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Background@#Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube.Case: We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS). @*Conclusions@#Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.
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Some studies have demonstrated that chemotherapy drugs enhance sensitivity to anesthetics owing to its systemic toxicity, while others have demonstrated that chemotherapy drugs have no effect. This study aimed to determine whether neoadjuvant chemotherapy influences the effect-site concentration (Ce) of propofol for sedation in patients withbreast cancer.Methods: This study included patients aged 19–75 years who were scheduled to undergobreast cancer surgery under general anesthesia. Patients who received neoadjuvant chemotherapy were assigned to group C, whereas those who never received chemotherapy wereassigned to group N. Propofol was administered through an effect-site target-controlled infusion, and the Modified Observer’s Assessment of Alertness/Sedation scale (MOAA/S) scoreand Bispectral Index (BIS) were recorded. When the plasma concentration and Ce wereequal to the target Ce, and if the MOAA/S score did not change, the target Ce was increasedby 0.2 μg/ml; otherwise, the Ce was maintained for 2 min and then increased. This processwas repeated until the MOAA/S score became 0.Results: No significant differences were observed in Ce values at each sedation level between both groups. Ce values for loss of consciousness (LOC) of groups C and N were 2.76± 0.29 and 2.67 ± 0.27 μg/ml (P = 0.285), respectively. However, the BIS value at LOC ofgroup C (63.87 ± 7.04) was lower than that (68.44 ± 6.01) of group N (P = 0.018).Conclusions: Neoadjuvant chemotherapy for breast cancer has no effect on the Ce ofpropofol for sedation.
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Background@#The depth of anesthesia is an essential factor in surgical prognosis. The neurotoxic effect of chemotherapeutic drugs affects the sensitivity to anesthetics. This study was conducted to determine whether the effect-site concentration (Ce) of propofol for loss of consciousness (LOC) differs in patients undergoing preoperative chemotherapy. @*Methods@#A total of 60 patients scheduled for surgery for colorectal cancer under general anesthesia were included in this study. Patients who had received chemotherapy comprised the experimental (C) group, and those without a previous history of chemotherapy comprised the control (N) group. Propofol was administered as an effect-site target-controlled infusion, and the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scores were evaluated. When the plasma concentration and Ce were similar, and if the MOAA/S score did not change, the target Ce was increased by 0.2 μg/ml; otherwise, the Ce was maintained for 2 min and then increased. @*Results@#The Ce values of propofol for loss of verbal contact (LVC) in groups C and N were 2.40 ± 0.39 and 2.29 ± 0.39 μg/ml (P = 0.286), respectively, and those for LOC in groups C and N were 2.69 ± 0.43 and 2.50 ± 0.36 μg/ml (P = 0.069), respectively. No significant difference was observed in Ce values between the two groups. @*Conclusions@#Chemotherapy had no effect on the Ce of propofol for LVC and LOC in patients with colorectal cancer. We do not recommend reducing the dose of propofol for the induction of LOC in patients with colorectal cancer undergoing chemotherapy.
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Background@#Differences in the effects of propofol and dexmedetomidine sedation on electroencephalogram patterns have been reported previously. However, the reliability of the Bispectral Index (BIS) value for assessing the sedation caused by dexmedetomidine remains debatable. The purpose of this study is to evaluate the correlation between the BIS value and the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale in patients sedated with dexmedetomidine. @*Methods@#Forty-two patients (age range, 20–80 years) who were scheduled for elective surgery under spinal anesthesia were enrolled in this study. Spinal anesthesia was performed using 0.5% bupivacaine, which was followed by dexmedetomidine infusion (loading dose, 0.5–1 μg/kg for 10 min; maintenance dose, 0.3–0.6 μg/kg/h). The MOAA/S score was used to evaluate the level of sedation, and the Vital Recorder program was used to collect data (vital signs and BIS values). @*Results@#A total of 215082 MOAA/S scores and BIS data pairs were analyzed. The baseline variability of the BIS value was 7.024%, and the decrease in the BIS value was associated with a decrease in the MOAA/S score. The correlation coefficient and prediction probability between the two measurements were 0.566 (P < 0.0001) and 0.636, respectively. The mean ± standard deviation values of the BIS were 87.22 ± 7.06, 75.85 ± 9.81, and 68.29 ± 12.65 when the MOAA/S scores were 5, 3, and 1, respectively. Furthermore, the cut-off BIS values in the receiver operating characteristic analysis at MOAA/S scores of 5, 3, and 1 were 82, 79, and 73, respectively. @*Conclusion@#The BIS values were significantly correlated with the MOAA/S scores. Thus, the BIS along with the clinical sedation scale might prove useful in assessing the hypnotic depth of a patient during sedation with dexmedetomidine.
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Background@#Postoperative sore throat (POST) is a complication that decreases patient satisfaction and increases postoperative complaints. The present study was conducted to investigate effects of gargling with dexamethasone, intravenous dexamethasone injection and the combination of the two on the incidence and severity of POST. @*Methods@#Study participants were 96 patients who had undergone laparoscopic cholecystectomy, randomly allocated into three groups. Group G gargled with 0.05% dexamethasone solution and were infused intravenous 0.9% normal saline before general anesthesia; group I gargled with 0.9% normal saline and were infused intravenous 0.1 mg/kg dexamethasone; group GI gargled with 0.05% dexamethasone solution and were infused intravenous 0.1 mg/kg dexamethasone. The incidence and severity of POST, hoarseness and cough were evaluated and recorded at 1, 6, and 24 h after the surgery. @*Results@#There were no significant differences in the total incidence of POST up to 24 postoperative hours among Group G, Group I and Group GI (P = 0.367, Group G incidence = 34.38%, [95% confidence interval, 95% CI = 17.92–50.83], Group I incidence = 18.75%, [95% CI = 5.23–32.27], Group GI incidence = 28.13%, [95% CI = 12.55–43.70]). The other outcomes were comparable among the groups. @*Conclusions@#In patients who had undergone laparoscopic cholecystectomy, gargling with 0.05% dexamethasone solution demonstrated the same POST prevention effect as intravenous injection of 0.1 mg/kg dexamethasone. The incidence and severity of POST were not significantly different between the combination of gargling with 0.05% dexamethasone solution and intravenous injection of 0.1 mg/kg dexamethasone and use of each of the preventive methods alone.
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Frequently, we encounter the phenomenon of hysteresis in kinetic-dynamic modeling. The hysteresis loop in the concentration-effect curve suggests a time discrepancy caused by various pharmacokinetic and pharmacodynamic factors. To collapse the hysteresis loop and to simplify the concentration-effect relationship, several kinetic-dynamic modeling approaches including the effect compartment link model, turnover model (indirect response model), and tolerance/rebound model, have been used. The semicompartmental model is one method to describe the hysteresis of the pharmacokineticpharmacodynamic relationship. Furthermore, this semi-compartmental model differs from other models (full parametric approaches) as it does not require pharmacokinetic parameters to estimate pharmacodynamic parameters and ke0. Therefore, we could employ a semi-compartmental approach in case it is difficult to apply the compartment model to pharmacokinetic data, as required for the pharmacodynamic analysis of inhalational anesthetics.
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Background@#This clinical trial was conducted to determine whether combined use of magnesium sulfate and vitamin C more significantly reduced postoperative fentanyl consumption and pain than magnesium sulfate or vitamin C alone. @*Methods@#The prospective, double-blinded, randomized controlled study enrolled 132 patients scheduled for laparoscopic gynecologic surgery. The patients were randomly allocated to one of the four groups (n = 33 for each group; Group M [magnesium sulfate 40 mg/kg], Group V [vitamin C 50 mg/kg], Group MV [magnesium sulfate 40 mg/kg and vitamin C 50 mg/kg] and Group C [isotonic saline 40 ml]). Cumulative postoperative fentanyl consumption (primary endpoint measure), postoperative pain score by numeric rating scale, and postoperative nausea and vomiting were recorded at 1, 6, 24, and 48 h after discharge from the postanesthesia care unit. @*Results@#Cumulative postoperative fentanyl consumption was significantly less in Groups M, V, and MV than in Group C at all time points. Group MV showed significantly less cumulative postoperative fentanyl consumption than Group M at postoperative 24 h (mean ± standard deviation, 156.6 ± 67.5 vs. 235.6 ± 94.6 μg, P = 0.001), as well as significantly less consumption than Groups M and V at postoperative 48 h (190.8 ± 74.6 vs. 301.0 ± 114.8 or 284.1 ± 128.6 μg, P < 0.001, P = 0.003, respectively). @*Conclusions@#Combined use of magnesium sulfate and vitamin C provides an additional benefit in postoperative pain management after laparoscopic gynecologic surgery in comparison to single administration of magnesium sulfate or vitamin C.
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Background@#Higher levels of anxiety increase the risks of surgery, including morbidity and mortality. The objectives of this study were to measure anxiety and depression during the preoperative period and to identify the degree of knowledge and concerns of older patients and their family protectors regarding anesthesia, and the causes of these concerns. @*Methods@#We administered a questionnaire to older patients scheduled to undergo surgery and their family protectors one day prior to the surgery. The questionnaire included tools for quantifying anxiety and depression (Anxiety-Visual Analogue Scale, the Amsterdam Preoperative Anxiety and Information Scale, State-Trait Anxiety Inventory Korean YZ Form, and Short Form Geriatric Depression Scale). We also asked about the concrete causes of anxiety using pre-created forms. @*Results@#There were 140 older patients and family protectors who participated in the study. The majority of older patients (n = 114, 81.4%) undergoing surgery and their family protectors (n = 114, 81.4%) indicated that they were anxious. Most of the older patients and their family protectors responded that they had insufficient knowledge about anesthesia, and they were mostly worried about failure to awaken following surgery, and postoperative pain. Older patients with higher anxiety scores showed higher depression scores. There were significant differences in depression scores depending on the presence of cohabitating family members. @*Conclusions@#It is important to remember that older patients with higher depression scores have higher anxiety during the preoperative period.
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Background@#Vocal cord paralysis (VCP) is one of the most stressful experiences for patients undergoing general anesthesia. Moreover, it is a risk factor for aspiration pneumonia and may increase morbidity and mortality. We examined several clinical features of the condition by reviewing the medical records of patients who experienced VCP following general anesthesia. @*Methods@#We reviewed the medical records of 321 patients who consulted an otolaryngologist owing to hoarseness, sore throat, throat discomfort, or dysphagia after general anesthesia. Among these, we included in the present study 43 patients who were diagnosed with VCP by laryngoscopy, who did not have symptoms of suspected VCP before surgery, who had no past history of VCP, and for whom endotracheal intubation was not continued after surgery. @*Results@#The mean age of patients with VCP was 51.28 years. With respect to surgical site, the most common was upper limb surgery, performed in 12 cases (9 cases were performed in sitting posture. With respect to surgical duration, only 11 cases lasted less than 3 h, whereas 32 cases required a surgical duration longer than 3 h. The most common symptom of VCP was hoarseness. Nine of the patients with VCP recovered spontaneously, but VCP persisted in 13 cases until the final follow-up examination. @*Conclusions@#We hope that this study might call attention to the occurrence of VCP following general anesthesia. Moreover, it is necessary to further evaluate the reasons for the higher incidence of VCP in upper limb surgery performed in sitting posture.
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BACKGROUND: Postoperative sore throat (POST) is a complication that undermines patient satisfaction and increases discomfort in the postoperative period. The present study examined the effects of dexamethasone gargle and endotracheal tube cuff soaking on the incidence and severity of POST. METHODS: Ninety patients undergoing laparoscopic cholecystectomy were randomly allocated into three groups: 0.9% normal saline gargling and tube soaking (group C), 0.05% dexamethasone solution gargling and 0.9% normal saline tube soaking (group G), 0.9% normal saline gargling and 0.05% dexamethasone tube soaking (group S). The incidence and severity of POST were then assessed and recorded at 24 hours after surgery. RESULTS: The total incidence of POST was significantly different among the groups (P < 0.05), and group S exhibited a significantly lower incidence of POST than group C (P < 0.0167). In addition, the POST intensity of group G and group S was less severe than those of group C (Both P < 0.0167). CONCLUSIONS: Among patients undergoing laparoscopic cholecystectomy, those who gargled with 0.05% dexamethasone solution exhibited lower severity of POST than the control group, and those whose endotracheal tube cuff was soaked in the dexamethasone solution before intubation exhibited significantly lower incidence and severity of POST than the control group.
Subject(s)
Humans , Cholecystectomy, Laparoscopic , Dexamethasone , Incidence , Intubation , Intubation, Intratracheal , Patient Satisfaction , Pharyngitis , Postoperative Complications , Postoperative PeriodABSTRACT
Central venous catheterization is a useful method for monitoring central venous pressure and maintaining volume status. However, it is associated with several complications, such as pneumothorax, hydrothorax, hemothorax, and air embolism. Here we describe a case of iatrogenic tension hydrothorax after rapid infusion of fluid into the pleural space, following the misplacement of an internal jugular vein catheter. Despite ultrasonographic guidance during insertion of the central venous catheter, we were not able to avoid malposition of the catheter. The patient went into hemodynamic compromise during surgery, necessitating chest tube drainage and a mechanical ventilator postoperatively. This case shows that central venous catheter insertion under ultrasonographic guidance does not guarantee proper positioning of the catheter.
Subject(s)
Humans , Catheterization, Central Venous , Catheters , Central Venous Catheters , Central Venous Pressure , Chest Tubes , Drainage , Embolism, Air , Hemodynamics , Hemothorax , Hydrothorax , Jugular Veins , Methods , Pneumothorax , Ventilators, MechanicalABSTRACT
BACKGROUND: Sugammadex is a novel neuromuscular reversal agent, but its associated hypersensitivity reaction and high cost have been obstacles to its widespread use. In the interest of reducing the necessary dosage of sugammadex, the reversal time of the combined use of sugammadex and neostigmine from moderate neuromuscular blockade were investigated. METHODS: The patients enrolled ranged in age from 18 to 65 years old with American Society of Anesthesiologists class 1 or 2. The subjects were randomly assigned into one of the four groups (Group S2, S1, SN, and N; n = 30 per group). The reversal agents of each groups were as follows: S2 - sugammadex 2 mg/kg, S1 - sugammadex 1 mg/kg, SN - sugammadex 1 mg/kg + neostigmine 50 microg/kg + glycopyrrolate 10 microg/kg, N - neostigmine 50 microg/kg + glycopyrrolate 10 microg/kg. The time to recovery of the train-of-four (TOF) ratio was checked in each group. RESULTS: The time to 90% recovery of TOF ratio was 182.6 +/- 88.9, 371.1 +/- 210.4, 204.3 +/- 103.2, 953.2 +/- 379.7 sec in group S2, S1, SN and N, respectively. Group SN showed a significantly shorter recovery time than did group S1 and N (P < 0.001). However, statistically significant differences between the S2 and SN groups were not be observed (P = 0.291). No hypersensitivity reactions occurred in all groups. CONCLUSIONS: For the reversal from rocuronium-induced moderate neuromuscular blockade, the combined use of sugammadex and neostigmine may be helpful to decrease the recovery time and can also reduce the required dosage of sugammadex. However, the increased incidence of systemic muscarinic side effects must be considered.
Subject(s)
Humans , Glycopyrrolate , Hypersensitivity , Incidence , Neostigmine , Neuromuscular BlockadeABSTRACT
BACKGROUND: Postoperative pain is the most common complaint of patients following laparoscopic cholecystectomy (LC). Intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory effects, and dexmedetomidine has anti-nociceptive and analgesic sparing effects. We evaluated the effects of perioperative intravenous infusion of lidocaine and dexmedetomidine on postoperative pain control and analgesic consumption after LC. METHODS: Eighty-four patients, aged 20-60 years, who were undergoing elective LC were assigned randomly to three groups (n = 28 in each). The patients in group L received an intravenous lidocaine bolus of 1.5 mg/kg and then continuous infusion of 2 mg/kg/hr. The group D received an intravenous dexmedetomidine bolus of 1 microg/kg, followed by continuous infusion of 0.4 microg/kg/hr. The group N received saline as described for group L. Bolus doses were given during the 10 minutes before the induction of anesthesia, followed by continuous infusion until end of the surgery. Visual analogue scale (VAS) score and postoperative analgesics consumption were evaluated during 24 hours after the surgery. RESULTS: No significant difference was observed in VAS score among the groups during the first 24 hr after LC. The amount of fentanyl consumption in the post-anesthesia care unit was significantly less in groups L and D compared to group N. CONCLUSIONS: Both perioperative intravenous infusion of dexmedetomidine and lidocaine reduced postoperative requirements of fentanyl in the early post-operative period after LC. However, there was no significant difference between dexmedetomidine and lidocaine in the analgesic sparing effect.