Anesthesiologist’s role as a communication coordinator of perioperative medicine: stressing the recognition of role in the changing medical atmosphere

Perioperative care process in a hospital is considerably complex, involving multiple subprocesses, healthcare professionals, and systems in support of surgical care. The perioperative process is often the primary source of hospital admissions, driving the dominant part of hospital margins and accounts for a major part of all adverse events occurring in hospitals. The recent trend stresses the importance of adopting patient-centered and quality-proven care in many medical fields. Further, the emphasis on changing from fee-for-service to fee-for-value is increasing. These changes present challenges to anesthesiologists who play a central role in perioperative medicine.Current Concepts: Anesthesiologists are in contact with many surgeons and patients and are positioned to improve clinical outcomes. They need to have up-to-date, evidence-based knowledges on perioperative clinical management and know-how to apply, organize and practice them into efficient pathways for optimal outcomes. To accomplish such purposes, anesthesiologists need to acquire communication skills to reason and convincing related personnel including surgeons and patients.Discussion and Conclusion: The recent changing climate of perioperative medicine calls upon anesthesiologists to acquire knowledges driving quality care and demands the application of communicative skills to accomplish the required tasks.

Anesthesiologist’s role as a communication coordinator of perioperative medicine: stressing the recognition of role in the changing medical atmosphere

Perioperative care process in a hospital is considerably complex, involving multiple subprocesses, healthcare professionals, and systems in support of surgical care. The perioperative process is often the primary source of hospital admissions, driving the dominant part of hospital margins and accounts for a major part of all adverse events occurring in hospitals. The recent trend stresses the importance of adopting patient-centered and quality-proven care in many medical fields. Further, the emphasis on changing from fee-for-service to fee-for-value is increasing. These changes present challenges to anesthesiologists who play a central role in perioperative medicine.Current Concepts: Anesthesiologists are in contact with many surgeons and patients and are positioned to improve clinical outcomes. They need to have up-to-date, evidence-based knowledges on perioperative clinical management and know-how to apply, organize and practice them into efficient pathways for optimal outcomes. To accomplish such purposes, anesthesiologists need to acquire communication skills to reason and convincing related personnel including surgeons and patients.Discussion and Conclusion: The recent changing climate of perioperative medicine calls upon anesthesiologists to acquire knowledges driving quality care and demands the application of communicative skills to accomplish the required tasks.

Novel alternative for submental intubation - A case report -

Background@#Submental intubation is commonly used during general anesthesia for maxillofacial surgeries as it provides a safe unrestricted surgical access compared to tracheostomy. During submental intubation, soft tissues and blood clots can become lodged in the endotracheal tube. To overcome this problem, we used a laparoscopic trocar.Case: A 52-year-old man with maxillofacial injury was scheduled to undergo an open reduction and internal fixation. We performed submental intubation using laparoscopic trocar, which created sufficient space for the insertion of the endotracheal tube. Unlike conventional methods, our method did not require any blunt dissection and caused significantly less soft tissue damage and required significantly less time. @*Conclusions@#Submental intubation with laparoscopic trocar is a one-step method and is quick and easy-to-perform technique with less complications.

Risk factors of 30-day mortality following endovascular thoracic and abdominal aortic repair with general anesthesia

BACKGROUND: Recently, endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), have been used for treatment of thoracic and abdominal aortic aneurysms. The purpose of this study was to analyze the outcome and predictors for 30-day mortality and complications, in patients that underwent EVAR and/or TEVAR under general anesthesia. METHODS: In this study, 151 cases of EVAR and/or TEVAR under general anesthesia in 140 patients during 2009–2017 were studied. The primary outcome was 30-day mortality after surgery. Multivariate logistic regression analysis was used, to clarify risk for postoperative 30-day mortality. RESULTS: Postoperative 30-day mortality rate was 9.9% in the study population (10.3% in EVAR, and 9.3% in TEVAR, respectively). Seventy-two cases (47.7%) experienced postoperative complications within 30 days. Elderly older than age 76.5 (odds ratio [ORs] = 48.89, 95% confidential interval [95% CI] 1.40–1,710.25, P = 0.032), technically expertness (OR = 0.01, 95% CI 0.00–0.40, P = 0.013), severity of systemic complications (OR = 23.24, 95% CI, 2.27–238.24, P = 0.008), and severity of local-vascular complications (OR = 31.87, 95% CI, 1.29–784.66, P = 0.034) were significantly associated with 30-day mortality. CONCLUSIONS: This study revealed that elderly, technically expertness, and severity of systemic and local-vascular complications were associated with 30-day mortality of EVAR and TEVAR in aortic aneurysm.

Controversy related to the preliminary coverage system of health insurance

Korea is regarded as a country that provides a high level of medical services despite a low burden of public health insurance premiums. However, patients face the burden of covering the costs of medical services that are not covered by health insurance, and providers face difficulties because the price of the medical service guaranteed by the health insurance system is very low. In this situation, the government is trying to expand health insurance coverage in the form of the ‘preliminary coverage system’ also known as the ‘selective coverage system’. In this system the government sets the price for a particular health care service not covered by health insurance and then the patient pays for the majority (50% to 90%) of the cost. Although it is possible to manage information about the amount of medical service usage at the national level through this system, it still places a high economic burden on patients with low incomes. In addition, since medical providers are forced to receive uniformly undervalued prices, specialized technologies that have been optimized by medical research institutions are threatened with extinction. Therefore, the preliminary coverage system needs to be reviewed before implementation of expanded coverage within this framework. First, the concept of essential medical care should be established. Based on this concept, the percentage of the cost to be paid by patients should be derived. If the preliminary coverage system is applied to medical services that are not covered by health insurance, a reasonable classification system should be developed and applied along with pricing considering customary market prices.

Controversy related to the preliminary coverage system of health insurance

Korea is regarded as a country that provides a high level of medical services despite a low burden of public health insurance premiums. However, patients face the burden of covering the costs of medical services that are not covered by health insurance, and providers face difficulties because the price of the medical service guaranteed by the health insurance system is very low. In this situation, the government is trying to expand health insurance coverage in the form of the ‘preliminary coverage system’ also known as the ‘selective coverage system’. In this system the government sets the price for a particular health care service not covered by health insurance and then the patient pays for the majority (50% to 90%) of the cost. Although it is possible to manage information about the amount of medical service usage at the national level through this system, it still places a high economic burden on patients with low incomes. In addition, since medical providers are forced to receive uniformly undervalued prices, specialized technologies that have been optimized by medical research institutions are threatened with extinction. Therefore, the preliminary coverage system needs to be reviewed before implementation of expanded coverage within this framework. First, the concept of essential medical care should be established. Based on this concept, the percentage of the cost to be paid by patients should be derived. If the preliminary coverage system is applied to medical services that are not covered by health insurance, a reasonable classification system should be developed and applied along with pricing considering customary market prices.

The effect of pre-anesthetic administration of dexmedetomidine on the consumption of opioids in postoperative gynecologic patients

BACKGROUND: This study was designed to assess whether pre-anesthetic administration of dexmedetomidine reduces the postoperative consumption of opioids, in patients receiving patient-controlled fentanyl after gynecological laparotomy. METHODS: This was a prospective, randomized, double-blind, controlled study. Ten minutes before induction of anesthesia, 36 patients scheduled for elective gynecological laparotomy were assigned to receive either normal saline (group N) or dexmedetomidine 1 µg/kg (group D). A patient-controlled analgesia (PCA) device was used to administer fentanyl for the postoperative 24 h period. Cumulative fentanyl consumption and pain score were assessed at postoperative 30 min, 6 h and 24 h. Patient's satisfaction for pain control and other side effects (nausea, sedation score) were recorded for all corresponding time points. RESULTS: There was no significant difference between the groups in cumulative fentanyl consumption (Group N: 11.1 ± 3.2 µg/kg, Group D: 10.3 ± 2.9 µg/kg, P value: 0.706). The incidence of side-effects did not differ between the groups. Both groups showed similar blood pressure after anesthesia induction. However, 10 min after anesthesia induction, the heart rates in group D were significantly lower than group N (P = 0.0002). CONCLUSIONS: In patients undergoing gynecological laparotomy, the pre-anesthetic administration of single loading dose dexmedetomidine (1 µg/kg) given 10 min before anesthesia induction did not reduce the PCA consumption of postoperative fentanyl or the pain score.

The efficacy of warming blanket on reducing intraoperative hypothermia in patients undergoing transurethral resection of bladder tumor under general anesthesia

BACKGROUND: Perioperative hypothermia, defined as a core temperature under 36℃, increases the risk of cardiac complication, bleeding and infection. This study aimed to compare the hypothermia-preventing effects of a warming blanket (Ready-heat®) and one-layer cotton blanket in patients undergoing transurethral resection of the bladder (TURBT) under general anesthesia. METHODS: Patients undergoing TURBT under general anesthesia were allocated to the warming blanket (N = 23) or one-layer cotton blanket (N = 23) groups. Ten minutes before induction of anesthesia, warming blanket or one-layer cotton blanket was applied according to the assigned group. Tympanic temperature was measured just before induction of anesthesia. Esophageal temperature and tympanic temperature were measured from 20 min after induction of anesthesia at 10-min intervals. Tympanic temperature was measured at 10-min intervals over a 30-min period in the post-anesthesia care unit (PACU). In addition, the incidence and intensity of shivering and thermal comfort were also measured. RESULTS: The core temperature during general anesthesia showed no significant intergroup difference. The warming blanket group showed a lower incidence of hypothermia at 1 h after induction of anesthesia. Tympanic temperature, the incidence and intensity of shivering, and thermal comfort in the PACU showed no significant intergroup differences. CONCLUSIONS: Application of the warming blanket or one-layer cotton blanket for 10 min before induction of anesthesia showed no hypothermia-preventing effects. However, at one hour after induction of anesthesia, warming blanket application reduced the incidence of hypothermia to a greater degree than one-layer cotton blanket.

Risk factors associated with outcomes of hip fracture surgery in elderly patients / 대한마취과학회지

BACKGROUND: Hip fracture surgery on elderly patients is associated with a high incidence of morbidity and mortality. The aim of this study is to identify the risk factors related to the postoperative mortality and complications following hip fracture surgery on elderly patients. METHODS: In this retrospective study, the medical records of elderly patients (aged 65 years or older) who underwent hip fracture surgery from January 2011 to June 2014 were reviewed. A total of 464 patients were involved. Demographic data of the patients, American Society of Anesthesiologists physical status, preoperative comorbidities, type and duration of anesthesia and type of surgery were collected. Factors related to postoperative mortality and complications; as well as to intensive care unit admission were analyzed using logistic regression. RESULTS: The incidence of postoperative mortality, cardiovascular complications, respiratory complications and intensive care unit (ICU) admission were 1.7, 4.7, 19.6 and 7.1%, respectively. Postoperative mortality was associated with preoperative respiratory comorbidities, postoperative cardiovascular complications (P < 0.05). Postoperative cardiovascular complications were related to frequent intraoperative hypotension (P <0.05). Postoperative respiratory complications were related to age, preoperative renal failure, neurological comorbidities, and bedridden state (P < 0.05). ICU admission was associated with the time from injury to operation, preoperative neurological comorbidities and frequent intraoperative hypotension (P < 0.05). CONCLUSIONS: Adequate treatment of respiratory comorbidities and prevention of cardiovascular complications might be the critical factors in reducing postoperative mortality in elderly patients undergoing hip fracture surgery.

Public awareness about the specialty of anesthesiology and the role of anesthesiologists: a national survey / 대한마취과학회지

BACKGROUND: The aims of this national survey were to determine the views of Korean people regarding the specialty of anesthesiology and the role of anesthesiologists and to consider the ways in which individual anesthesiologists and the Korean Society of Anesthesiologists inform the public. METHODS: This off-line national survey was conducted by a professional research organization to obtain exact and reliable data. The questionnaire included structured questions to identify perceptions of the specialty of anesthesiology and the role of anesthesiologists inside and outside the operating room, people's desire for explanation of anesthesia by anesthesiologists, and their opinion about the best way to raise awareness about anesthesia and anesthesiologists. RESULTS: Of the respondents, 25.2% did not know that anesthesiologists are in charge of anesthesia during surgery. Furthermore, even respondents who knew that had very little knowledge of anesthesiologists' actual roles inside and outside the operating room. Respondents wanted their anesthesiologist to inform them about their anesthesia. CONCLUSIONS: The public's awareness regarding the role of anesthesiologists seems to be inadequate. To improve this awareness, in hospitals, each anesthesiologist should provide patients with more exact and detailed information. Simultaneously, the National Society of Anesthesiology should provide systematic information reflecting the public's thoughts.

Erratum: Comparison of two types of combined spinal-epidural sets in terms of catheter positioning: reinforced catheter vs. non-reinforced catheter

We found an error in our published article.

General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture / 대한마취과학회지

BACKGROUND: Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures. METHODS: Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS: Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon's satisfaction, postoperative pain scores and incidence of PONV. CONCLUSIONS: MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient%s preference and medical condition.

Comparison of two types of combined spinal-epidural sets in terms of catheter positioning: reinforced catheter vs. non-reinforced catheter

BACKGROUND: The purpose of this study is to examine the usefulness of a combined spinal-epidural set with reinforced catheter (CombiSpeed(R), Ace Medical, Seoul, Korea) as compared with the non-reinforced catheter (PORTEX(R), Smiths medical, Brisbane, Australia) in terms of catheter positioning and clinical aspects of anesthesia. METHODS: One hundred and two patients scheduled for regional anesthesia were enrolled in this study. They were allocated randomly either into group A (CombiSpeed(R)) or group P (PORTEX(R)). Vital signs and the levels of sensory and motor block were measured every 5 minutes. Ease of insertion and the removal of the catheter were assessed, so was the incidence of venous cannulation and paresthesia during epidural catheter insertions. After the placement of epidural catheter, we checked the location of catheter by radiography and measured in a clockwise angle from the midline to catheter tip (angle X). In laboratory, tensile strength of the two products was measured by using tonometry. RESULTS: There were no significant differences between groups in intra-operative vital sign, block level and ease of catheter insertion and removal. No difference was observed in angle X between the groups (group A: 93.6 +/- 129.5degrees, group P: 124.5 +/- 127.7degrees, P = 0.22). There were no complications such as paresthesia or venous cannulation during catheter insertion. The tensile strength was higher in group A (group A: 1.70 +/- 0.05 kg, group P: 1.30 +/- 0.03 kg, P < 0.05). CONCLUSIONS: CombiSpeed(R) is as useful as PORTEX(R) in terms of ease for catheter placement, positioning of catheter tip and clinical aspects of anesthesia.

Transverse myelitis following combined spinal-epidural anesthesia / 대한마취과학회지

No abstract available.

The comparative study to evaluate the effect of palonosetron monotherapy versus palonosetron with dexamethasone combination therapy for prevention of postoperative nausea and vomiting / 대한마취과학회지

BACKGROUND: 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are effective and safe on postoperative nausea and vomiting (PONV). Palonosetron, the newest 5-HT3 antagonist, has potent antiemetic property. We hypothesized that a combination of palonosetron and dexamethasone could more decrease PONV than palonosetron alone. METHODS: Among the patients scheduled to undergo laparoscopic gynecologic surgery, mastoidectomy with tympanoplasty or thyroidectomy under general anesthesia, eighty four female patients with at least two PONV risk factors were enrolled in this study. They were received randomly 0.075 mg palonosetron and 4 mg dexamethasone (group C) or 0.075 mg palonosetron alone (group P). The severity of PONV using Rhodes index and the percentage of complete response during postoperative 24 hours were compared between groups. RESULTS: The frequency of mild/moderate/great/severe PONV based on Rhodes index were 9.8%/0%/0%/0% and 9.3%/2.3%/2.3%/0% in group P and group C, respectively. Complete response for PONV was observed in 90.2% and 86% of patients in group P and group C, respectively. The overall incidence of PONV in group P and C was 9.8% and 14%, respectively. There was no significant difference between the two groups. CONCLUSIONS: There were no differences between palonosetron monotherapy and combination therapy of palonosetron and dexamethasone in patients with high emetogenic risk.

Frequency of unexpected antibody and consideration during transfusion / 대한마취과학회지

BACKGROUND: In this retrospective study, we measured the frequency of unexpected antibodies in the blood. Specific considerations for preoperative preparations were kept in mind for the patients undergoing surgery positive for these antibodies. METHODS: After reviewing the results of antibody screening tests lasted for 2 years, the frequency of unexpected antibodies was determined. Surgical patients who were positive for unexpected antibodies were selected and divided into two groups based on their potential need for an intra-operative transfusion (groups with high versus low possibility of transfusion). Blood for the high possibility group was prepared before surgery. For the low possibility group for which preoperative blood preparation was not performed, cases of this group were reviewed whether a blood preparation was delayed or not in case of transfusion. RESULTS: Among a total 22,463 cases, 340 (1.52%) had positive results for antibody screening tests. Among the 243 patients who were positive for unexpected antibodies, Lewis, Rh, Xga, and mixed antibodies were found in 85, 25, five, and eight cases, respectively. Out of 243 patients, 117 patients, specificities of the unexpected antibodies were not determined and 125 (51.4%) had a history of pregnancy and delivery, and 49 (20.2%) had a history of transfusion. In the low probability group, transfusions were administered for nine patients; transfusion was delayed for two patients due to difficulties with obtaining matched blood. CONCLUSIONS: Patients with unexpected blood antibodies may be at increased risk for delayed transfusion. For rapid transfusion, it might be helpful to keep a record about blood antibodies and introduce a notification system such as medical alert cards. Preoperative blood preparation is needed for timely intraoperative transfusion.

Effect of ulinastatin on the rocuronium-induced neuromuscular blockade / 대한마취과학회지

BACKGROUND: Ulinastatin is a glycoprotein derived from human urine and a serine protease inhibitor found in human urine and blood. Ulinastatin increases both liver blood flow and urine output. Rocuronium is eliminated mainly through the liver and partly through the kidney, hepatic elimination of rocuronium might be enhanced by ulinastatin. We examined the effect of ulinastatin on the neuromuscular block caused by rocuronium. METHODS: Forty four adult patients were randomly divided into two groups of 22 patients each, i.e. the study group and the control group. In the study group, a bolus dose of ulinastatin 5,000 U/kg was administered 2 min before the injection of rocuronium 0.6 mg/kg. In the control group, normal saline was administered instead of ulinastatin. For the monitoring of both onset and recovery from neuromuscular blockade, train-of-four (TOF) and post-tetanic count were used with TOF-Watch Sx. All patients underwent general anesthesia with total intravenous anesthesia (TIVA) of remifentanil and propofol, using the effect site target infusion system. RESULTS: In the study group, the onset of neuromuscular block was significantly slower than in the control group (P < 0.05). The recovery time from the rocuronium injection to the return of PTC was also significantly shorter in the study group than in the control group (P < 0.05). Similarly, times to the return of T1, T2, T3, and T4 (i.e. the first, second, third, and fourth response of TOF) were significantly shorter in the study group than in the control group (P < 0.05). CONCLUSIONS: Ulinastatin significantly delays the onset of neuromuscular block and accelerates the recovery from the block caused by rocuronium.

The effect of remifentanil versus N2O on postoperative pain and emergence agitation after pediatric tonsillectomy/adenoidectomy / 대한마취과학회지

BACKGROUND: Remifentanil can be an alternative to N2O in general anesthesia. Intraoperative remifentanil may lead to acute opioid tolerance. This study aims to assess the effect of remifentanil substituted for 70% N2O on postoperative pain in children undergoing tonsillectomy/adenoidectomy. In addition, we evaluated the effect of remifentanil infusion on incidence of emergence agitation in these patients. METHODS: Eighty children, aged 2-12 years, undergoing tonsillectomy/adenoidectomy were randomly allocated to the N2O group (Group N; n = 40, sevoflurane and 70% N2O) or remifentanil group (Group R; n = 40, sevoflurane with remifentanil infusion at the rate of 0.17 microg/kg/min). In the recovery room, severity of pain and agitation were assessed by an investigator blinded to the assigned group. Time to eye opening and incidence of severe pain and agitation were compared between groups. Logistic regression was used to identify factors related to occurrence of severe pain and agitation. RESULTS: Number of patients with severe postoperative pain was 6 and 16 in groups N and R, respectively (P = 0.012). Incidence of emergence agitation was not significantly different between groups. Remifentanil infusion was a significant factor related to the occurrence of severe postoperative pain (P = 0.015), and age was inversely related to occurrence of emergence agitation (P = 0.001). CONCLUSIONS: In children undergoing tonsillectomy/adenoidectomy, intraoperative remifentanil infusion may increase incidence of severe postoperative pain compared to N2O, but it may not affect incidence of emergence agitation.

Effect-site concentration of remifentanil for blunting hemodynamic responses to tracheal intubation using light wand during target controlled infusion-total intravenous anesthesia / 대한마취과학회지

BACKGROUND: Transillumination using a light wand is an alternative type of laryngoscope used for tracheal intubation. There is little information available on the effect-site concentration of remifentanil required to control hemodynamic changes induced by tracheal intubation using the transillumination method during total IV anesthesia. We therefore conducted this study to determine the effect-site concentration of remifentanil blunting hemodynamic responses after tracheal intubation in patients receiving propofol anesthesia. METHODS: We enrolled 26 healthy adult patients (ASA physical status I-II), aged 16-67 scheduled for surgery within 2 hours. All patients received a target-controlled infusion of 4 microg/ml propofol. The effect-site target-concentration of remifentanil of 5.0 ng/ml was chosen for the first patient. We used the Dixon's up-and-down sequential allocation method for determining the next remifentanil concentration. The time required for tracheal intubation was measured as the level of intubation stimulation. RESULTS: The average intubation time was 13.9 +/- 9.1 seconds. From the Dixon's method, the EC50 of remifentanil blunting the hemodynamic response to tracheal intubation was 2.94 ng/ml. CONCLUSIONS: This study shows that effect-site concentrations of remifentanil of 2.94 ng/ml is effective in blunting sympathetic responses to tracheal intubation in 50% of patients with normal airway anatomy when combined with a target controlled infusion of propofol (4 microg/ml).

Anesthetic management of patient with congenital insensitivity to pain with anhidrosis (CIPA) by using BIS monitor: A case report

Congenital insensitivity to pain with anhidrosis (CIPA, or hereditary sensory and autonomic neuropathy type IV) is a rare, autosomal recessive disease, is characterized by inability to sweat, insensitivity to pain, recurrent episodes of hyperpyrexia, self-mutilation and mental retardation. Because of lacking autonomic response to painful stimuli, it is difficult to determine adequate depth of anesthesia in patients with CIPA. We report an anesthetic experience for child with CIPA who had undergone an orthopedic operation. Anesthesia was induced by propofol and maintained by Sevoflurane with 50% nitrous oxide and anesthetic depth was monitored by using bispectral index (BIS). Throughout the operation, anesthesia was maintained with low end-tidal Sevoflurane concentrations (<1.5 vol%), BIS was within 28-62 and vital signs were stable. After operation, he did not remember anything about the surgery. The BIS monitor may be a useful tool to guide the adequate depth of anesthesia for the patient with CIPA.