High-flow nasal oxygenation (HFNO) is a promising new technique for anesthesiologists. The use of HFNO during the induction of anesthesia and during upper airway surgeries has been initiated, and its applications have been rapidly growing ever since. The advantages of this technique include its easy set-up, high tolerability, and its abilities to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide to some extent. HFNO, via a nasal cannula, can provide oxygen both to patients who can breathe spontaneously and to those who are apneic; further, this technique does not interfere with bag-mask ventilation, attempts at laryngoscopy for tracheal intubation, and surgical procedures conducted in the airway. In this review, we describe the techniques associated with HFNO and the advantages and disadvantages of HFNO based on the current state of knowledge.

Pulse pressure variation (PPV) is increasingly advocated as a predictor of fluid responsiveness in patients receiving mechanical ventilation. However, the ability of PPV has never been studied during one-lung ventilation (OLV). Therefore, we evaluated the value of PPV to predict fluid responsiveness in patients receiving conventional and protective OLV using receiver operating characteristic (ROC) analysis, respectively. Forty-nine patients undergoing lung surgery requiring OLV were enrolled in this study. Patients were randomised either to group P [patients receiving protective OLV with tidal volume 6 ml kg−1, inspired oxygen fraction (FIO2) of 0.5 and positive end-expiratory pressure (PEEP) of 5 cmH2O) or group C (patients receiving conventional OLV with tidal volume of 10 ml kg−1, FIO2 of 1.0 and no PEEP). Following OLV, PPV and cardiac output were measured before and 12 min after fluid loading (7 ml kg−1 hydroxyethyl starch 6%). Patients whose cardiac indices increased by at least 15% to fluid loading were defined as the responders. The areas under ROC curve for PPV were 0.857 (P = 0.006) in group P and 0.524 (P = 0.839) in group C, respectively. The optimal threshold value given by ROC analysis for PPV was 5.8% in group P. PPV could predict fluid responsiveness only during protective OLV, but not conventional OLV. PPV would be helpful for fluid management in patients receiving protective OLV for lung surgery using thoracotomy.

Myocardial injury is associated with an adverse outcome after off-pump coronary artery bypass graft surgery (OPCAB). The authors conducted a randomized controlled trial to evaluate whether remote ischemic preconditioning (RIPC) with remote ischemic postconditioning (RIPostC) reduces myocardial injury in patients undergoing OPCAB. Seventy patients scheduled for OPCAB were randomly assigned to an RIPC+RIPostC group (n=35) or a control group (n=35). In the RIPC+RIPostC group, 4 cycles of 5-min ischemia and 5-min reperfusion were done on a lower limb before anastomoses (RIPC) and after anastomoses (RIPostC). RIPC+RIPostC significantly reduced postoperative serum troponin I levels (P=0.001). The area under the curve for postoperative troponin I was 48.7% lower in the RIPC+RIPostC group (median [interquartile range], 21.3 h·ng⁻¹·ml⁻¹, 16.5-53.1 h·ng⁻¹·ml⁻¹ vs. 41.5 h·ng⁻¹·ml⁻¹, 24.6-90.2 h·ng⁻¹·ml⁻¹, P=0.020). There was no significant difference in creatinine levels and PaO₂/F(i)O₂ ratios between the 2 groups. RIPC+RIPostC by lower limb ischemia decreased postoperative myocardial enzyme elevation by almost half postoperatively in patients undergoing OPCAB.

During endobronchial intubation with a double-lumen endobronchial tube (DLT), the DLT is conventionally rotated through 90° when the bronchial tip is just past the vocal cords. This study was performed to investigate if rotation of the DLT through 180° decreases postoperative hoarseness, sore throat, or vocal cord injuries. Patients (n=164) undergoing thoracic surgery were randomized into two groups. Just after the bronchial tip passed the glottis, left-sided DLTs were rotated 90° (Group 90, n=84) or 180° (Group 180, n=80) counterclockwise and advanced. In the Group 180, DLTs were re-rotated 90° clockwise after the tracheal tip passed the glottis. Resistance during the advance of DLTs was assessed. Hoarseness and sore throat were evaluated for three postoperative days. Vocal cords were examined on the first postoperative day. In nine patients allocated to Group 90, the DLT could not be advanced past the glottis because of severe resistance. There was less resistance to advancement of the DLT in Group 180 compared with Group 90 (P<0.001). The incidence of hoarseness was comparable between the two groups. Sore throat and vocal cord injuries occurred less frequently in Group 180 compared with Group 90 (20 vs 40%, P=0.008; 19 vs 47%, P=0.032). Rotation of a DLT through 180° facilitated its passage through the glottis and reduced the incidence of postoperative sore throat and vocal cord injuries. NCT01441362.

The first aim of this study was to develop a prothrombin time international normalized ratio (PT INR) prediction model. The second aim was to develop a warfarin maintenance dose decision support system as a precise warfarin dosing platform. Data of 19,719 inpatients from three institutions was analyzed. The PT INR prediction algorithm included dense and recurrent neural networks, and was designed to predict the 5th-day PT INR from data of days 1–4. Data from patients in one hospital (n = 22,314) was used to train the algorithm which was tested with the datasets from the other two hospitals (n = 12,673). The performance of 5th-day PT INR prediction was compared with 2000 predictions made by 10 expert physicians. A generator of individualized warfarin dose-PT INR tables which simulated the repeated administration of varying doses of warfarin was developed based on the prediction model. The algorithm outperformed humans with accuracy terms of within ± 0.3 of the actual value (machine learning algorithm: 10,650/12,673 cases (84.0%), expert physicians: 1647/2000 cases (81.9%), P = 0.014). In the individualized warfarin dose-PT INR tables generated by the algorithm, the 8th-day PT INR predictions were within 0.3 of actual value in 450/842 cases (53.4%). An artificial intelligence-based warfarin dosing algorithm using a recurrent neural network outperformed expert physicians in predicting future PT INRs. An individualized warfarin dose-PT INR table generator which was constructed based on this algorithm was acceptable.