Showing papers in "Korean Journal of Anesthesiology in 2016"
TL;DR: The concept and estimating principles of effect sizes and CIs facilitate authors and readers to discriminate between a multitude of treatment effects and expand the approach to statistical thinking.
Abstract: The previous articles of the Statistical Round in the Korean Journal of Anesthesiology posed a strong enquiry on the issue of null hypothesis significance testing (NHST). P values lie at the core of NHST and are used to classify all treatments into two groups: "has a significant effect" or "does not have a significant effect." NHST is frequently criticized for its misinterpretation of relationships and limitations in assessing practical importance. It has now provoked criticism for its limited use in merely separating treatments that "have a significant effect" from others that do not. Effect sizes and CIs expand the approach to statistical thinking. These attractive estimates facilitate authors and readers to discriminate between a multitude of treatment effects. Through this article, I have illustrated the concept and estimating principles of effect sizes and CIs.
214 citations
TL;DR: The basic concepts and practical use of nonparametric tests are discussed for the guide to the proper use.
Abstract: Conventional statistical tests are usually called parametric tests. Parametric tests are used more frequently than nonparametric tests in many medical articles, because most of the medical researchers are familiar with and the statistical software packages strongly support parametric tests. Parametric tests require important assumption; assumption of normality which means that distribution of sample means is normally distributed. However, parametric test can be misleading when this assumption is not satisfied. In this circumstance, nonparametric tests are the alternative methods available, because they do not required the normality assumption. Nonparametric tests are the statistical methods based on signs and ranks. In this article, we will discuss about the basic concepts and practical use of nonparametric tests for the guide to the proper use.
171 citations
TL;DR: It is provided the possibility that propofol-based TIVA for breast cancer surgery can reduce the risk of recurrence during the initial 5 years after MRM.
Abstract: Background The optimal combination of anesthetic agent and technique may have an influence on long-term outcomes in cancer surgery. In vitro and in vivo studies suggest that propofol independently reduces migration of cancer cells and metastasis. Thus, the authors retrospectively examined the link between propofol-based total intravenous anesthesia (TIVA) and recurrence or overall survival in patients undergoing modified radical mastectomy (MRM). Methods A retrospective analysis of the electronic database of all patients undergoing MRM for breast cancer between January 2007 and December 2008 was undertaken. Patients received either propofol-based TIVA (propofol group) or sevoflurane-based anesthesia (sevoflurane group). We analyzed prognostic factors of breast cancer and perioperative factors and compared recurrence-free survival and overall survival between propofol and sevoflurane groups. Results A total of 363 MRMs were carried out during the period of the trial; 325 cases were suitable for analysis (173 cases of propofol group, and 152 cases of sevoflurane group). There were insignificant differences between the groups in age, weight, height, histopathologic results, surgical time, or postoperative treatment (chemotherapy, hormonal therapy, and radiotherapy). The use of opioids during the perioperative period was greater in propofol group than in sevoflurane group. Overall survival was no difference between the two groups. Propofol group showed a lower rate of cancer recurrence (P = 0.037), with an estimated hazard ratio of 0.550 (95% CI 0.311-0.973). Conclusions This retrospective study provides the possibility that propofol-based TIVA for breast cancer surgery can reduce the risk of recurrence during the initial 5 years after MRM.
122 citations
TL;DR: The clinical course and the emergency C-sec in a pregnant woman with MERS is presented and a healthy baby is delivered by emergency cesarean section.
Abstract: Only a few reports have been published on women with an infectious respiratory viral pathogen, such as Middle East Respiratory Syndrome (MERS) Coronavirus delivering a baby. A laboratory confirmed case of MERS was reported during a MERS outbreak in the Republic of Korea in a woman at gestational week 35 + 4. She recovered, and delivered a healthy baby by emergency cesarean section (C-sec). We present the clinical course and the emergency C-sec in a pregnant woman with MERS.
44 citations
TL;DR: Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.
Abstract: Monitored anesthesia care (MAC) is an anesthesia technique combining local anesthesia with parenteral drugs for sedation and analgesia. The use of MAC is increasing for a variety of diagnostic and therapeutic procedures in and outside of the operating room due to the rapid postoperative recovery with the use of relatively small amounts of sedatives and analgesics compared to general anesthesia. The purposes of MAC are providing patients with safe sedation, comfort, pain control and satisfaction. Preoperative evaluation for patients with MAC is similar to those of general or regional anesthesia in that patients should be comprehensively assessed. Additionally, patient cooperation with comprehension of the procedure is an essential component during MAC. In addition to local anesthesia by operators or anesthesiologists, systemic sedatives and analgesics are administered to provide patients with comfort during procedures performed with MAC. The discretion and judgment of an experienced anesthesiologist are required for the safety and efficacy profiles because the airway of the patients is not secured. The infusion of sedatives and analgesics should be individualized during MAC. Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.
34 citations
TL;DR: The aim of this work is to simplify the understanding of the mathematical processes that allow for translation of complex patterns of brain electrical activity into dimensionless indices.
Abstract: Currently, anesthesiologists use clinical parameters to directly measure the depth of anesthesia (DoA). This clinical standard of monitoring is often combined with brain monitoring for better assessment of the hypnotic component of anesthesia. Brain monitoring devices provide indices allowing for an immediate assessment of the impact of anesthetics on consciousness. However, questions remain regarding the mechanisms underpinning these indices of hypnosis. By briefly describing current knowledge of the brain's electrical activity during general anesthesia, as well as the operating principles of DoA monitors, the aim of this work is to simplify our understanding of the mathematical processes that allow for translation of complex patterns of brain electrical activity into dimensionless indices. This is a challenging task because mathematical concepts appear remote from clinical practice. Moreover, most DoA algorithms are proprietary algorithms and the difficulty of exploring the inner workings of mathematical models represents an obstacle to accurate simplification. The limitations of current DoA monitors - and the possibility for improvement - as well as perspectives on brain monitoring derived from recent research on corticocortical connectivity and communication are also discussed.
33 citations
TL;DR: The author discusses the brief history, definition, methods, and limitations of EBM and emphasizes the process of performing evidence-based medicine: generate the clinical question, find the best evidence, perform critical appraisal, apply the evidence, and then evaluate.
Abstract: Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions regarding the care of individual patients. This concept has gained popularity recently, and its applications have been steadily expanding. Nowadays, the term "evidence-based" is used in numerous situations and conditions, such as evidence-based medicine, evidence-based practice, evidence-based health care, evidence-based social work, evidence-based policy, and evidence-based education. However, many anesthesiologists and their colleagues have not previously been accustomed to utilizing EBM, and they have experienced difficulty in understanding and applying the techniques of EBM to their practice. In this article, the author discusses the brief history, definition, methods, and limitations of EBM. As EBM also involves making use of the best available information to answer questions in clinical practice, the author emphasizes the process of performing evidence-based medicine: generate the clinical question, find the best evidence, perform critical appraisal, apply the evidence, and then evaluate. Levels of evidence and strength of recommendation were also explained. The author expects that this article may be of assistance to readers in understanding, conducting, and evaluating EBM.
30 citations
TL;DR: A 76-year-old man with no notable medical history was scheduled for a robot-assisted radical prostatectomy and given sugammadex after the operation, two minutes later, ventricular premature contraction bigeminy began, followed by cardiac arrest.
Abstract: A 76-year-old man with no notable medical history was scheduled for a robot-assisted radical prostatectomy. After the operation, he was given sugammadex. Two minutes later, ventricular premature contraction bigeminy began, followed by cardiac arrest. Cardiac arrest occurred three times and cardiopulmonary resuscitation was done. The patient recovered after the third cardiopulmonary resuscitation and was transferred to the intensive care unit. Coronary angiography was done on postoperative day 1. The patient was diagnosed with variant angina and discharged uneventfully on postoperative day 8.
26 citations
TL;DR: A single bolus administration of fentanyl 2 µg/kg during anesthesia induction increases the incidence of PONV, but intraoperative remifentanil infusion with 2 ng/ml effect-site concentration did not affect the incidence.
Abstract: Background Although the use of postoperative opioids is a well-known risk factor for postoperative nausea and vomiting (PONV), few studies have been performed on the effects of intraoperative opioids on PONV. We examined the effects of a single bolus administration of fentanyl during anesthesia induction and the intraoperative infusion of remifentanil on PONV. Methods Two hundred and fifty women, aged 20 to 65 years and scheduled for thyroidectomy, were allocated to a control group (Group C), a single bolus administration of fentanyl 2 µg/kg during anesthesia induction (Group F), or 2 ng/ ml of effect-site concentration-controlled intraoperative infusion of remifentanil (Group R) groups. Anesthesia was maintained with sevoflurane and 50% N2O. The incidence and severity of PONV and use of rescue antiemetics were recorded at 2, 6, and 24 h postoperatively. Results Group F showed higher incidences of nausea (60/82, 73% vs. 38/77, 49%; P = 0.008), vomiting (40/82, 49% vs. 23/77 30%; P = 0.041) and the use of rescue antiemetics (47/82, 57% vs. 29/77, 38%; P = 0.044) compared with Group C at postoperative 24 h. However, there were no significant differences in the incidence of PONV between Groups C and R. The overall incidences of PONV for postoperative 24 h were 49%, 73%, and 59% in Groups C, F, and R, respectively (P = 0.008). Conclusions A single bolus administration of fentanyl 2 µg/kg during anesthesia induction increases the incidence of PONV, but intraoperative remifentanil infusion with 2 ng/ml effect-site concentration did not affect the incidence of PONV.
24 citations
TL;DR: Facilitating perioperative bundle care by combining prophylactic and postoperative positive-pressure ventilation with intraoperative lung-protective ventilation may be helpful to reduce postoperative pulmonary complications.
Abstract: The occurrence of postoperative pulmonary complications is strongly associated with increased hospital mortality and prolonged postoperative hospital stays. Although protective lung ventilation is commonly used in the intensive care unit, low tidal volume ventilation in the operating room is not a routine strategy. Low tidal volume ventilation, moderate positive end-expiratory pressure, and repeated recruitment maneuvers, particularly for high-risk patients undergoing major abdominal surgery, can reduce postoperative pulmonary complications. Facilitating perioperative bundle care by combining prophylactic and postoperative positive-pressure ventilation with intraoperative lung-protective ventilation may be helpful to reduce postoperative pulmonary complications.
21 citations
TL;DR: Adjusting the dose of isobaric bupivacaine to a patient's height and weight provides adequate anesthesia for elective cesarean section and is associated with a decreased incidence and severity of maternal hypotension and less use of ephedrine.
Abstract: Background
Spinal anesthesia with bupivacaine, typically used for elective and emergency cesarean section, is associated with a significant incidence of hypotension resulting from sympathetic blockade. A variety of dosing regimens have been used to administer spinal anesthesia for cesarean section. The objective of this study was to compare the incidence of hypotension following two different fixed dosing regimens.
TL;DR: Both nefopam and ketamine infusion may be useful in managing in postoperative pain control under concomitant infusion of remifentanil, however, ne fopam may be preferred to ketamine in terms of sedation.
Abstract: Background Although intraoperative opioids provide more comfortable anesthesia and reduce the use of postoperative analgesics, it may cause opioid induced hyperalgesia (OIH). OIH is an increased pain response to opioids and it may be associated with N-methyl-D-aspartate (NMDA) receptor. This study aimed to determine whether intraoperative nefopam or ketamine, known being related on NMDA receptor, affects postoperative pain and OIH after continuous infusion of intraoperative remifentanil. Methods Fifty-four patients undergoing laparoscopic cholecystectomy were randomized into three groups. In the nefopam group (N group), patients received nefopam 0.3 mg/kg at the induction of anesthesia followed by a continuous infusion of 0.065 mg/kg/h. In the ketamine group (K group), patients received ketamine 0.3 mg/kg at the induction of anesthesia followed by a continuous infusion of 3 µg/kg/min. The control group did not received any other agents except for the standard anesthetic regimen. Postoperative pain score, first time and number of demanding rescue analgesia, OIH and degrees of drowsiness/sedation scale were examined. Results Co-administrated nefopam or ketamine significantly reduced the total amount of intraoperative remifentanil and postoperative supplemental morphine. Nefopam group showed superior property over control and ketamine group in the postoperative VAS score and recovery index (alertness and respiratory drive), respectively. Nefopam group showed lower morphine consumption than ketamine group, but not significant. Conclusions Both nefopam and ketamine infusion may be useful in managing in postoperative pain control under concomitant infusion of remifentanil. However, nefopam may be preferred to ketamine in terms of sedation.
TL;DR: BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not, and an ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.
Abstract: BACKGROUND Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM). METHODS We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant. RESULTS The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01). CONCLUSIONS BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.
TL;DR: A simulation study indicated that the minimum effective analgesic concentration (MEAC, as indicated by relief of pain by administering rescue analgesics) of oxycodone was reached most quickly with a higher loading dose of 0.1 mg/kg and IV PCA with background infusion.
Abstract: Fentanyl is the most commonly used opioid analgesic in intravenous patient-controlled analgesia (IV PCA) in Korea. IV oxycodone was approved for postoperative IV PCA by the Ministry of Food and Drug Safety of Korea in 2013. The approved dosage regimen for postoperative pain relief with IV oxycodone is IV bolus loading of 2 mg followed by PCA composed of demand boluses of 1 mg and no background infusion with an oxycodone concentration of 1 mg/ml. However, a simulation study indicated that the minimum effective analgesic concentration (MEAC, as indicated by relief of pain by administering rescue analgesics) of oxycodone was reached most quickly with a higher loading dose of 0.1 mg/kg and IV PCA with background infusion. Oxycodone is a therapeutic option as an analgesic for postoperative pain management. It is necessary to reduce the analgesic dose of oxycodone in elderly patients because metabolic clearance decreases with age.
TL;DR: The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH2O PEEP was improved by a single RM, but this benefit did not last long, and it did not lead to an ameliorated of the lung mechanics.
Abstract: Background This randomized, controlled study was designed to compare the effects of recruitment maneuvers (RMs) with a 15 cmH2O positive end-expiratory pressure (PEEP) on the systemic oxygenation and lung compliance of patients with healthy lungs following robot-assisted laparoscopic prostatectomy (RALP). Methods Sixty patients undergoing a RALP with an intraoperative 15 cmH2O PEEP were randomly allocated to an RM or a Control group. The patients in the RM group received a single RM through the application of a continuous positive airway pressure of 40 cmH2O for 40 s 15 min after being placed in the Trendelenburg position. The arterial oxygen tension (PaO2, primary endpoint) and the pulmonary dynamic and static compliances (secondary endpoints) were measured 10 min after the anesthetic induction (T1), 10 min after establishment of the pneumoperitoneum (T2), 10 min after establishment of the Trendelenburg position (T3), 10 min after the RM (T4), 60 min after the RM (T5), and 10 min after deflation of the pneumoperitoneum in the supine position (T6). Results The intergroup comparisons of the PaO2 showed significantly higher values in the RM group than in the Control group at T4 and T5 (193 ± 35 mmHg vs. 219 ± 33 mmHg, P = 0.015, 188 ± 41 mmHg vs. 214 ± 42 mmHg, P = 0.005, respectively). However, the PaO2 at T6 was similar in the two groups (211 ± 39 mmHg vs. 224 ± 41 mmHg, P = 0.442). Moreover, there were no statistical differences between the groups in the dynamic and static compliances of the lungs at any time point. Conclusions The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH2O PEEP was improved by a single RM. However, this benefit did not last long, and it did not lead to an amelioration of the lung mechanics.
TL;DR: A 35-year-old male patient who was scheduled for laparoscopic cholecystectomy and developed a life-threatening anaphylactic reaction 2 min after the administration of sugammadex is described.
Abstract: We describe a case of a 35-year-old male patient who was scheduled for laparoscopic cholecystectomy and developed a life-threatening anaphylactic reaction 2 min after the administration of sugammadex. He manifested erythematous wheals on the entire body, dyspnea, hypotension, and tachycardia. These symptoms disappeared after the administration of epinephrine. The patient recovered and was discharged at postoperative day 5 without any complications. After 7 weeks, we performed a skin prick test, and there was a weakly positive reaction for sugammadex. This case is suspected anaphylaxis associated with sugammadex, and we need to be aware that the use of sugammadex is associated with a serious risk of anaphylaxis.
TL;DR: The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes and contain 33 recommendations that have been endorsed by the KSA Executive Committee.
Abstract: In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.
TL;DR: The use of glycopyrrolate 0.3 mg as premedication in patients receiving Ureteroscopic removal of ureteral stone reduced the incidence and severity of CRBD, and decreased postoperative pain in the PACU.
Abstract: Background Glycopyrrolate given as reversing agents of muscle relaxants has been reported to be effective in reducing postoperative catheter-related bladder discomfort (CRBD). However, it remains unclear whether glycopyrrolate as premedication is also effective. This study aims to investigate the effectiveness of glycopyrrolate as premedication on preventing CRBD in the post-anesthesia care unit (PACU). Methods Eighty-three patients who received elective ureteroscopic removal of ureteral stone were randomly assigned to the control (n = 43) or the glycopyrrolate group (n = 40). The glycopyrrolate group was treated with glycopyrrolate 0.3 mg as premedication while the control group received 0.9% saline 1.5 ml. The incidence and severity of CRBD and pain score using numerical rating scale (NRS) were measured in the PACU. Results The incidence of CRBD (26 of 40 patients vs. 41 of 43 patients, relative risk [RR] = 0.68, 95% Confidence interval [CI] = 0.53-0.86, P = 0.001) and the moderate to severe CRBD incidence (6 of 40 patients vs. 20 of 43 patients, RR = 0.32, 95% CI = 0.14-0.72, P = 0.002) were lower in the glycopyrrolate group than in the control group. Also, postoperative pain NRS score was found to be lower in the glycopyrrolate group (median = 1 [Q1 = 0, Q3 = 2]) compared to the control group (3 [1, 5], median difference = 1.00, 95% CI = 0.00-2.00, P = 0.002). Conclusions The use of glycopyrrolate 0.3 mg as premedication in patients receiving ureteroscopic removal of ureteral stone reduced the incidence and severity of CRBD, and decreased postoperative pain in the PACU.
TL;DR: The aim of this work is to help researchers know what is important statistically and how to present it in papers.
Abstract: Manuscripts submitted to journals should be understandable even to those who are not experts in a particular field. Moreover, they should use publicly available materials and the results should be verifiable and reproducible. Readers and reviewers will want to check the strengths and weaknesses of the research study design, and ways to make this determination should be clear through proper analysis methods. Studies should be described in detail so as to help readers understand the results. Statistical analysis is one of the key methods by which to do this. The inappropriate application of statistical methods could be misleading to readers and clinicians. While many researchers describe their general research methods in detail, statistical methods tend to be described briefly, with certain omissions or errors or other incorrect aspects. For instance, researchers should describe whether the median or mean was used, whether parametric or nonparametric tests were used, whether the data meet the normality test, whether confounding factors were corrected, and whether stratification or matching methods were used. Statistical analysis regardless of the program should be reported correctly. The results may be less reliable if the statistical assumptions before applying the statistical method are not met. These common errors in statistical methods originate from the researcher's lack of knowledge of statistics and/or from the lack of any statistical consultation. The aim of this work is to help researchers know what is important statistically and how to present it in papers.
TL;DR: Ropivacaine continuous infusion with an inverse ‘v ’ shaped bilateral, subfascial catheter placement showed significantly enhanced bowel recovery and analgesic efficacy was not different from IV PCA in LCRC surgery.
Abstract: Background
There is a need for investigating the analgesic method as part of early recovery after surgery tailored for laparoscopic colorectal cancer (LCRC) surgery. In this randomized trial, we aimed to investigate the analgesic efficacy of an inverse ‘v’ shaped bilateral, subfascial ropivacaine continuous infusion in LCRC surgery.
TL;DR: The prophylactic use of dexamethasone 0.1 mg/kg and 0.2 mg/ kg in prone surgery reduces the incidence of postoperative sore throat and dexamETHasone0.2mg/kg decreases the occurrence of hoarseness.
Abstract: BACKGROUND Sore throat and hoarseness are common complications after general anesthesia with tracheal intubation. The position for patients can affect the incidence of postoperative sore throat (POST) by causing displacement of the endotracheal tube. This study investigated the prophylactic effect of dexamethasone in prone position surgeries. METHODS One hundred-fifty patients undergoing lumbar spine surgery (18-75 yr) were randomly allocated into the normal saline group (group P, n = 50), dexamethasone 0.1 mg/kg group (group D1, n = 50) or dexamethasone 0.2 mg/kg group (group D2, n = 50). The incidence and severity of POST, hoarseness, and cough were measured using direct interview at 1, 6, and 24 h after tracheal extubation. The severity of POST, hoarseness, and cough were graded using a 4-point scale. RESULTS At 1, 6, and 24 h after extubation, the incidence of sore throat was significantly lower in group D1 (1 h; P = 0.015, 6 h; P < 0.001, 24 h; P = 0.038) and group D2 (1 h; P < 0.001, 6 h; P < 0.001, 24 h; P = 0.017) compared to group P. There were less number of patients in the groups D1 and D2 than group P suffering from moderate grade of POST at 1, 24 h after extubation. The incidence of hoarseness at 1, 6, and 24 h after extubation was significantly lower in groups D2 than group P (P < 0.001). There were no significant differences in the incidence of cough among the three groups. CONCLUSIONS The prophylactic use of dexamethasone 0.1 mg/kg and 0.2 mg/kg in prone surgery reduces the incidence of postoperative sore throat and dexamethasone 0.2 mg/kg decreases the incidence of hoarseness.
TL;DR: The results of this study suggest that intravenous anesthesia may have beneficial effects for reducing SSI in colorectal surgery compared to volatile anesthesia.
Abstract: BACKGROUND Anesthetic agents used for general anesthesia are emerging possible influential factors for surgical site infection (SSI). In this retrospective study, we evaluated the incidence of SSI after colorectal surgery according to the main anesthetic agents: volatile anesthetics vs. propofol. METHODS A total 1,934 adult patients, who underwent elective colorectal surgery under general anesthesia between January 2011 and December 2013, were surveyed to evaluate the incidence of SSI: 1,519 using volatile anesthetics and 415 using propofol for main anesthetic agents. Patient, surgery, and anesthesia-related factors were investigated from all patients. Propensity-score matching was performed to reduce the risk of confounding and produced 390 patients in each group. RESULTS Within the propensity-score matched groups, the incidence of SSI was higher in the volatile group compared with the propofol group (10 [2.6%] vs. 2 [0.5%], OR = 5.0 [95% CI = 1.1-2.8]). C-reactive protein was higher in the volatile group than in the propofol group (8.4 ± 5.6 vs. 7.1 ± 5.3 mg/dl, P = 0.001), and postoperative white blood cells count was higher in the volatile group than in the propofol group (9.2 ± 3.2 × 10(3)/µl vs. 8.6 ± 3.4 × 10(3)/µl, P = 0.041). CONCLUSIONS The results of this study suggest that intravenous anesthesia may have beneficial effects for reducing SSI in colorectal surgery compared to volatile anesthesia.
TL;DR: The choice of an optimal catheter insertion site, use of all barrier precautions, and removal of catheters when they are no longer needed are essential to decrease the CLABSI rate.
Abstract: Background The importance and efficacy of a care bundle for preventing central line-associated bloodstream infections (CLABSIs) and infectious complications related to placing a central venous catheter (CVC) in patients in the intensive care unit (ICU). Methods A care bundle was implemented from July 2013 to June 2014 in a medical ICU and surgical ICU. Data were divided into three periods: the prior period (July 2012-June 2013), the intervention period (July 2013-June 2014; first and second periods), and the post-intervention period (July 2014-December 2014; third period). A care bundle consisting of optimal hand hygiene, skin antisepsis with chlorhexidine (2%) allowing the skin to dry, maximal barrier precautions for inserting a catheter (sterile gloves, gown, mask, and drapes), choice of optimal insertion site, prompt catheter removal, and daily evaluation of the need for the CVC was introduced. Results The catheterization duration was longer and femoral access was more frequently observed in patients with CLABSIs. CLABSI rates decreased with use of the care bundle. The CLABSI rate in the medical ICU was 6.20/1,000 catheter days during the prior period, 3.88/1,000 catheter days during the intervention period, and 1.05/1,000 catheter days during the third period. The CLABSI rate in the surgical ICU was 8.27/1,000, 4.60/1,000, and 3.73/1,000 catheter days during these three periods, respectively. Conclusions The choice of an optimal catheter insertion site, use of all barrier precautions, and removal of catheters when they are no longer needed are essential to decrease the CLABSI rate.
TL;DR: Valsalva can be performed routinely in ASA I and II patients undergoing spinal anesthesia as it is safe, painless and non-pharmacological method of pain attenuation.
Abstract: Background
Valsalva maneuver reduces pain by activating sinoaortic baroreceptor reflex arc. We planned this study to evaluate the role of valsalva in attenuating spinal needle-puncture pain.
TL;DR: During general anesthesia, the temperatures measured at the upper nasopharynx and the oropharynx, but not the nasal cavity, reflected the core temperature, therefore, the authors recommend that a probe should be placed at the naspharynx or oroph throat with mucosal attachment for accurate core temperature measurement.
Abstract: BACKGROUND The purpose of this study was to compare temperatures measured at three different sites where a nasopharyngeal temperature probe is commonly placed. METHODS Eighty elective abdominal surgical patients were enrolled. After anesthesia induction, four temperature probes were placed at the nasal cavity, upper portion of the nasopharynx, oropharynx, and the esophagus. The placement of the nasopharyngeal temperature probes was evaluated using a flexible nasendoscope, and the depth from the nares was measured. The four temperatures were simultaneously recorded at 10-minute intervals for 60 minutes. RESULTS The average depths of the probes that were placed in the nasal cavity, upper nasopharynx, and the oropharynx were respectively 5.7 ± 0.9 cm, 9.9 ± 0.7 cm, and 13.6 ± 1.7 cm from the nares. In the baseline temperatures, the temperature differences were significantly greater in the nasal cavity 0.32 (95% CI; 0.27-0.37)℃ than in the nasopharynx 0.02 (0.01-0.04)℃, and oropharynx 0.02 (-0.01 to 0.05)℃ compared with the esophagus (P < 0.001). These differences were maintained for 60 minutes. Twenty patients showed a 0.5℃ or greater temperature difference between the nasal cavity and the esophagus, but no patient showed such a difference at the nasopharynx and oropharynx. CONCLUSIONS During general anesthesia, the temperatures measured at the upper nasopharynx and the oropharynx, but not the nasal cavity, reflected the core temperature. Therefore, the authors recommend that a probe should be placed at the nasopharynx (≈ 10 cm) or oropharynx (≈ 14 cm) with mucosal attachment for accurate core temperature measurement.
TL;DR: On December 15, 2015, the US Food and Drug Administration (FDA) approved sugammadex for the reversal of neuromuscular blockade induced by rocuronium bromide or vecur oncology treatment in adults who received either of these neuromUScular blocking agents during surgery.
Abstract: On December 15, 2015, the US Food and Drug Administration (FDA) approved sugammadex for the reversal of neuromuscular blockade induced by rocuronium bromide or vecuronium bromide in adults who received either of these neuromuscular blocking agents during surgery.
TL;DR: This study demonstrated that a single bolus administration of fentanyl during anesthesia induction increased the incidence of PONV, while an intraoperative remifentanil infusion did not affect the incidence and severity of PonV.
Abstract: Postoperative nausea and vomiting (PONV) is usually defined as any nausea, retching, or vomiting occurring within the first 24–48 hours of surgery. PONV can be extremely distressing to patients and is one of the most common causes of patient dissatisfaction and discomfort after anesthesia. The average incidence of PONV after general anesthesia is about 30% in all post-surgical patients but up to 80% in high-risk patients despite advances in anesthetics and anesthesia techniques [1,2,3]. In addition, PONV is rated highly in preoperative surveys, as the clinical anesthesia outcome that the patient would most like to avoid [4]. Therefore it is not surprising that patients express a high willingness-to-pay ($50–100) to avoid PONV [5,6]. While bleeding, wound dehiscence, pulmonary aspiration of gastric contents, esophageal perforation, and other serious complications associated with PONV are rare, nausea and vomiting is still an unpleasant, unwanted and all-too-common postoperative morbidity that can delay patient discharge from the postanesthesia care unit, require expanded levels of nursing care and increase unanticipated overnight hospital admissions in outpatients.
The public now believes that anesthesia is extraordinarily safe from catastrophic outcomes, including major organ dysfunction or failure and even death. Therefore, many patients are more concerned about pain and PONV than surgical outcomes, such as whether the surgery would improve their condition. This is especially true for the majority of patients undergoing less invasive surgery. Moreover, minimally invasive surgery is now increasingly and routinely used across almost all surgical specializations. An important aspect of the quality of anesthetic care is the satisfaction of the patient with their care.
Possible strategies to prevent the incidence of PONV include the prophylactic use of antiemetics such as dexamethasone or 5-HT3 antagonists, and avoiding use of emetic drugs such as inhalational anesthetics or opioids. However, no drug is completely effective at preventing PONV. If we can avoid drugs that cause PONV, all the better.
The etiology of PONV remains unclear, but involves anesthetic, surgical and patient factors. Well-known risk factors are female gender, non-smoking status, a history of motion sickness or previous PONV, inhalational anesthetics, certain types of surgery, and opioid use [7]. Among the risk factors for PONV, the use of postoperative opioids is one of four major risk factors in the simplified risk-scoring system introduced by Apfel et al. [8].
In this month's Korean Journal of Anesthesiology, Lim et al. [9] report a study focusing on the effects of intraoperative opioid use on the incidence and severity of PONV and the effects of a single bolus administration of fentanyl during anesthesia induction versus intraoperative infusion of remifentanil on PONV. In a previous randomized controlled trial in over 5000 patients, the use of a short-acting opioid, like remifentanil, instead of fentanyl did not decrease the incidence of PONV [10]. However, in that study, patients who had been assigned to receive intraoperative remifentanil were given 50 µg of morphine per kilogram or an equivalent opioid at the end of surgery. Therefore, the current study has meaningful results based on comparing only fentanyl versus remifentanil itself, without the other factors that affect PONV. They demonstrated that a single bolus administration of fentanyl during anesthesia induction increased the incidence of PONV, while an intraoperative remifentanil infusion did not affect the incidence and severity of PONV. These results should have a marked synergistic effect with antiemetic prophylaxis.
It should be kept in mind that even a single bolus administration of fentanyl during anesthesia induction can increase the incidence of PONV in high-risk patients.
TL;DR: A case of acute aortic dissection (Stanford type A) in a pregnant woman with Marfan syndrome at the 29th week of gestation is reported, and the newborn survived after endotracheal intubation and management in a neonatal intensive care unit.
Abstract: Aortic dissection during pregnancy is a devastating event for both the pregnant woman and the baby. We report a case of acute aortic dissection (Stanford type A) in a pregnant woman with Marfan syndrome at the 29th week of gestation. She underwent a cesarean section followed by an ascending aorta and total arch replacement with cardiopulmonary bypass, without a prior sternotomy. The hemodynamic parameters were kept stable during the cesarean section by using inotropes and vasopressors under transesophageal echocardiography monitoring. The newborn survived after endotracheal intubation and management in a neonatal intensive care unit.
TL;DR: These two lipid emulsions had different inotropic effects depending on their triglyceride component, and the inotropic effect of lipid emulsion could be related with intracellular calcium level.
Abstract: BACKGROUND Lipid emulsions have been used to treat various drug toxicities and for total parenteral nutrition therapy. Their usefulness has also been confirmed in patients with local anesthetic-induced cardiac toxicity. The purpose of this study was to measure the hemodynamic and composition effects of lipid emulsions and to elucidate the mechanism associated with changes in intracellular calcium levels in myocardiocytes. METHODS We measured hemodynamic effects using a digital analysis system after Intralipid® and Lipofundin® MCT/LCT were infused into hearts hanging in a Langendorff perfusion system. We measured the effects of the lipid emulsions on intracellular calcium levels in H9c2 cells by confocal microscopy. RESULTS Infusion of Lipofundin® MCT/LCT 20% (1 ml/kg) resulted in a significant increase in left ventricular systolic pressure compared to that after infusing modified Krebs-Henseleit solution (1 ml/kg) (P = 0.003, 95% confidence interval [CI], 2.4-12.5). Lipofundin® MCT/LCT 20% had a more positive inotropic effect than that of Intralipid® 20% (P = 0.009, 95% CI, 1.4-11.6). Both lipid emulsion treatments increased intracellular calcium levels. Lipofundin® MCT/LCT (0.01%) increased intracellular calcium level more than that of 0.01% Intralipid® (P < 0.05, 95% CI, 0.0-1.9). CONCLUSIONS These two lipid emulsions had different inotropic effects depending on their triglyceride component. The inotropic effect of lipid emulsions could be related with intracellular calcium level.
TL;DR: Intensive dexmedetomidine infusion was used to provide sedation to 2 pediatric patients over more than 20 sessions of radiation therapy, on both occasions, and provided adequate sedation without respiratory depression, however, the required dosage increased with repeated radiation therapy sessions.
Abstract: Dexmedetomidine is a highly selective α2-adrenoceptor agonist that demonstrates anxiolytic and analgesic properties without inducing respiratory compromise, which makes it a suitable agent for procedural sedation and imaging studies. In our current case reports, intravenous dexmedetomidine infusion was used to provide sedation to 2 pediatric patients over more than 20 sessions of radiation therapy. On both occasions, dexmedetomidine provided adequate sedation without respiratory depression. However, the required dosage increased with repeated radiation therapy sessions.