The learner-adjusted assessment tool for endotracheal intubation considering examiners' different expectations of competence

OBJECTIVE: Endotracheal intubation (ETI) is the most reliable way to manage the airway. Stepwise deliberate practice and mastery training is essential in maintaining and promoting the skill of intubation. This study was conducted to identify differences in examiners' expectations regarding competent skill performance and to develop learner-adjusted assessment tools with appropriate levels according to student and resident learners based on the expectations and limited observation of performance by examiners. METHODS: This was an exploratory, psychometric study using a simple airway part task trainer. The draft ETI assessment tool from the literatures, previous tools, and the preliminary learner-adjusted assessment tool for students and residents were developed and analyzed. Knowledge-based and competence-based items for each learner group were identified based on experts' expectations. The final learner-adjusted tools were refined through analyzing the content validity, internal consistency, and interrater reliability based on assessing the observed performance of 14 students and 12 residents by ten experts. RESULTS: The preliminary student-adjusted assessment tool and resident-adjusted assessment tool had 12 items on the checklist with a ternary scoring system and a ternary scoring checklist including 15 items, and an overall Global Rating Scale. The final student-adjusted assessment tool was composed of a ternary scoring checklist including 9 items (total CVI, 86.6%; Cronbach's α, 0.83; interrater reliability, 0.64). The resident-adjusted assessment, on the other hand, was also composed of a ternary scoring checklist including 12 items (total CVI, 86.4%; Cronbach's α, 0.7; interrater reliability, 0.78), in addition to global rating scale including ‘rating of the overall process’. CONCLUSION: The experts had different expectations regarding the level of competence in each step according to learner groups with different levels of difficulty. Understanding the factors influencing assessments can provide a guide for teaching and objectively assessing to the examiner.

Normal aging: definition and physiologic changes

Aging is a process of the progressive functional decline with time, leading to disability, dependence, morbidity, and mortality. While the organ function in the elderly is relatively uncompromised under basal conditions, their ability to tolerate increased physiologic stress is reduced. And the extent and onset of the deterioration in functional reserve is quite diverse from patient to patient. The aging population is rapidly growing and their medical management is becoming one of the greatest challenges to anesthesiologists. The understanding of the normal physiologic changes with aging is essential to frame any discussion of perioperative management in the elderly. In this review, we will focus on the physiologic changes in neurologic, cardiac, pulmonary, renal, and hepatic function, and thermoregulation.

Incidence and Risk Factors of Postoperative Nausea and Vomiting in Patients with Fentanyl-Based Intravenous Patient-Controlled Analgesia and Single Antiemetic Prophylaxis

PURPOSE: We evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT3)-receptor antagonist after the general anesthesia. MATERIALS AND METHODS: In this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries. RESULTS: Four hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV. CONCLUSION: Despite antiemetic prophylaxis with 5 HT3-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel's score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.

A brief cardiac arrest due to saline irrigation during surgery for infratentorial cerebellar tumor / 대한마취과학회지

No abstract available.

A brief cardiac arrest due to saline irrigation during surgery for infratentorial cerebellar tumor / 대한마취과학회지

No abstract available.

Medical simulation is needed in anesthesia training to achieve patient's safety / 대한마취과학회지

Many medical schools and hospitals throughout the world are equipped with a simulation center for the purpose of training anesthesiologists to perform both technical and non-technical skills. Because induction, maintenance, and emergence of general anesthesia are critical to patient welfare, various simulation mannequins and tools are utilized for the purpose of training anesthesiologists for safer patient care. Traditionally, anesthesia residency training mostly consisted of didactic lectures and observations. After completion of "traditional" training, anesthesia residents were allowed to perform procedures on patients under supervision. However, simulation would be a more effective training tool for which to teach anesthesiologists the skills necessary to perform invasive procedures, such as endotracheal intubation, central venous catheter insertion, and epidural catheter insertion. Recently, non-technical skills, such as the Anesthesia Non-Technical Skills developed by anesthesiologists from Aberdeen University, have been emphasized as an important training resource. Technical skills and non-technical skills can be learned by anesthesiology residents through a standardized and organized simulation program. Such programs would be beneficial in training anesthesia residents to work efficiently as a team in the operation room.

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma / 대한마취과학회지

No abstract available.

Risk factors for perioperative respiratory adverse events in pediatric anesthesia; multicenter study

BACKGROUND: Perioperative respiratory adverse events remain a major cause of postoperative morbidity and mortality during pediatric anesthesia. This multicenter study was designed to evaluate the incidence of perioperative respiratory adverse events during elective pediatric surgery and to identify the risk factors for these events. METHODS: Pediatric patients undergoing elective surgery under general anesthesia in 11 hospitals were randomly selected for this prospective, multicenter study. Preanesthetic assessments, anesthetic and surgical conditions were recorded by anesthesiologists in charge. Adverse respiratory events were registered. RESULTS: Eight hundred and twenty-three patients were included. The overall incidence of any perioperative respiratory adverse respiratory event was 15.1%. The incidences of perioperative bronchospasm, laryngospasm, coughing, desaturatioin (oxygen saturation or =2, OR 1.62. CONCLUSIONS: Multiple attempts for airway device insertion, recent URI, induction with intravenous anesthetics, airway related surgery and ASA class > or =2 were associated with increased risk for perioperative respiratory adverse events.

Effects of APACHE II Score and Initial Nutritional Status on Prognosis of the Critically Ill Patients / 대한구급학회지

BACKGROUND: Malnutrition is common in hospitalized patients, especially in critically ill patients and affects their mortality and morbidity. However, the correlation between malnutrition and poor outcome is not fully understood. Our hypothesis is that the nutritional effect on the patient's prognosis would differ depending on the severity of the disease. METHODS: 3,758 patients admitted to the intensive care unit (ICU) were observed retrospectively. Patients were divided into well, moderate and severe groups, according to their nutritional status as assessed by their serum albumin level and total lymphocyte count (TLC). The severity of the disease was assessed by the Acute Physiologic and Chronic Health Evaluation (APACHE II score). All patients were followed clinically until discharge or death and ICU days, hospital days, ventilator days, and mortality rates were recorded. RESULTS: Depending on the definition used, the prevalence of hospital malnutrition is reported to be 68.3%. Hospital days, ICU days, as well as ventilator days of moderate and severe groups were longer than the well group. In patients exhibiting mild severity of disease, moderate and severe malnutrition groups have 3-5 times the mortality rate than the well group. CONCLUSIONS: Malnutrition affects the prognosis of patients who have an APACHE II score ranging from 4-29 points. Active nutritional support may be more effective for patients with a disease of mild severity.

Nutrition Support in the Intensive Care Unit of 6 Korean Tertiary Teaching Hospitals: A National Multicenter Observational Study / 대한구급학회지

BACKGROUND: Malnutrition is a frequent nutritional problem among ICU patients, and their nutritional status is known to affect clinical prognosis. We conducted this study to examine nutritional status and actual nutrition delivery in the ICU patients and its relations to clinical outcomes. METHODS: This study was a multicenter retrospective observational study based on the medical records of 163 patients admitted to ICU of tertiary teaching hospitals in Korea. We included the patients who were treated with mechanical ventilation for 3 or more days and received enteral or parenteral nutrition. RESULTS: According to albumin and total lymphocyte count levels, 54.6% of the subjects were moderately or severely malnourished. Mean percentage of calorie and protein delivery to estimated needs for 10 days were 55.8 +/- 29.3% and 46.1 +/- 30.1%, respectively. While parenteral nutrition (PN) started at 1.6 +/- 1.4 days after admission, enteral nutrition (EN) did at 3.6 +/- 2.1 days. Days to PN and EN start, the calorie and protein amount via EN or PN were significantly different among 6 hospitals. No clinical outcomes differed by the levels of calorie or protein delivery. In-hospital mortality was significantly higher in the severely malnourished group at admission as compared to the other 2 groups (54.3% vs. 31.2% vs. 27.7%, p < 0.05) CONCLUSIONS: Malnutrition prevalence is high among Korean intensive care unit patients, but current nutritional therapy practice is inconsistent across institutions and far below the international guidelines. Systematic efforts should be made to develop nutritional support guidelines for Korean ICU patients.

Stress-induced cardiomyopathy after negative pressure pulmonary edema during emergence from anesthesia: A case report / 대한마취과학회지

Stress-induced cardiomyopathy (SICM) presenting as an acute myocardial dysfunction is characterized by transient left ventricular wall motion abnormality, which has been known to be associated with excessive catecholamine production caused due to various types of stress. Sympathetic hyperactivity is common during the perioperative period, and reports of SICM occurring during this period have actually increased. We present a case of SICM following negative pressure pulmonary edema due to upper airway obstruction during emergence from anesthesia. Excessive catecholamine release in response to respiratory difficulty could have been the underlying inciting factor.

Comparison of the trapezius squeezing test and jaw thrust as indicators for laryngeal mask airway insertion in adults / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the effectiveness of the trapezius squeezing test with that of the jaw thrust maneuver as clinical indicators of adequate conditions for laryngeal mask airway (LMA) insertion in adults under sevoflurane anesthesia. METHODS: One hundred adult patients of ASA physical status 1 or 2 undergoing minor surgical procedures were randomly allocated to the T (trapezius squeezing, n = 50) group or the J (jaw thrust, n = 50) group. The LMA was inserted immediately after the loss of response to trapezius squeezing or jaw thrust. Successful and unsuccessful attempts were recorded. An unsuccessful attempt was defined as the occurrence of coughing, gagging, gross purposeful movements, breath-holding, laryngospasm, or an SpO2 < 90% during LMA insertion. Insertion time, end-tidal sevoflurane concentration, mean arterial pressure, and heart rate were recorded. RESULTS: The incidence of successful attempts was significantly higher in the T than in the J group (48/50 vs. 36/50, respectively). CONCLUSIONS: The trapezius squeezing test is a superior indicator of an adequate condition for LMA insertion compared to the jaw thrust maneuver in adults under sevoflurane anesthesia.

Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation / 대한마취과학회지

BACKGROUND: For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar. METHODS: Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation. RESULTS: The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 +/- 20%) than in Group L (6 +/- 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups. CONCLUSIONS: The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injury.

Cardiac arrest from acute hyperkalemia during liver surgery: A case report / 대한마취과학회지

We experienced a case of sudden onset of hyperkalemia during liver lobectomy and this was followed by ventricular tachycardia and cardiac arrest. The main cause of this fatality is assumed to be the wide range of surgical manipulation that induced reduced hepatic blood flow and ischemic necrosis of the hepatic cells. We report here on this case and we review the relevant medical literature.

Effects of propofol on beta-adrenoceptor-mediated signal transduction in cardiac muscle; role of cAMP / 대한마취과학회지

BACKGROUND: Propofol may decrease myocardial contractility via actions on the beta-adrenoceptor-mediated signal transduction. The aim of this study was to evaluate the effect of propofol via beta-adrenoceptor-mediated signal transduction by measuring the tissue levels of cAMP (cyclic adenosine monophosphate). METHODS: The effects of propofol on beta-adrenoceptor mediated cascades were measured with cAMP concentrations, which were stimulated by agonists (l-isoproterenol, GTPgammaS, and forskolin) of each step of beta-adrenoceptor-mediated cascades. RESULTS: While the production of cAMP stimulated by isoproterenol, GTPgammaS, or forskolin are increased (P < 0.05), application of each concentration of propofol (0.1, 1, 10, 100 micrometer) did not alter the levels of cAMP. CONCLUSIONS: Considering that propofol did not alter the tissue cAMP levels when stimulated by isoproterenol, GTPgammaS, and forskolin, propofol appears to have no effect on the beta-adrenoceptor signaling pathway in guinea pig ventricular myocardium.

Spinal Anesthesia with Isobaric Tetracaine in Patients with Previous Lumbar Spinal Surgery

PURPOSE: Previous lumbar spinal surgery (PLSS) is not currently considered as a contraindication for regional anesthesia. However, there are still problems that make spinal anesthesia more difficult with a possibility of worsening the patient's back pain. Spinal anesthesia using combined spinal-epidural anesthesia (CSEA) in elderly patients with or without PLSS was investigated and the anesthetic characteristics, success rates, and possible complications were evaluated. MATERIALS AND METHODS: Fifty patients without PLSS (Control group) and 45 patients with PLSS (PLSS group) who were scheduled for total knee arthroplasty were studied prospectively. A CSEA was performed with patients in the left lateral position, and 10 mg of 0.5% isobaric tetracaine was injected through a 27 G spinal needle. An epidural catheter was then inserted for patient controlled analgesia. Successful spinal anesthesia was defined as adequate sensory block level more than T12. The number of skin punctures and the onset time were recorded, and maximal sensory block level (MSBL), time to 2-segment regression, success rate and complications were observed. RESULTS: The success rate of CSEA in Control group and PLSS group was 98.0%, and 93.3%, respectively. The median MSBL in PLSS group was higher than Control group [T4 (T2-L1) vs. T6 (T3-T12)] (p < 0.001). There was a significant difference in the number of patients who required ephedrine for the treatment of hypotension in PLSS group (p = 0.028). CONCLUSION: The success rate of CSEA in patients with PLSS was 93.3%, and patients experienced no significant neurological complications. The MSBL can be higher in PLSS group than Control group.

Unilateral pulmonary edema during an operation in patient with undiagnosed pheochromocytoma: A case report / 대한마취과학회지

Pheochromocytoma is a rare tumor, but it can cause severe hemodynamic disturbances during anesthesia, and particularly in patients whose pheochromocytoma was not diagnosed preoperatively. We report here on a case of unilateral pulmonary edema during laparoscopic adrenalectomy, and this edema was due to pheochromocytoma that was not diagnosed preoperatively.

Intubation through a Laryngeal Mask Airway by Fiberoptic Bronchoscope in an Infant with a Mass at the Base of the Tongue: A case report / 대한마취과학회지

Failed or difficult tracheal intubation remains an important cause of mortality and morbidity during anesthesia, especially in infants with anatomical or pathological abnormalities of the airway.We report on a 4.1 kg, 85-day-male infant with a thyroglossal duct cyst at the tongue base who could not be conventionally ventilated and intubated in the supine position.The infant was intubated with a 3-mm endotracheal tube through the laryngeal mask airway (LMA) with guidance of a fiberoptic bronchoscope (FOB).However, the pilot balloon did not pass through the 1.5-mm LMA conduit.After cutting the pilot balloon, we removed the LMA and inserted a central venous catheter guide-wire through the endotracheal tube to increase the endotracheal tube to 3.5 mm.This maneuver allowed us to secure the airway without further problems.

Weaning Approach with Weaning Index for Postoperative Patients with Mechanical Ventilator Support in the ICU / 대한마취과학회지

BACKGROUND: The weaning index is a useful tool for avoiding the detrimental consequences of weaning failure, rapidly identifying patients who are potentially ready for spontaneous breathing, and accelerating the process of liberation from mechanical ventilation. This study examined the use of the weaning index as a weaning and extubation predictor in postoperative patients on mechanical ventilatory support in an intensive care unit (ICU). METHODS: Mechanical ventilation was discontinued in patients through pressure support ventilation (PSV), and a T-piece was applied to 169 patients. The success or failure of the weaning process was evaluated according to the preoperative conditions of the patient and their weaning indices, such as the rapid shallow breathing index (RSBI), vital capacity, inspiratory pressure. The duration of mechanical ventilation and the length of stay in the ICU and the hospital were recorded. RESULTS: Weaning from mechanical ventilatory support and extubation was performed successfully in 94.6% of patients. Sixty minutes after applying the T-piece, the PaO2/FiO2 ratio (P/F ratio) was significantly higher and the RSBI was significantly lower in the weaning success group than in the weaning failure group. The ASA class and the percentage of emergency procedures were significantly lower (p < 0.05) in the weaning success group. CONCLUSIONS: Not only the weaning index as RSBI but also P/F ratio, ASA class and emergency status need to be considered for successful weaning and extubation in postoperative ICU patients on mechanical ventilator support.

Obstruction of an Endotracheal Tube with Change of the Head Position in a Trachea Deviated Patient : A case report / 대한마취과학회지

Various causes of endotracheal tube obstruction during general anesthesia exist. Herein, the case of a 77-year old male patient, with tracheal deviation, who was intubated with an endotracheal tube in the emergency room, without a Murphy eye, is reported. He was transferred to the operating room for the removal of a subdural hematoma. The endotracheal tube suddenly became obstructed during flexion of neck for the craniotomy procedure. The distal bevel of the endotracheal tube, without Murphy eye, was discovered to have come into contact with the tracheal wall, with the airway being obstructed during the fiberoptic bronchoscopy. Shortly after extubation of the obstructed tube, an armored tube, with a Murphy eye, was reintubated, after which the respiration pattern immediately returned to normal.