BACKGROUND: Intraoperative monitoring with pupillometry has shown promising results for nociception/antinociception balance monitoring. However, its benefits in clinical practice remain unproven. The aim of this study was to evaluate the efficacy of intraoperative pupillometry monitoring on intraoperative opioid consumption and postoperative pain compared to surgical pleth index (SPI), another widely investigated monitoring. METHODS: American Society of Anesthesiologists (ASA) I–II patients scheduled for elective laparoscopic cholecystectomy were included. This prospective, parallel-arm, single-center study was conducted in 2 steps. First, we evaluated the feasibility of using pupillometry and SPI monitoring compared with conventional hemodynamic monitoring. Next, a parallel-arm, double-blind randomized study compared the peak postoperative pain measured with numerical rating scale (NRS) from 0 (no pain) to 10 (extreme pain) as a primary outcome between pupillometry (pupillometry group, n = 43) and SPI monitoring (SPI group, n = 43) using Mann-Whitney U test. Secondary outcomes included intraoperative remifentanil consumption, postoperative opioid responsiveness (a decrease in NRS by ≥1 after fentanyl administrations), number of analgesic administrations, and opioid-related complications. RESULTS: In the preliminary study (n = 50), remifentanil consumption was less under pupillometry monitoring compared to SPI monitoring, and peak postoperative pain was lower under pupillometry compared to conventional monitoring. In the main study (n = 86), peak postoperative pain and intraoperative remifentanil consumption were lower in the pupillometry group (median [first to third quartile], 5 [4–6]; mean ± standard deviation [SD], 0.078 ± 0.019 μg·kg−1·minute−1) compared to the SPI group (7 [5–8] and 0.0130 ± 0.051 μg·kg−1·minute−1; P < .001), with the median difference in peak postoperative pain of −1 and its 95% confidence interval between −2 and −0.5. The pupillometry group had better responsiveness to fentanyl (84.6% vs 61.0%; P = .005) and lower number of analgesic administrations (2 [1–2] vs 2 [1–3]; P = .048) compared to the SPI group. CONCLUSIONS: Intraoperative pupillometry monitoring reduced intraoperative remifentanil consumption and postoperative pain. It may be an alternative option for intraoperative opioid control under general anesthesia in adult patients.

Background The induction of general anesthesia may cause hemodynamic instability. Remifentanil is often administered to suppress the hemodynamic response. We aimed to evaluate the effect of remifentanil infusion on the hemodynamic response to induction of anesthesia in hypertensive and normotensive patients. Methods Patients were divided into two groups: Group H (n = 102) were hypertensive patients and Group C (n = 107) were normotensive patients. During induction, all patients received 1 µg/kg of remifentanil as a loading dose over 2 minutes, followed by a continuous infusion at 0.05 µg/kg/minute. We analyzed the systolic, diastolic, and mean pressures and heart rate pre-induction, pre-intubation, immediately post-intubation, and at 2, 4, 6, 8, and 10 minutes after intubation. Results The systolic, diastolic, and mean pressures before induction were significantly higher in group H compared with group C, but there was no significant difference between the two groups immediately after intubation. Blood pressures immediately after intubation were similar to the pre-induction blood pressure. There was no significant difference in heart rate between the two groups at any time point. Conclusions Remifentanil infusion effectively attenuates the hemodynamic response to induction of general anesthesia in hypertensive and normotensive patients.

Rationale:Liver transplantation is an increasingly common treatment for patients with liver cirrhosis or hepatocellular carcinoma. Liver transplantation in patients with heart disease can pose a significant challenge to the transplant teams.Patient concerns:A 46-year-old woman was diagnosed with hepatitis B virus-related hepatocellular carcinoma 3 years ago and had received 3 times transarterial chemoembolization.Diagnoses:The patient was diagnosed as end-stage liver disease due to hepatocellular carcinoma and was scheduled to undergo living-donor liver transplantation. The preoperative echocardiogram revealed mass in the right atrium and the inferior vena cava.Interventions:The patient underwent mass removal under cardiopulmonary bypass followed by liver transplantation.Outcomes:A month later, she was discharged without any complications.Lessons:There have only been a few reported cases of anesthetic liver transplantation after a cardiopulmonary bypass. The successful experience described in this case report suggests that some patients may be eligible to undergo a liver transplantation after a cardiopulmonary bypass.

Ventilation difficulty during general anesthesia via laryngeal mask airway (LMA) has been a subject of debate since its developments. Here, we present a patient who experienced difficulty of ventilation immediately after initial skin incision followed by a period of sufficient ventilation. The difficulty of ventilation was not relieved by positive pressure ventilation or propofol injection. Ventilation recovered after administration of rocuronium. We assumed that closure of the vocal cords caused a sudden obstruction of the airway and that subsequent administration of a neuromuscular blocking agent restored airway patency by opening a closed vocal cord. This case report may support the potential importance of neuromuscular blocking agents for management and prevention of difficult ventilation that may occur with LMA.