Review the Change of Chronic Disease Care in Korea / 임상당뇨병

Globally, chronic diseases have a high burden and are a significant factor affecting society, such as through economic productivity and deepening social inequality. Deaths from chronic diseases in Korea accounted for 79.6% of all deaths as of 2021, and medical expenses from chronic diseases in Korea accounted for 85.0% of all national medical expenses as of 2020. Since the 1970s, chronic disease management in Korea has focused on projects such as acute infectious diseases, maternal and child health, and family planning by region, sporadically centered on universities. Since then, the importance of prevention and management of chronic diseases has been highlighted, and a comprehensive plan for national health promotion was established in 2002 to provide policy support. Here, we looked at the progress of the chronic disease management project and its effects and review suggestions for efficient establishment of a primary medical chronic disease management project to be carried out in the future.

The Review and Future Perspectives of the Postpartum Care Service System for the Improvement of the Private-Postpartum Care Center’s Publicity

The study aimed to review the current postpartum care service system and suggest measures of improvement for the public reinforcement of the private-postpartum care center (PCC). We conducted a review of literature, including an internet search, and we analyzed the in-depth interviews using questionnaires answered by workers from the 6 private-PCCs operated in Goyang city. Using these data, we derived possible measures which could improve the publicity of private-PCCs. It was found that the 11 nationwide public-PCCs had serious operating deficits, and its utilization by the vulnerable was insufficient. In areas where private-PCCs are concentrated, we can propose the following policies to strengthen publicity, rather than establishing another public-PCC. First, it is important to provide support for private-PCCs to apply cost reductions for vulnerable groups, similar to the maternal and newborn medical care of public-PCCs. Second, publicity would be strengthened by reorganizing the pregnancy and childbirth education program, while also offering additional services for mothers with stillbirths and abortions. For the integrated management of postpartum care services, this should be shifted towards reinforcing the publicity of private-PCCs, rather than operating a public-PCC in relatively concentrated private-PCC areas. Through these policies, it is expected that financial and administrative waste will be reduced, and an integrated management system for postpartum care services will be established.

The Review and Future Perspectives of the Postpartum Care Service System for the Improvement of the Private-Postpartum Care Center’s Publicity

The study aimed to review the current postpartum care service system and suggest measures of improvement for the public reinforcement of the private-postpartum care center (PCC). We conducted a review of literature, including an internet search, and we analyzed the in-depth interviews using questionnaires answered by workers from the 6 private-PCCs operated in Goyang city. Using these data, we derived possible measures which could improve the publicity of private-PCCs. It was found that the 11 nationwide public-PCCs had serious operating deficits, and its utilization by the vulnerable was insufficient. In areas where private-PCCs are concentrated, we can propose the following policies to strengthen publicity, rather than establishing another public-PCC. First, it is important to provide support for private-PCCs to apply cost reductions for vulnerable groups, similar to the maternal and newborn medical care of public-PCCs. Second, publicity would be strengthened by reorganizing the pregnancy and childbirth education program, while also offering additional services for mothers with stillbirths and abortions. For the integrated management of postpartum care services, this should be shifted towards reinforcing the publicity of private-PCCs, rather than operating a public-PCC in relatively concentrated private-PCC areas. Through these policies, it is expected that financial and administrative waste will be reduced, and an integrated management system for postpartum care services will be established.

The comparison of desflurane and sevoflurane on postoperative hepatic function of infant with biliary atresia undergoing Kasai operation

BACKGROUND: Biliary atresia is an extrahepatic progressive obliterate cholangiopathy that occurs in infants. Kasai procedure, a surgical method that can help re-establish bile flow from the liver into the intestine, is its first line treatment. Since infants with biliary atresia already have advanced hepatic dysfunction, all kinds of schemes should be considered to minimize further liver damage during surgery. The objective of this study was to compare the postoperative hepatic functions between the two commonly used inhalational anesthetics in infants undergoing the Kasai procedure (i.e., desflurane and sevoflurane). METHODS: This prospective, randomized, double-blind, single-center, and parallel group study included 40 children undergoing Kasai procedure. They were randomly allocated to Group S (sevoflurane) or Group D (desflurane). All the patients were anesthetized with designated anesthetic agent with the end-tidal concentration of about 0.8–1 minimum alveolar concentration. Postoperative hepatic functions were assessed by aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, prothrombin time, and total bilirubin. RESULTS: A total of 38 patients were selected for the study. In both groups, AST, ALT were increased in magnitude to the peak on postoperative day 0 and decreased to preoperative value at postoperative day 3. There were no significant differences between the groups in any laboratory results related to liver function. CONCLUSIONS: Sevoflurane and desflurane, inhalation anesthetics for maintaining anesthesia used in infants undergoing the Kasai procedure, did not show any difference in preserving postoperative hepatic function.

Factors affecting determination of the optimal ketamine dose for pediatric sedation

OBJECTIVE: Children are sedated before undergoing diagnostic imaging tests in emergency medicine or pediatric sedation anesthesia units. The aim of this study was to identify variables potentially affecting the dose of ketamine required for induction of sedation in pediatric patients undergoing diagnostic imaging.METHODS: This retrospective study included children aged 0 to 18 years who underwent sedation with ketamine for computed tomography or magnetic resonance imaging in the pediatric sedation anesthesia unit of a tertiary medical center between January 2011 and August 2016. The children’s hemodynamic status and depth of sedation were monitored during the examination. We recorded data on demographics, categories of imaging tests, ketamine doses administered, adverse events, respiratory interventions, and duration of sedation. Data for patients who experienced adverse events were excluded.RESULTS: Sixty-six patients were included in the final analysis. Univariate linear regression analysis revealed that patient age, height, and body surface area (BSA) affected the sedative dose of ketamine administered. These three variables showed multicollinearity in multivariate linear regression analysis and were analyzed in three separate models. The model with the highest adjusted R-squared value suggested the following equation for determination of the dose of ketamine required to induce sedation: ketamine dose (mg)=-1.62+0.7×age (months)+36.36×BSA (m²).CONCLUSION: Variables such as age and BSA should be considered when estimating the dose of ketamine required for induction of sedation in pediatric patients.

Does pediatric anesthesia cause brain damage? – Addressing parental and provider concerns in light of compelling animal studies and seemingly ambivalent human data / 대한마취과학회지

Anesthesia facilitates surgery in millions of young children every year. Structural brain abnormalities and functional impairment observed in animals have created substantial concerns among clinicians, parents, and government regulators. Clinical studies seemed ambivalent; it remains unclear whether differential species effects exist towards anesthetic exposure. The current literature search and analysis attempts to unify the available clinical and animal studies, which currently comprise of > 530 in vivo animal studies and > 30 clinical studies. The prevalence of abnormalities was lowest for exposures < 1 hour, in both animals and humans, while studies with injurious findings increased in frequency with exposure time. Importantly, no exposure time, anesthetic technique, or age during exposure was clearly identifiable to be entirely devoid of any adverse outcomes. Moreover, the age dependence of maximum injury clearly identified in animal studies, combined with the heterogeneity in age in most human studies, may impede the discovery of a specific human neurological phenotype. In summary, animal and human research studies identify a growing prevalence of injurious findings with increasing exposure times. However, the existing lack of definitive data regarding safe exposure durations, unaffected ages, and non-injurious anesthetic techniques precludes any evidence-based recommendations for drastically changing current clinical anesthesia management. Animal studies focusing on brain maturational states more applicable to clinical practice, as well as clinical studies focusing on prolonged exposures during distinct developmental windows of vulnerability, are urgently needed to improve the safety of perioperative care for thousands of young children requiring life-saving and quality of life-improving procedures daily.

Updated review in pediatric airway management

With respect to anesthesia for pediatric patients, the most challenging component is airway management because it has been known to be the most significant cause of anesthesia-related morbidity or mortality. Recently, in the field of pediatric anesthesia, several interesting studies have been published; one study presents the incidence of complications related to difficult tracheal intubation, and the other studies have performed re-examination of the upper airway anatomy. In addition, supraglottic airway devices (SGA) are the main devices not only for securing the airway in an emergent situation but also for routine anesthetic management. Therefore, it is necessary to summarize and re-consider the results of studies on SGA for better use. This review presents an introduction to the recent progressive studies regarding pediatric airway management and it provides several considerations which have been overlooked for safe and effective use of SGA.

Updated review in pediatric airway management

With respect to anesthesia for pediatric patients, the most challenging component is airway management because it has been known to be the most significant cause of anesthesia-related morbidity or mortality. Recently, in the field of pediatric anesthesia, several interesting studies have been published; one study presents the incidence of complications related to difficult tracheal intubation, and the other studies have performed re-examination of the upper airway anatomy. In addition, supraglottic airway devices (SGA) are the main devices not only for securing the airway in an emergent situation but also for routine anesthetic management. Therefore, it is necessary to summarize and re-consider the results of studies on SGA for better use. This review presents an introduction to the recent progressive studies regarding pediatric airway management and it provides several considerations which have been overlooked for safe and effective use of SGA.

Evidence for Questions by Diabetes Educators When Teaching Insulin Injection in Clinical Practice / 임상당뇨병

International injection recommendations for patients with diabetes have recently been published and have identified specific recommendations for health care professionals. The purpose of this article is to provide evidence-based insight based in relevant papers that provide useful information for the questions that educators in the field of insulin injection training may have. Research regarding skin and subcutaneous thickness reveals that shorter needles may be appropriate for the majority of patients regardless of body mass index. With respect to reusing needles, further research is needed to provide evidence that this is safe. Periodic reassessment of injection techniques, including suspension of cloudy insulin and inspection of injection sites for lipohypertrophy, is a critical aspect of the role of the diabetes educator. Education of diabetic patients should be conducted throughout their lives. It will be necessary to continually review each patient's social, economic, and physical needs as they change over time and modify their care and education needs accordingly.

Comparison of Dexmedetomidine and Remifentanil on Airway Reflex and Hemodynamic Changes during Recovery after Craniotomy

PURPOSE: During emergence from anesthesia for a craniotomy, maintenance of hemodynamic stability and prompt evaluation of neurological status is mandatory. The aim of this prospective, randomized, double-blind study was to compare the effects of dexmedetomidine and remifentanil on airway reflex and hemodynamic change in patients undergoing craniotomy. MATERIALS AND METHODS: Seventy-four patients undergoing clipping of unruptured cerebral aneurysm were recruited. In the dexmedetomidine group, patients were administered dexmedetomidine (0.5 µg/kg) for 5 minutes, while the patients of the remifentanil group were administered remifentanil with an effect site concentration of 1.5 ng/mL until endotracheal extubation. The incidence and severity of cough and hemodynamic variables were measured during the recovery period. Hemodynamic variables, respiration rate, and sedation scale were measured after extubation and in the post-anesthetic care unit (PACU). RESULTS: The incidence of grade 2 and 3 cough at the point of extubation was 62.5% in the dexmedetomidine group and 53.1% in the remifentanil group (p=0.39). Mean arterial pressure (p=0.01) at admission to the PACU and heart rate (p=0.04 and 0.01, respectively) at admission and at 10 minutes in the PACU were significantly lower in the dexmedetomidine group. Respiration rate was significantly lower in the remifentanil group at 2 minutes (p<0.01) and 5 minutes (p<0.01) after extubation. CONCLUSION: We concluded that a single bolus of dexmedetomidine (0.5 µg/kg) and remifentanil infusion have equal effectiveness in attenuating coughing and hemodynamic changes in patients undergoing cerebral aneurysm clipping; however, dexmedetomidine leads to better preservation of respiration.

Acute gastric dilatation causing fatal outcome in a young female with eating disorder: a case report / 대한마취과학회지

A 21-year-old female with a history of bulimia nervosa came to the emergency room due to severe abdominal pain after excessive eating five hours previously. On arrival at the emergency room, extreme abdominal distension was detected and the patient's legs changed color. Computed tomography suggested severe gastric dilatation, so abdominal compartment syndrome was suspected and an emergent laparotomy was supposed to be conducted. Though anesthesia was induced without event, abrupt hemodynamic collapse developed just after the operation started. In spite of active resuscitation for 29 min, the patient did not recover and expired. As the incidence of eating disorders is increasing, anesthesiologists should keep in mind the possibility of abdominal compartment syndrome in patients with a recent history of binge eating, and prepare optimal anesthetic and resuscitation remedies against sudden deteriorations of a patient's condition.

Current Status of Management in Type 2 Diabetes Mellitus at General Hospitals in South Korea

BACKGROUND: In Korea, the prevalence, complications, and mortality rate of diabetes are rapidly increasing. However, investigations on the actual condition of diabetes management are very limited due to lack of nation-wide research or multicenter study. Hence, we have minutely inquired the current status of diabetes management and achievement of glucose target goal in general hospital offering education program. That way, we are able to furnish data for policy making of diabetes education and draw up guideline which may allow us to reduce the morbidity and mortality of diabetes. METHODS: The subjects consisted of 2,610 patients with type 2 diabetes who visited the 13 general hospital in Seoul or Gyeonggi region from March 19 to May 29, 2013. General characteristics, associated diseases, complications, and management status were investigated. RESULTS: The mean age was 61.0+/-11.6 years, body mass index was 25.0+/-3.3 kg/m2, and family history of diabetes was 50.5%. The mean duration of diabetes was 10.7+/-7.9 years and 53% received education about diabetes. The prevalence of hypertension and dyslipidemia were 59.2% and 65.5%, respectively, and 18.3% of the subjects were accompanied by liver disease. Diabetic retinopathy appeared in 31.6%, nephropathy in 28.1%, and neuropathy in 19.9% of the subjects. The mean glycosylated hemoglobin (HbA1c) level was 7.3%+/-1.3% and the achieving rate based on Korean Diabetes Association guideline (HbA1c <6.5%) was 24.8%, blood pressure (130/80 mm Hg or less) was 49.4%, and low density lipoprotein cholesterol (<100 mg/dL) was 63.6%. The reaching rate to the target level in four parameters (blood glucose, blood pressure, lipids, and body weight) was 7.8%. CONCLUSION: The blood glucose control rate was lower than other parameters, and the implementation rate of diabetes education was only 53%. Thus more appropriate glucose control and systematic diabetes education are imperative.

Clinical efficacy of the classic laryngeal mask airway in elderly patients: a comparison with young adult patients / 대한마취과학회지

BACKGROUND: The elderly have been reported to show anatomical and physiologic changes in the upper airway, which might affect the supraglottic airway (SGA) performance in geriatric populations. This study aimed to evaluate the clinical efficacy of the classic laryngeal mask airway (LMA-C) in the elderly compared with young adult patients. METHODS: Fifty patients aged 65-85 years (elderly group) and 50 patients aged 20-40 years (young group) who were scheduled for surgery using the LMA-C for general anesthesia were enrolled in this prospective, non-randomized, comparative study. Manipulations required during insertion, success rate, insertion time, oropharyngeal leak pressure, gastric insufflation, and intraoperative inadequate ventilation with the LMA-C were assessed. Fiberoptic evaluation was used to determine the position of the LMA-C. RESULTS: In the elderly group, the insertion success rate on the first attempt was significantly lower than that in the young group (84 vs. 96%, P = 0.02). The insertion time in the elderly group was significantly longer than that in the young group (28.5 +/- 19.6 vs. 22.2 +/- 6.4 seconds, P = 0.001). However, there was no difference in oropharyngeal leak pressure or fiberoptic grade between the two groups after proper placement of the LMA-C. During the surgery, inadequate ventilation events occurred more frequently in the elderly group than in the young group (31.3 vs. 4.0%, P < 0.001). CONCLUSIONS: The clinical efficacy of the LMA-C in elderly patients was inferior to that in young adult patients. Therefore, further studies are required to determine the type of SGA that can provide excellent clinical efficacy in the geriatric population.

Association of 5-HT3B Receptor Gene Polymorphisms with the Efficacy of Ondansetron for Postoperative Nausea and Vomiting

PURPOSE: Postoperative nausea and vomiting (PONV) is a common problem after general anesthesia. Although 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists have significantly reduced PONV, over 35% of patients treated with ondansetron can experience PONV. In this study, we investigated whether the Y129S and -100_-102AAG deletion polymorphisms of the 5-HT3B receptor gene affect the efficacy of ondansetron in preventing PONV. MATERIALS AND METHODS: Two hundred and forty-five adult patients who underwent laparoscopic cholecystectomy were enrolled. Ondansetron 0.1 mg/kg was intravenously administered 30 minutes before the end of surgery. Genomic DNA was prepared from blood samples using a nucleic acid isolation device. Both the Y129S variant and the -100_-102AAG deletion variant were screened for using a single base primer extension assay and a DNA direct sequencing method, respectively. The relationship between genetic polymorphisms and clinical outcomes of ondansetron treatment was investigated. RESULTS: Among the 5-HT3B AAG deletion genotypes, the incidence of PONV was higher in patients with the homomutant than with other genotypes during the first 2 hours after surgery (p=0.02). There were no significant differences in the incidence of PONV among genotypes at 2-24 hours after surgery. In the Y129S variants of the 5-HT3B receptor gene, there were no significant differences in the incidence of PONV among genotypes during the first 2 hours and at 2-24 hours after surgery. CONCLUSION: The response to ondansetron for PONV was significantly influenced by the -100_-102AAG deletion polymorphisms of the 5-HT3B gene. Thus, the -100_-102AAG deletion variants may be a pharmacogenetic predictor for responsiveness to ondansetron for PONV.

Anesthetic considerations for robotic surgery / 대한마취과학회지

Recently, demand for minimally invasive surgery has increased greatly. As a result, robot-assisted techniques have gained in popularity, because they overcome several of the shortcomings of conventional laparoscopic techniques. However, robotic surgery may require innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel, which may go against the conservative nature of anesthesia care. Anesthesiologists should become familiar with these changes by learning the basic features of robotic surgical systems to offer better anesthetic care and promote patient safety.

Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report / 대한마취과학회지

We present a 55-year-old female patient who underwent burr-hole drainage due to chronic subdural hematoma, with obstructive prosthetic aortic valve dysfunction. Anesthetic management of a patient with severe obstructive prosthetic aortic valve dysfunction can be challenging. Similar considerations should be given to patients with aortic stenosis with an additional emphasis on thrombotic complication due to discontinuation of anticoagulation, which may further jeopardize the valve dysfunction. This case emphasizes the importance of a comprehensive understanding of the etiology and hemodynamic consequences of obstructive prosthetic valve dysfunction and the adequacy of anticoagulation for patients undergoing noncardiac surgery even after a successful valve replacement.

Dental Health Care for Patients with Diabetes / 임상당뇨병

Diabetes mellitus is emerging as a global epidemic whose complications impact significantly on quality of life, longevity and health care costs. Periodontal Disease is more severe, but not necessarily more prevalent, in patients with diabetes than in those without. Current evidence suggests that periodontal disease adversely affects diabetes outcomes, although evidence for treatment benefits is currently lacking. Patients with diabetes should be told that periodontal disease risk is increased by diabetes. They should also be told that if they suffer from periodontal disease, they may have more difficulty with glycemic control. As part of their initial evaluation, patients with type 1, type 2 and gestational diabetes (GDM) should receive a thorough oral examination that includes a comprehensive periodontal examination. Subsequent periodontal examinations should occur (as directed by dental professionals) as part of their ongoing management of diabetes. Even if no periodontitis is diagnosed initially, annual periodontal review is recommended.

Sex Differences in Remifentanil Requirements for Preventing Cough during Anesthetic Emergence

PURPOSE: Target-controlled infusion (TCI) of remifentanil can suppress coughing during emergence from general anesthesia; nevertheless, previous studies under different clinical conditions recommend significantly different effective effect-site concentrations (effective Ce) of remifentanil for 50% of patients (EC50). The differences among these studies include type of surgery and patient sex. In recent years, study of sex differences in regards to anesthetic pharmacology has drawn greater interest. Accordingly, we attempted to determine the effective Ce of remifentanil for preventing cough for each sex under the same clinical conditions. MATERIALS AND METHODS: Twenty female and 25 male ASA physical status I-II grade patients between the ages of 20 and 46 years who were undergoing thyroidectomy were enrolled in this study. The effective Ce of remifentanil for preventing cough was determined for each sex using the isotonic regression method with a bootstrapping approach, following Dixon's up-and-down method. RESULTS: Isotonic regression with a bootstrapping approach revealed that the estimated EC50 of remifentanil for preventing coughing during emergence was significantly lower in females {1.30 ng/mL [83% confidence interval (CI), 1.20-1.47 ng/mL]} than in males [2.57 ng/mL (83% CI, 2.45-2.70 ng/mL)]. Mean EC50 in females was also significantly lower than in males (1.23+/-0.21 ng/mL vs. 2.43+/-0.21 ng/mL, p<0.001). Mean arterial pressure, heart rate, and respiratory rate over time were not significantly different between the sexes. CONCLUSION: When using remifentanil TCI for cough prevention during anesthetic emergence, patient sex should be a considered for appropriate dosing.

Kidney Function in Living Donors Undergoing Nephrectomy by Sevoflurane or Desflurane Anesthesia

PURPOSE: Although there is no clinical evidence of nephrotoxicity with the volatile anesthetics currently used in general anesthesia, a better agent should be needed in terms of preserving postoperative renal function in living kidney donors who have only single remaining kidney. The purpose of the current retrospective, single-center study was to evaluate and compare renal function of living kidney donors after nephrectomy under either sevoflurane or desflurane anesthesia. MATERIALS AND METHODS: From January 2006 through December 2011, a total of 228 donors undergoing video assisted minilaparotomy surgery nephrectomy for kidney donation were retrospectively enrolled in the current study. The donors were categorized into a sevoflurane group or desflurane group based on the type of volatile anesthetic used. We collected laboratory data from the patients preoperatively, immediately after the operation, on the first postoperative day and on the third postoperative day. We also compared renal function of the kidney donors after donor nephrectomy by comparing creatinine level and estimated glomerular filtration rate (eGFR). RESULTS: The decrease in renal function after surgery in both groups was the most prominent on the first postoperative day. There were no significant differences between the two groups in postoperative changes of creatinine or eGFR. CONCLUSION: Sevoflurane and desflurane can be used safely as volatile anesthetics in donors undergoing nephrectomy.

Risk Assessment of Postoperative Nausea and Vomiting in the Intravenous Patient-Controlled Analgesia Environment: Predictive Values of the Apfel's Simplified Risk Score for Identification of High-Risk Patients

PURPOSE: Opioid-based intravenous patient-controlled analgesia (IV PCA) is popular method of postoperative pain control, but many patients suffer from IV PCA-related postoperative nausea and vomiting (PONV). In this retrospective observational study, we have determined independent predictors of IV PCA-related PONV and predictive values of the Apfel's simplified risk score in pursuance of identifying high-risk patients. MATERIALS AND METHODS: We analyzed 7000 patients who received IV PCA with background infusion after elective surgery. Patients who maintained IV PCA for a postoperative period of 48 hr (completion group, n=6128) were compared with those who have discontinued IV PCA within 48 hr of surgery due to intractable PONV (cessation group, n=872). Patients, anesthetics, and surgical factors known for predicting PONV were evaluated by logistic regression analysis to identify independent predictors of IV PCA related intractable PONV. RESULTS: In a stepwise multivariate analysis, weight, background infusion dose of fentanyl, addition of ketolorac to PCA, duration of anesthesia, general anesthesia, head and neck surgery, and Apfel's simplified risk score were revealed as independent risk factors for intractable PONV followed by the cessation of IV PCA. In addition, Apfel's simplified risk score, which demonstrated the highest odds ratio among the predictors, was strongly correlated with the cessation rate of IV PCA. CONCLUSION: Multimodal prophylactic antiemetic strategies and dose reduction of opioids may be considered as strategies for the prevention of PONV with the use of IV PCA, especially in patients with high Apfel's simplified risk scores.