablet in the intensive care unit, placebo group patients received placebo at the same time periods. Serum levels of IL-9 and IL-6 were measured as baseline (T1), before induction of anesthesia (T2), 6 and 24 h after off pump (T3, T4). Data were analyzed using SPSS 23 software (IBM Corp., Armonk, NY, USA). Results: The mean serum level of IL-6 was significantly lower in the melatonin group at T3 and T4 (p ＜ 0.05). Also, in both groups, serum levels of IL-6 in T3 showed a significant increase compared to T1. Serum levels of IL-9 had no significant difference between the two groups at T1, T2, T3, and T4. Conclusion: The results of this study showed that pre-operative melatonin administration could modify inflammatory cytokines secretion such as IL-6 while it has no significant effect on the serum levels of IL- 9. Neither of the changes was clinically significant.

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Mortality Risks for Dialysis Patients: A Nationwide Population-Based Study

Objective: Several studies have demonstrated increased postoperative mortality rates in patients on chronic hemodialysis compared with non-dialyzed patients. However, limited studies have examined factors that may contribute to postoperative mortality. Methods: In this retrospective cohort study, data were collected from 9,140 dialysis and 45,725 non-dialysis patients undergoing surgery between 2007 to 2009 from Taiwan's National Health Insurance Registry Database. Patient demographics, comorbidities, and anesthesia duration were used to compare 30-day postoperative mortality differences in dialysis patients. Results: Dialysis patients undergoing first-time surgery were significantly older, more likely male, and possessed more comorbidities. Overall, dialysis patients had significantly higher all-cause postoperative mortality (odds ratio, 15.005; 95% confidence interval, 11.917-18.893). Gender (hazard ratio [HR], 0.762), age (HR, 1.012), longer duration of inhalation general anesthesia (HR, 1.113), and comorbidities of hypertension (HR, 0.759), diabetes (HR, 1.339), congestive heart failure (HR, 1.232), coronary artery disease (HR, 1.326), cerebral vascular accident (HR, 1.312), intracranial hemorrhage (HR, 6.765), gastrointestinal bleeding (HR, 1.396), and liver cirrhosis (HR, 2.027), independently increased postoperative mortality risk in dialysis patients. Of the comorbidities, intracranial hemorrhage posed the greatest risk. Conclusion: Patient demographics, anesthesia factors, and comorbidities help dialysis patients understand their postoperative mortality. These potential risk factors also inform anesthesiologists and surgeons weight perioperative conditions in dialysis patients before surgery.

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Evaluating a Dynamic Trend in the Estimated Continuous Cardiac Output Calibrated With Invasive and Non-Invasive Methods

Objective: This study compared the estimated continuous cardiac output (esCCO) system and an arterial pressure-based cardiac output (APCO) system. The goal of this study was to evaluate the dynamic trend of the esCCO calibrated with an invasive and non-invasive method. Methods: We retrospectively identified 12 cases with complete data for the two calibration methods. Two calibration methods were analysed and compared with APCO using polar plots. Results: Polar plotting revealed that the mean angular bias was 10.0°, and the radial limit of agreement was 37.1° when calibrated with the invasive method, while the mean angular bias was 3.5°, and the radial limits of agreement were 28.3° with the non-invasive method. Conclusion: This study suggested that the accuracy of a dynamic trend of esCCO may not be affected by the calibration methods, and the esCCO measurement by the non-invasive calibration method may be an effective device similar to that by the invasive calibration method.