Purpose To analyze the cause of prolonged recovery from general anesthesia with remimazolam. Methods We studied 65 patients under general anesthesia with remimazolam. According to time to extubation, patients were divided into short period (SP) (n = 34, < 15 min) and long period (LP) (n = 31, ≥ 15 min) groups. Variables affecting time to extubation such as age, sex, height, body weight, body mass index (BMI), plasma albumin concentration, ASA class, duration of surgery, and total duration of general anesthesia, and total dose of remimazolam were compared between SP and LP groups. At the end of remimazolam infusion and upon extubation, predictive remimazolam concentrations were calculated using pharmacokinetic/pharmacodynamic three compartment modeling. Results LP group showed significantly higher BMI, older age, and lower plasma albumin concentration compared with those of SP group. Logistic regression analysis showed that the probability of time to extubation of ≥ 15 min was higher in patients with BMI greater than 22.0 kg/m2 (AUC 0.668, 95% CI 0.533‒0.803), ages older than 79.0 years (AUC 0.662, 95% CI 0.526‒0.798), and plasma albumin concentrations lower than 3.60 g/dl (AUC 0.720, 95% CI 0.593‒0.847). LP group showed significantly lower predicted remimazolam concentration than SP group upon extubation despite no difference in concentration between both groups at the end of infusion. Pharmacological analysis estimates that LP group is more sensitive to remimazolam than SP group through amplified responses. Conclusions Lower remimazolam doses should be considered for the overweight patients, elderly, and those with lower plasma albumin concentration.
Objective:Diagnostic/therapeutic accidents Background:Intraoperative tracheal rupture due to endotracheal intubation is a rare but serious complication that requires prompt responses. Transoral laser microsurgery is effective for dissection of laryngeal and nasopharyngeal lesions, and a laser-resistant endotracheal tube is therefore commonly used under general anesthesia. Case Report:We present the case of a 69-year-old man in whom a rare complication involving endotracheal tube tip dislodgement during transoral laser surgery led to iatrogenic tracheal rupture. We used a Laser-Flex cuffed endotracheal tube, which is a non-inflammable, armored stainless-steel tube with a Murphy eye. Repeated mobilization of the laryngoscope blade and excessive neck extension for adequate laryngeal exposure during surgery may have led to significant soft tissue swelling and tube tip displacement, inducing tracheal rupture with the keen edge of the Murphy eye. At the end of the surgical procedure, subcutaneous emphysema was observed in the right anterior neck. Computed tomography revealed subcutaneous emphysema and pneumomediastinum without esophageal injury or mediastinitis. The injury was 1 cm in length, with wall involvement to a depth to the muscular wall in the membranous trachea at a point 2 cm proximal to the carina, in which we could position the alternative endotracheal tube distal to the tracheal rupture. After conservative treatment, the patient was extubated and mechanical ventilation was ceased. Conclusions:During transoral laser laryngeal and nasopharyngeal surgery, dislodgement of the laser-resistant endotracheal tube tip can lead to iatrogenic tracheal rupture. In this case, injury during application of a Laser-Flex cuffed endotracheal tube with a Murphy eye, was followed by conservative treatment. This treatment achieved a successful outcome.
Background Electroconvulsive therapy (ECT) remains the mainstay treatment option for patients with psychiatric diseases, such as severe depression. Although various anesthetic techniques provide adequate therapeutic seizures, hyperventilation is a useful adjunct to augment seizure duration and improve seizure quality. We investigated how to efficiently use a facemask to accomplish protocolized hyperventilation and evaluate its effect on ECT seizure. Methods We studied 60 patients aged ≥18 years who underwent ECT. The patients were divided into two groups according to the technique of facemask ventilation used: the one-handed (n = 30) and two-handed (n = 30) groups. Following anesthesia induction under preoxygenation conditions, hyperventilation induced hypocapnia in the one-handed facemask group with manual bag ventilation was compared to that in the two-handed facemask group with assisted pressure-controlled ventilation. Ictal and peri-ictal electroencephalogram parameters and cardiovascular responses were monitored and compared between the one-handed and two-handed groups. Results The two-handed technique demonstrated better electroencephalogram regularity and minimized cardiovascular stress compared to the one-handed technique. These conclusions come from the fact that the one-handed technique induced a substantial volume of leaks around the facemask (201.7 ± 98.6 mL/breath), whereas minimal leaks (25.8 ± 44.6 mL/breath) with stabler and higher ventilation rate led to greater inhaled minute ventilation in the two-handed group (the one-handed group, 9.52 ± 3.94 L/min; the two-handed group, 11.95 ± 2.29 L/min; p < 0.005). At the end of ECT treatment, all parameters of blood pressure and heart rate increased significantly in both groups equally, with lower SpO2 and more ST-segment depression on the electrocardiogram in the one-handed group. Comparing baseline values before anesthesia, ECT treatment significantly depressed ST-segment in both groups, while the degree of depression in ST-segment increased significantly in the one-handed group compared to that in the two-handed group. Conclusions End-tidal carbon dioxide monitoring for hyperventilation can reliably ensure hypocapnia only in the two-handed group. In ECT, the two-handed technique assisted by pressure-controlled ventilation is an effective and practical method for hyperventilation to induce adequate therapeutic seizures. While, the two-handed group with sufficient preoxygenation did not cause more cardiovascular stress than the one-handed group. Trial registration UMIN Clinical Trials Registry 000046544, Date of registration 05/01/2022.
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