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Sedation protocols during spinal anesthesia often involve sedative drugs associated with complications. We investigated whether virtual reality (VR) distraction could be applied during endoscopic urologic surgery under spinal anesthesia and yield better satisfaction than pharmacologic sedation. VR distraction without sedative was compared with pharmacologic sedation using repeat doses of midazolam 1⁻2 mg every 30 min during urologic surgery under spinal anesthesia. We compared the satisfaction of patients, surgeons, and anesthesiologists, as rated on a 5-point prespecified verbal rating scale. Two surgeons and two anesthesiologists rated the scale and an overall score was reported after discussion. Thirty-seven patients were randomized to a VR group (n = 18) or a sedation group (n = 19). The anesthesiologist's satisfaction score was significantly higher in the VR group than in the sedation group (median (interquartile range) 5 (5⁻5) vs. 4 (4⁻5), p = 0.005). The likelihood of both patients and anesthesiologists being extremely satisfied was significantly higher in the VR group than in the sedation group. Agreement between the scores for surgeons and those for anesthesiologists was very good (kappa = 0.874 and 0.944, respectively). The incidence of apnea was significantly lower in the VR group than in the sedation group (n = 1, 5.6% vs. n = 7, 36.8%, p = 0.042). The present findings suggest that VR distraction is better than drug sedation with midazolam in terms of patient's and anesthesiologist's satisfaction and avoiding the respiratory side effects of midazolam during endoscopic urologic surgery under spinal anesthesia.

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BACKGROUND: High-intensity focused ultrasound (HIFU) is a noninvasive thermodestructive procedure targeting internal organs with concentrated sonification energy that may cause pain. We aimed to compare the effectiveness of epidural analgesia (EA) and monitored anesthesia care (MAC) in HIFU treatment of uterine adenomyosis. MATERIALS AND METHODS: Sixty-eight patients were included in this case-control study. Thirty-seven patients underwent MAC; 31 patients underwent fluoroscope-guided epidural analgesia. The primary outcome was a frequency of patients reporting severe or very severe intraoperative pain. Secondary outcomes were differences in dosages of analgesics, ablation ratio, and other clinical factors. RESULTS: The EA group reported a significantly lower frequency of severe or very severe intraoperative pain than did the MAC group (41.9% vs. 75.7%; p = .006). Consumption of remifentanil during treatment was significantly lower in the EA group (173 ± 189 µg vs. 426 ± 380 µg; p = .001), as was the use of fentanyl in the recovery room (52 ± 38 µg vs. 75 ± 44 µg; p = .030). Multivariable analysis revealed EA to be the largest contributing factor to increased nonperfused volume ratio (B = 0.41; 95% confidence interval = 0.29 to 0.53; p < .001). The frequency of thermal injury after HIFU was significantly lower in the EA group (22.6% vs. 54.1%; p = .008). CONCLUSIONS: EA during HIFU treatment of uterine adenomyosis improved quality of pain control and ablation ratio over MAC without increasing risk of treatment-related complications. EA also reduced consumption of opioid analgesics during and after HIFU treatment.

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OBJECTIVE: To investigate reference levels for central venous pressure or pulmonary artery occlusion pressure monitoring in a lateral position. DESIGN: Retrospective observational study. SETTING: A tertiary university hospital. PARTICIPANTS: A total of 204 adults who underwent chest computed tomography scan in the 90° lateral position from November 2006 to February 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Distances from the mid-sternum to the uppermost and lowermost blood levels of both atria were measured. Ratios of the distance from the bottom of the thorax to the uppermost and the lowermost blood levels of both atria to the largest diameter of the thorax were calculated. There were significant differences between the distances from the mid-sternum to the uppermost and the lowermost blood levels of the right atrium and those of the left atrium in the right and left lateral positions, respectively. There were significant differences in the uppermost (3.3±0.1 cm; 95% confidence interval [CI] 3.1-3.5) and the lowermost (4.4±0.1 cm; 95% CI 4.2-4.7) blood levels of the right atrium between the right and left lateral positions. Although the uppermost (1.5±0.1 cm; 95% CI 1.3-1.8) and the lowermost (0.4±0.1 cm; 95% CI 0.2-0.6) blood levels of the left atrium between the right and left lateral positions showed differences, their extent was smaller than the right atrium. The uppermost and the lowermost blood levels of the right atrium lay lower than those of the left atrium in the 90° right lateral position. In contrast, in the 90° left lateral position, the uppermost and the lowermost blood levels of the right atrium lay higher than those of the left atrium. CONCLUSIONS: When monitoring the central venous pressure and pulmonary artery occlusion pressure with patients in the lateral position, changes in the blood level of both atria should be considered when releveling the reference transducer.

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BACKGROUND: Red blood cell (RBC) transfusion, especially with "old" blood, is associated with adverse clinical outcomes. We compared the effects of fresh blood versus old blood transfusion on poor neurologic outcomes and symptomatic vasospasm in patients with ruptured cerebral aneurysms. METHODS: In this retrospective study, 211 patients with aneurysmal rupture were divided into 3 groups: nontransfusion (n = 136), fresh blood (RBC storage ≤ 14 days) transfusion (n = 39), and old blood (RBC storage >14 days) transfusion (n = 36). Unfavorable neurologic outcomes (modified Rankin Scale score ≥ 3) and symptomatic cerebral vasospasm were assessed. RESULTS: The incidence of unfavorable neurologic outcomes was significantly higher in the fresh blood and old blood transfusion groups compared with the nontransfused group (71.8% and 58.3% vs. 21.3%; P < 0.01); the incidence of symptomatic vasospasm was significantly higher in the old blood group compared with the fresh blood and nontransfusion groups (57.1% vs. 26.7% and 22.2%; P < 0.05). On binary logistic regression, old age, Hunt and Hess grade 3-4, high postoperative C-reactive protein level, RBC transfusion, delayed infarction, and hydrocephalus were independent predictors of unfavorable neurologic outcomes. Young age, Fisher grade 3-4, old RBC transfusion, and surgical clipping were independent predictors of postoperative symptomatic vasospasm. CONCLUSIONS: RBC transfusion itself, regardless of the duration of RBC storage, was associated with unfavorable neurologic outcomes in patients with ruptured cerebral aneurysms. Also, old blood transfusion, but not fresh blood transfusion, was associated with increased symptomatic cerebral vasospasm.

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