For this guidance article, the Ethics Review Task Force (ERTF) of the Journal reviewed and discussed the ethics issues related to publication of human research in the field of anesthesia. ERTF first introduced internatio...For this guidance article, the Ethics Review Task Force (ERTF) of the Journal reviewed and discussed the ethics issues related to publication of human research in the field of anesthesia. ERTF first introduced international ethics principles and minimal requirements of reporting of ethics practices, followed by discussing the universal problems of publication ethics. ERTF then compared the accountability and methodology of several medical journals in assuring authors' ethics compliance. Using the Taiwan Institutional Review Board system as an example, ERTF expressed the importance of institutional review board registration and accreditation to assure human participant protection. ERTF presented four major human research misconducts in the field of anesthesia in recent years. ERTF finally proposed a flow-chart to guide journal peer reviewers and editors in ethics review during the editorial process in publishing. Examples of template languages applied in the Ethics statement section in the manuscript are expected to strengthen the ethics compliance of the authors and to set an ethical culture for all the stakeholders involved in human research.
Cytokines are key modulators of inflammatory responses, and play an important role in the defense and repair mechanisms following trauma. After traumatic injury, an immuno-inflammatory response is initiated immediately,...Cytokines are key modulators of inflammatory responses, and play an important role in the defense and repair mechanisms following trauma. After traumatic injury, an immuno-inflammatory response is initiated immediately, and cytokines rapidly appear and function as a regulator of immunity. In pathologic conditions, imbalanced cytokines may provide systemic inflammatory responses or immunosuppression. Expression of perioperative cytokines vary by different intensities of surgical trauma and types of anesthesia and anesthetic agents. Inflammatory cytokines play important roles in postoperative organ dysfunction including central nervous system, cardiovascular, lung, liver, and kidney injury. Inhibition of cytokines could protect against traumatic injury in some circumstances, therefore cytokine inhibitors or antagonists might have the potential for reducing postoperative tissue/organ dysfunction. Cytokines are also involved in wound healing and post-traumatic pain. Application of cytokines for the improvement of surgical wound healing has been reported. Anesthesia-related immune response adjustment might reduce perioperative morbidity because it reduces proinflammatory cytokine expression; however, the overall effects of anesthetics on postoperative immune-inflammatory responses needs to be further investigated.
OBJECTIVES: Platonin possesses potent anti-inflammatory and antioxidative capacities. Because systemic inflammation and oxidative stress are crucial in mediating sepsis-induced blood-brain barrier (BBB) integrity loss, t...OBJECTIVES: Platonin possesses potent anti-inflammatory and antioxidative capacities. Because systemic inflammation and oxidative stress are crucial in mediating sepsis-induced blood-brain barrier (BBB) integrity loss, this study elucidated the effects of platonin on preserving BBB integrity in septic rats. METHODS: A total of 72 adult male rats (200-250 g) were randomized to receive cecal ligation and puncture (CLP), CLP plus platonin, sham operation, or sham operation plus platonin (n = 18 in each group). Systemic inflammation and oxidation levels and BBB integrity in the surviving rats were determined after 24-hour monitoring. RESULTS: Plasma levels of interleukin-6 (IL-6) and malondialdehyde (MDA)-markers of systemic inflammation and oxidation-and the grading of Evans blue staining of the brains, BBB permeability to Evans blue dye, and brain edema levels-markers of BBB integrity-in rats that received CLP were significantly higher than rats that received sham operation (all p < 0.001). By contrast, the plasma levels of IL-6 (p < 0.001) and MDA (p < 0.001), and the grading of Evans blue staining (p = 0.015), BBB permeability to Evans blue dye (p = 0.043), and brain edema levels (p = 0.034) in rats that received CLP plus platonin were significantly lower than rats that received CLP. Experimental data further revealed that the concentration of tight junction protein claudin-5, a major structural component of BBB, in rats that received CLP was significantly lower than rats that received CLP plus platonin (p = 0.023). CONCLUSION: Platonin could attenuate sepsis-induced BBB integrity loss in rats.
INTRODUCTION: This study aimed to investigate different types of regional anesthesia for cesarean section (CS) following epidural labor analgesia that could lead to various perioperative and postoperative outcomes. METHO...INTRODUCTION: This study aimed to investigate different types of regional anesthesia for cesarean section (CS) following epidural labor analgesia that could lead to various perioperative and postoperative outcomes. METHODS: We retrospectively included those parturients who received epidural labor analgesia but needed subsequent CS under regional anesthesia in our institution from January 2008 to June 2012. RESULTS: In all, 2341 of 6609 parturients underwent painless labor, and 334 of them converted to CS. Spinal anesthesia (SA) was used with 163 parturients, and epidural anesthesia (EA) with 96; the two groups were then compared. No high-level block or total SA was noted. The primary outcome revealed that the time from anesthesia to surgical incision and the total anesthesia time were shorter, hypotension episodes were more frequent, the rate of perioperative ephedrine administration was higher, and the rate of midazolam was lower in the SA group. With regard to secondary outcomes, the Apgar scores of the neonates recorded at 1 minute and 5 minutes and maternal satisfaction were similar. The neuraxial morphine dose was converted to parenteral morphine equivalent dose (MED), which revealed that the parturients in the spinal morphine group had lower dosages and visual analog scale (VAS) pain scores on postoperative Day 1. CONCLUSION: For parturients with labor epidural analgesia needing CS, the use of SA led to shorter anesthetic time and lower postoperative pain scores, with lower morphine doses compared with EA. However, the high failure rate with both neuraxial techniques needs to be addressed.
AIM: To evaluate and compare the Truview picture capture device (PCD) and C-MAC laryngoscope to the standard Macintosh laryngoscope in pediatric patients. METHODS: One hundred and fifty patients with American Society of...AIM: To evaluate and compare the Truview picture capture device (PCD) and C-MAC laryngoscope to the standard Macintosh laryngoscope in pediatric patients. METHODS: One hundred and fifty patients with American Society of Anesthesiology status Grade I-II (ASA I-II) who were 1-6 years old (10-20 kg) were scheduled for elective surgery. They were randomized into three equal groups for laryngoscopy and intubation by either the Truview PCD (Group T), C-MAC (Group C), or Macintosh laryngoscope (Group M) under general anesthesia. The percentage of glottic opening (POGO) score, application of external laryngeal maneuver, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation, and trauma were recorded and statistically analyzed. A value of p < 0.05 was considered significant. RESULTS: The POGO scores were significantly better with the Truview PCD (94.7 ± 12.91) than with the C-MAC and Macintosh laryngoscopes (82 ± 24.97 and 85.1 ± 17.07, respectively; p < 0.01). There were no failures, episodes of desaturation, or trauma in any of the patients. It took 19.24 seconds to intubate with the Truview PCD, compared to 12.32 seconds with the C-MAC laryngoscope and 10.7 seconds with the Macintosh laryngoscope (p < 0.01). An external laryngeal maneuver was required in 42% of patients in group C, compared to 38% in Group M and 16% in group T (p < 0.01). CONCLUSION: The Truview PCD offers the best laryngeal view, although it takes a longer time for intubation. The C-MAC laryngoscope provides similar laryngeal views as the Macintosh blade, and is an excellent teaching aid.
Both pneumocephalus and pneumorrhachis are rare but serious complications following epidural anesthesia. We report a rare case of simultaneous pneumocephalus and pneumorrhachis in a patient after undergoing epidural anes...Both pneumocephalus and pneumorrhachis are rare but serious complications following epidural anesthesia. We report a rare case of simultaneous pneumocephalus and pneumorrhachis in a patient after undergoing epidural anesthesia. The patient lost consciousness and received emergent external ventricular drainage for pneumocephalus in another medical center. The patient was clear after external ventricular drain placement until 4 days later, when sudden onset of subdural hemorrhage occurred and an emergent craniectomy was performed. The patient passed away 2 days after craniectomy, due to multiorgan failure. Pneumocephalus with or without pneumorrhachis should be kept in mind when there is a sudden change of consciousness or persistent convulsions after epidural anesthesia.
OBJECTIVE: This study evaluated the visibility of echogenic needles with older ultrasound devices in an in vitro phantom study. METHODS: We compared three echogenic needles from B. Braun (BB), Unisis (UN), and Hakko (HK)...OBJECTIVE: This study evaluated the visibility of echogenic needles with older ultrasound devices in an in vitro phantom study. METHODS: We compared three echogenic needles from B. Braun (BB), Unisis (UN), and Hakko (HK) with a nonechogenic needle. Each needle was inserted into an ultrasound phantom 10 times at 30° and 45° with the bevels up. The captured images of the needle and background contrast were digitally analyzed, and the median of 10 insertions for each angle was calculated to determine objective needle visibility. Needle images were also shown to 12 anesthesiologists to evaluate subjective visibility on a five-point Likert scale. RESULTS: The shafts of all the echogenic needles were significantly more objectively visible than the nonechogenic needles. Subjective visibilities of the BB and UN needles were significantly higher than that of the nonechogenic needle. Therefore, the BB and UN needles were judged to have more than fair subjective visibility. However, subjective visibility of the HK needle was consistently and significantly lower than that of the BB and UN echogenic needles. At 45°, the HK needle had nearly the same poor visibility as the nonechogenic needle. CONCLUSION: The results of our study indicate that the BB and UN needles are more visible than nonechogenic needles in an ultrasound phantom, even on older devices.
From September 2012 to March 2013, a total of 63 adult-to-adult living donor liver transplantations were performed at our institution. All the patients were monitored for their coagulation functions using rotation thromb...From September 2012 to March 2013, a total of 63 adult-to-adult living donor liver transplantations were performed at our institution. All the patients were monitored for their coagulation functions using rotation thromboelastometry (ROTEM, Tem Innovations GmbH) during the procedure at the following points: preoperative baseline, 5 minutes, 30 minutes, and 120 minutes, respectively, after reperfusion of the liver graft. A total of 84.13% of cases (n = 53) revealed fibrinolysis after reperfusion of the graft and the condition was reversed after 30 minutes without any need for additional treatment. No significant coagulopathy was observed during this period in all of the cases. The result of the ROTEM finding must correlate with the clinical situation before instituting any management to avoid the risk of thrombosis of the hepatic artery.
Air in the scrotum is an unusual clinical finding and a thorough search should be done in order to locate the air leak or source of gas production. We report an 81-year-old patient who developed severe acute respiratory...Air in the scrotum is an unusual clinical finding and a thorough search should be done in order to locate the air leak or source of gas production. We report an 81-year-old patient who developed severe acute respiratory failure after fiberoptic bronchoscopy and was intubated immediately. After tracheal intubation, excessive subcutaneous emphysema from the head to the scrotum was obvious. Chest tube thoracostomies were placed to treat pneumothorax. The emphysema was absorbed after 13 days without any sequela. Air or gas inside the scrotum may originate from intraperitoneal, extraperitoneal, or local sources. The majority of the cases can be managed conservatively, but emergent intervention is needed in life-threatening situations.
OBJECTIVES: Pediatric dentists perform moderate sedation frequently to facilitate dental treatment in uncooperative children. Assessing the depth and quality of sedation is an important factor in the clinical utilization...OBJECTIVES: Pediatric dentists perform moderate sedation frequently to facilitate dental treatment in uncooperative children. Assessing the depth and quality of sedation is an important factor in the clinical utilization of moderate sedation. We aimed to determine if the level of noise, created by the children who are undergoing moderate sedation during dental procedures, could be used as a nonsubjective measurement of the depth of sedation and compare it to the Ohio State Behavior Rating Score (OSBRS). METHODS: Following Institutional Review Board approval and after receiving informed consent, we studied 51 children with a mean age of 4.2 years and average weight of 18.5 kg, who were undergoing restorative or extractive dental procedures, requiring moderate sedation. Sedation efficacy was assessed using OSBRS at several stages of the procedure. The noise level was measured by using a NoisePRO logging device to record the noise level at a rate of every second throughout the procedure. RESULTS: The depth of sedation assessed by OSBRS during the operative procedure was significantly correlated with noise level. The act of administering the local anesthesia and the operative procedure itself were two phases of the encounter that were significantly associated with higher OSBRS as well as noise levels. CONCLUSION: Measurement of noise level can be used as an effective guide to quantify the depth of sedation at different stages of the dental procedure. It is a nonsubjective and continuous measurement, which could be useful in clinical practice for the administration of moderate sedation during dental procedures. By using noise level analysis we are able to determine successful, poor, and failed sedation outcome.
INTRODUCTION: Tolerance to and dependence on the analgesic effect of opioids is a pharmacological phenomenon that occurs after their prolonged administration. OBJECTIVE: The aim of this study was to evaluate the protecti...INTRODUCTION: Tolerance to and dependence on the analgesic effect of opioids is a pharmacological phenomenon that occurs after their prolonged administration. OBJECTIVE: The aim of this study was to evaluate the protective effects of ceftriaxone and amitriptyline on the development of morphine-induced tolerance and dependence. METHODS: In this study, 18 groups (9 groups each for tolerance and dependency tests) of mice (n = 8) received saline [10 mL/kg, intraperitoneally (i.p.)], morphine (50 mg/kg, i.p.), ceftriaxone (50 mg/kg, i.p., 100 mg/kg, i.p., and 200 mg/kg, i.p.), amitriptyline (5 mg/kg, i.p., 10 mg/kg, i.p., and 15 mg/kg, i.p.), or a combination of ceftriaxone (50 mg/kg, i.p.) and amitriptyline (5 mg/kg, i.p.) once per day for 4 days for investigation and comparison of the effects of ceftriaxone and amitriptyline on the prevention of dependency and tolerance to morphine. Tolerance was assessed with administration of morphine (9 mg/kg, i.p.) and using the hot plate test on the 5(th) day. In dependency tests, withdrawal symptoms were assessed on the 4(th) day for each animal 30 minutes after the administration of naloxone (4 mg/kg, i.p.; 2 hours after the last dose of morphine). RESULTS: It was found that treatment with ceftriaxone or amitriptyline attenuated the development of tolerance to the antinociceptive effect of morphine and also reduced naloxone-precipitated withdrawal jumping and standing on feet. Furthermore, coadministration of ceftriaxone and amitriptyline at low doses (50 mg/kg, i.p. and 5 mg/kg, i.p., respectively) prior to morphine injection also decreased both morphine-induced tolerance and dependence. CONCLUSION: Results indicate that the treatment with ceftriaxone and amitriptyline, alone or in combination, could attenuate the development of morphine-induced tolerance and dependence.
Although the pathophysiology of sepsis has been elucidated with the passage of time, sepsis may be regarded as an uncontrolled inflammatory and procoagulant response to infection. The hemostatic changes in sepsis range f...Although the pathophysiology of sepsis has been elucidated with the passage of time, sepsis may be regarded as an uncontrolled inflammatory and procoagulant response to infection. The hemostatic changes in sepsis range from subclinical activation of blood coagulation to acute disseminated intravascular coagulation (DIC). DIC is characterized by widespread microvascular thrombosis, which contributes to multiple organ dysfunction/failure, and subsequent consumption of platelets and coagulation factors, eventually causing bleeding manifestations. The diagnosis of DIC can be made using routinely available laboratory tests, scoring algorithms, and thromboelastography. In this cascade of events, the inhibition of coagulation activation and platelet function is conjectured as a useful tool for attenuating inflammatory response and improving outcomes in sepsis. A number of clinical trials of anticoagulants were performed, but none of them have been recognized as a standard therapy because recombinant activated protein C was withdrawn from the market owing to its insufficient efficacy in a randomized controlled trial. However, these subgroup analyses of activated protein C, antithrombin, and thrombomodulin trials show that overt coagulation activation is strongly associated with the best therapeutic effect of the inhibitor. In addition, antiplatelet drugs, including acetylsalicylic acid, P2Y12 inhibitors, and glycoprotein IIb/IIIa antagonists, may reduce organ failure and mortality in the experimental model of sepsis without a concomitant increased bleeding risk, which should be supported by solid clinical data. For a state-of-the-art treatment of sepsis, the efficacy of anticoagulant and antiplatelet agents needs to be proved in further large-scale prospective, interventional, randomized validation trials.
Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants...Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.
Acute kidney injury (AKI) secondary to ischemia-reperfusion injury (IRI) is a major cause of patient morbidity and mortality in the perioperative period. It can lead to new onset of chronic kidney disease and accelerate...Acute kidney injury (AKI) secondary to ischemia-reperfusion injury (IRI) is a major cause of patient morbidity and mortality in the perioperative period. It can lead to new onset of chronic kidney disease and accelerate its progression. Patients with risk factors undergoing cardiac, vascular, and liver transplantation surgeries, which may inevitably involve IRI, are more susceptible to AKI. Anesthetic agents have been postulated to possess renoprotective properties. Thus, exploring the utilization of selective perioperative anesthetic agents with renoprotective properties may be a promising avenue to reduce the risk of AKI. This review discusses the effects and mechanisms of dexmedetomidine, inhalational and intravenous anesthetics, and xenon-mediated renoprotection. Although the renoprotective effects of these agents obtained in the laboratory are promising, much work especially via clinical trials is required to determine the translational value from the bench to the bedside.
OBJECTIVE: It is aimed to evaluate whether there is a difference in regional cerebral saturation of newborns measured by near infrared spectroscopy born either by general anesthesia or combined spinal epidural anesthesia...OBJECTIVE: It is aimed to evaluate whether there is a difference in regional cerebral saturation of newborns measured by near infrared spectroscopy born either by general anesthesia or combined spinal epidural anesthesia during elective cesarean deliveries. METHODS: After approval from the ethics committee of our hospital, and informed consents of the parturients were taken, 68 patients were included in the study. The regional cerebral oxygen saturations (RcSO2) of newborns were measured by near infrared spectroscopy (NIRS) measurements at 1st, 5th min after birth. In group I (n=32), general anesthesia was performed for the cesarean operation and in group II (n=36), combined spinal epidural anesthesia (CSEA) was the anesthetic management. The age of the mother, gestation, the problems related to the pregnancy, heart rate, blood pressure, oxygen saturation (SpO2) of the mother had been recorded. The measurements of the newborn were; SpO2 of right hand, RcSO2 measured by NIRS, the delivery time (from incision to the cessation of circulation in the placental cord), Apgar score. Data were analyzed using GraphPad Prism 5.0 (GraphPad Software, La Jolla, California) and presented as mean +/- SD. Results obtained in different groups were compared using upaired t-test. Differences were statistically significant at p < 0.05. RESULTS: There were no significant differences between the groups related to the mother's age, gestation week and baseline blood pressure. Both the systolic and diastolic blood pressures measured at 1st and 5th min after induction or start of the spinal block were significantly lower in the mothers who had undergone combined spinal epidural anesthesia. The heart rates of the mothers who had been under CSEA were significantly higher than the general anesthesia group. The Apgar at the 1st min were observed significantly higher in Group II. Oxygen saturation of the newborns were significantly higher in Group II. Regional cerebral oxygenation measured by NIRS were significantly higher in CSEA group. CONCLUSION: Combined spinal epidural anesthesia, besides other known advantages, had been shown to be superior to general anesthesia as a means of regional cerebral oxygenation of the newborns.
OBJECTIVES: Elderly patients (aged ≥ 80 years) undergo an increasing number of operations. Elderly patients undergoing operations usually develop more postoperative complications and have poorer outcomes. The aim of this...OBJECTIVES: Elderly patients (aged ≥ 80 years) undergo an increasing number of operations. Elderly patients undergoing operations usually develop more postoperative complications and have poorer outcomes. The aim of this study is to identify the relative importance between preoperative and intraoperative variables to predict adverse postoperative outcomes in these patients. METHODS: We retrospectively analyzed the records of 404 patients (aged ≥ 80 years and underwent a noncardiac surgery) collected from the quality assurance database in our department. We reviewed the patients' preoperative and intraoperative variables as well as postoperative complications and outcomes. Odds ratios of risk factors were then calculated by univariate and multivariate analyses. In addition, hazard ratios of incidence of discharge and mortality rates were analyzed. RESULTS: Overall, 26.4% of patients developed one or more postoperative complications, and the in-hospital mortality rate was 6.7%. The majority of these patients had pre-existing cardiovascular disorders such as hypertension (47.5%). Respiratory complication was the most common postoperative complication (12.9%). Multivariate analysis showed male sex, anesthesia method, and colloid infusion were risk factors for increased respiratory complication. Our results showed that patients who developed different kinds of postoperative complications had a different level of risks associated with prolonged hospital stay and mortality. CONCLUSION: Patients over the age of 80 years, of male sex, under general anesthesia, and receiving colloid infusion were at a higher risk of developing respiratory complications. Postoperative respiratory complications occurred in most of the geriatric surgical patients. Efforts to improve the surgical outcomes must include measures to minimize in-hospital complications. Detailed evaluation and better communicating the aforementioned risk factors to these patients are suggested for improving anesthesia quality and surgical outcomes.
Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida wo...Ebstein's anomaly is an uncommon congenital heart defect with an extremely variable natural history due to a wide spectrum of pathological features. We report on the anesthetic management of a 24-year-old primigravida woman with Ebstein's anomaly with recurrent supraventricular tachycardia for emergency cesarean section.
The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery,...The practice of anesthetic premedication embarked upon soon after ether and chloroform were introduced as general anesthetics in the middle of the 19(th) century. By applying opioids and anticholinergics before surgery, the surgical patients could achieve a less anxious state, and more importantly, they would acquire a smoother course during the tedious and dangerous induction stage. Premedication with opioids and anticholinergics was not a routine practice in the 20(th) century when intravenous anesthetics were primarily used as induction agents that significantly shorten the induction time. The current practice of anesthetic premedication has evolved into a generalized scheme that incorporates several aspects of patient care: decreasing preoperative anxiety, dampening intraoperative noxious stimulus and its associated neuroendocrinological changes, and minimizing postoperative adverse effects of anesthesia and surgery. Rational use of premedication in modern anesthesia practice should be justified by individual needs, the types of surgery, and the anesthetic agents and techniques used. In this article, we will provide our readers with updated information about premedication of surgical patients with a focus on the recent application of second generation serotonin type 3 antagonist, antidepressants, and anticonvulsants.
The review demonstrates the unique advantages of ultrasonography in pain control. Several imaging modalities can be used to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ul...The review demonstrates the unique advantages of ultrasonography in pain control. Several imaging modalities can be used to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ultrasonography has unique advantages over these other modalities in terms of its non-ionizing radiation, real-time imaging, portability, and cost-effectiveness. Ultrasonography with color Doppler and elastography can provide safer guidance to avoid blood vessels and the nerve trunk when using steroid or xylocaine infusions to encase the nerve trunk. This review focuses on the control of chronic pain in the upper limbs, lower limbs, and trunk.