Driving pressure guided ventilation / 대한마취과학회지

Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.

Whole-lung lavage complicated with pneumothorax: a case report / 대한마취과학회지

A patient with pulmonary alveolar proteinosis underwent whole lung lavage of the right lung. Lavage of the left lung was not immediately possible because of severe hypoxemia. Three days later, after correction of hypoxemia, we re-attempted the left lung lavage. However, the patient had severe hypoxemia (SpO₂< 80%) within a few minutes of performing right one lung ventilation (OLV). On bronchoscopic examination, proper tube location was confirmed. Bronchodilator nebulization and steroid injection were attempted with no effect. While searching for the cause of the hypoxemia, we found that the breath sound from the right lung had become very weak and distant compared with that from initial auscultation. Right pneumothorax was diagnosed on chest X-ray and a chest tube was inserted. After confirming pneumothorax resolution, we re-tried right OLV and were able to proceed with the left lung lavage without signs of aggravating air leak, loss of tidal volume, or severe hypoxemia.

Clinical benefits of preemptive thoracic epidural analgesia with hydromorphone and bupivacaine in open thoracotomy lung surgery

BACKGROUND: Preemptive analgesia is known to decrease the sensitization of the central nervous system and reduce subsequent amplification of nociceptive stimuli. We investigated whether preemptive thoracic epidural analgesia (TEA) demonstrated intraoperative and postoperative short and long term clinical advantages. METHODS: Thirty patients scheduled for open thoracotomy were randomly allocated to one of two groups to receive continuous TEA (0.15% bupivacaine and 8 microg/ml hydromorphone) either before surgical incision (preemptive group) or at the end of the operation (nonpreemptive group). Incidence of hypotension during surgery was recorded. Numerical rating scales (NRS) and the incidence of side effects such as nausea, pruritus, sedation, hypotension, and respiratory depression were recorded at 2, 6, 24, and 48 hours postoperatively. Pulmonary function test (PFT) was performed before, 24 and 48 hours after the operation. Persistence of pain control was investigated at 6 months postoperatively. RESULTS: The NRS score, side effects, and PFT changes were comparable between the two groups. TEA and intravenous rescue morphine consumed at 2, 6, 24, and 48 hours postoperatively were not different between the two groups. During surgery, the incidence of hypotension was significantly higher in the preemptive group (P = 0.027). At 6-month follow up, two patients in the nonpreemptive group complained of persistent pain at wound and none in the preemptive group. CONCLUSIONS: Preemptive TEA with hydromorphone and bupivacaine during surgery may cause unnecessary intraoperative hypotension without a prominent advantage in reducing acute or chronic pain or enhancing pulmonary function after thoracotomy. The advantageous concept of preemptive TEA may be dubious and may not provide perioperative clinical benefits.

Lung transplantation in a patient with massive pneumomediastinum following 66 days of awake extracorporeal membrane oxygenation support: A case report

In a 54-year-old man with interstitial lung disease associated with dermatomyositis, acute exacerbation of the disease had occurred and massive pneumothorax, pneumomediastinum and extensive subcutaneous emphysema were developed while waiting for lung transplantation. He was supported by awake extracorporeal membrane oxygenation (ECMO) for 66 days and bridged to lung transplantation, but mechanical ventilation was not done during ECMO period and induction period to avoid tension pneumothorax and cardiac tamponade. Notable points of this report are that the days of ECMO support were long, the type was awake ECMO, and positive pressure ventilation was not done during whole pretransplant period including anesthesia induction. The transplantation was done successfully and the patient was discharged 25 days after lung transplantation.

Comparison of respiratory mechanics between sevoflurane and propofol-remifentanil anesthesia for laparoscopic colectomy / 대한마취과학회지

BACKGROUND: The creation of pneumoperitoneum and Trendelenburg positioning during laparoscopic surgery are associated with respiratory changes. We aimed to compare respiratory mechanics while using intravenous propofol and remifentanil vs. sevoflurane during laparoscopic colectomy. METHODS: Sixty patients undergoing laparoscopic colectomy were randomly allocated to one of the two groups: group PR (propofol-remifentanil group; n = 30), and group S (sevoflurane group; n = 30). Peak inspiratory pressure (PIP), dynamic lung compliance (Cdyn), and respiratory resistance (Rrs) values at five different time points: 5 minutes after induction of anesthesia (supine position, T1), 3 minutes after pneumoperitoneum (lithotomy position, T2), 3 minutes after pneumoperitoneum while in the lithotomy-Trendelenburg position (T3), 30 minutes after pneumoperitoneum (T4), and 3 minutes after deflation of pneumoperitoneum (T5). RESULTS: In both groups, there were significant increases in PIP and Rrs while Cdyn decreased at times T2, T3, and T4 compared to T1 (P < 0.001). The Rrs of group PR for T2, T3, and T4 were significantly higher than those measured in group S for the corresponding time points (P < 0.05). CONCLUSIONS: Respiratory mechanics can be adversely affected during laparoscopic colectomy. Respiratory resistance was significantly higher during propofol-remifentanil anesthesia than sevoflurane anesthesia.

The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway / 대한마취과학회지

No abstract available.

Respiratory insufficiency and dynamic hyperinflation after rigid bronchoscopy in a patient with relapsing polychondritis: a case report / 대한마취과학회지

Relapsing polychondritis (RP) is an uncommon disease that is characterized by inflammation and destruction of cartilaginous structures. When tracheobronchial tree is involved, respiratory obstructive symptoms can occur. A 35-year-old man, with a previous diagnosis of RP, was scheduled for rigid bronchoscopy to relieve dyspnea, caused by subglottic stenosis. After laser splitting of the subglottic web, the spontaneous respiration of the patient was insufficient, and hypercarbia developed progressively even with assisted ventilation. After 20 minutes of aggressive hyperventilation to reduce end-tidal CO2 level, sudden extreme tachycardia and hypotension developed. Ventilation rate was reduced and prolonged expiration time was allowed to alleviate a near-tampon status from dynamic hyperinflation. After the hemodynamic status was stabilized, the patient was transferred to the ICU for mechanical ventilation. He received ICU care for 30 days, and now, he was on supportive care on a ward, considering Y stent insertion to prevent luminal collapse from tracheobronchomalacia.

Risk score for postoperative complications in thoracic surgery / 대한마취과학회지

BACKGROUND: Risk scoring system for thoracic surgery patients have not been widely used, as of recently. We tried to forge a risk scoring system that predicts the risk of postoperative complications in patients undergoing major thoracic surgery. We used a prolonged ICU stay as a representative of postoperative complications and tested various possible risk factors for its relation. METHODS: Data from all patients who underwent major lung and esophageal cancer surgeries, between 2005 and 2007 in our hospital, were collected retrospectively (n = 858). Multiple logistic regression analysis was performed with various possible risk factors to build the risk scoring system for prolonged ICU stay (> 3 days). RESULTS: A total of 9% of patients exhibited more than 3 days of ICU stay. Age, operation name, preoperative lung injury, no epidural analgesia, and predicted post operative forced expiratory volume in 1 second (ppoFEV1) were the risk factors for prolonged ICU stay, by multivariable analysis (P < 0.05). Risk score, p was derived from the formula: logit(p/[1-p]) = -5.39 + 0.06 x age + 1.12 x operation name(2) + 1.52 x operation name(3) + 1.32 x operation name(4) + 1.56 x operation name(5) + 1.30 x preoperative lung injury + 0.72 x no epidural analgesia - 0.02 x ppoFEV1 [Age in years, operation name(2): pneumonectomy, operation name(3): esophageal cancer operation, operation name(4): completion pneumonectomy, operation name(5): extended operation, preoperative lung injury(+), epidural analgesia(-), ppoFEV1 in %]. CONCLUSIONS: Age, operation name, preoperative lung injury, epidural analgesia, and ppoFEV1 can predict postoperative morbidity in thoracic surgery patients.

Postoperative nausea and vomiting after endoscopic thyroidectomy: total intravenous vs. balanced anesthesia / 대한마취과학회지

BACKGROUND: Endoscopic thyroidectomy was recently introduced and has been rapidly accepted by surgeons and patients. The present study was conducted to estimate and compare the incidences of postoperative nausea and vomiting (PONV) after endoscopic thyroidectomy using two different anesthetic methods: sevoflurane based balanced anesthesia; total intravenous anesthesia (TIVA). METHODS: Ninety nine female patients that were scheduled to undergo elective endoscopic thyroidectomy under general anesthesia were enrolled. These patients were randomly allocated to receive sevoflurane based balanced anesthesia (BA group) or propofol-remifentanil anesthesia (TIVA group). PONV was evaluated using a 4-point Likert scale, and pain using a visual analogue scale (VAS; range 0 to 100) for 0-2, 2-6, and 6-24 hours postoperatively. At 24 hours postoperatively, overall patient satisfaction regarding PONV and pain were recorded. RESULTS: The incidence of PONV was 14.6% in the TIVA group and 51.3% in the BA group. The incidence of nausea at 0-2 and 2-6 hours postoperatively was lower in the TIVA group than in the BA group (4.2% vs. 35.9%, 6.3% vs. 23.1%, respectively), but no between-group difference was observed at 6-24 hours postoperatively (8.3% vs. 5.1%). Antiemetic usage at 0-2 and 2-6 hours was lower in the TIVA than the BA group (4.2% vs. 38.5%, 6.3% vs. 23.1%), but no between-group difference was observed for 6-24 hours (6.3% vs. 7.7%). There were no differences in pain or in patient satisfaction. CONCLUSIONS: After endoscopic thyroidectomy, total intravenous anesthesia with propofol-remifentanil is associated with less PONV during the early postoperative period (0-6 hours) than sevoflurane based balanced anesthesia.

Does a single dose of intravenous nicardipine or nimodipine affect the bispectral index following rapid sequence intubation? / 대한마취과학회지

BACKGROUND: Theoretically, L-type calcium channel blockers could modulate anesthetic effects. Nicardipine does not affect the bispectral index (BIS), but nimodipine, which can penetrate the blood-brain barrier, has not been studied. The aim of this study was to evaluate whether a single dose of intravenous nicardipine or nimodipine could affect BIS following rapid sequence intubation. METHODS: This study was done in a double-blind, randomized fashion. Anesthesia was induced with fentanyl 2 microgram/kg, thiopental sodium 5 mg/kg, and 100% oxygen. After loss of consciousness, patients received rocuronium 1.0 mg/kg and either a bolus of 20 microgram/kg nicardipine, nimodipine, or a comparable volume of normal saline (n = 20). Intubation was performed 1 min after study drug administration. BIS, mean blood pressure (MBP), and heart rate (HR) were measured before anesthetic induction, after loss of consciousness, before intubation, during intubation, and 1, 2 and 5 min after intubation. RESULTS: BIS dropped rapidly after induction but increased to 60 before intubation in all groups irrespective of study drug. In nimodipine, the increase in BIS during intubation was not significant compared to pre-intubation, in contrast to the other two groups, but there was no difference in BIS during intubation. HR significantly increased, but MBP just rose to pre-induction values after intubation in nicardipine and nimodipine groups. BIS, MBP, and HR following intubation increased in control group. CONCLUSIONS: A single dose of intravenous nicardipine or nimodipine could attenuate blood pressure increases but not affect BIS increases in rapid sequence intubation.

Interactions of propofol and remifentanil on bispectral index under 66% N2O: analysis by dose-effect curve, isobologram, and combination index / 대한마취과학회지

BACKGROUND: Propofol and remifentanil are usually co-administered and have shown synergistic effect for anesthesia. However, the synergistic effect of the two drugs on hypnosis measured by bispectral index (BIS) was controversial in previous studies. The aim of this study was to identify the interaction of propofol and remifentanil on BIS and the optimal dose combinations for hypnosis under 66% N2O during surgery. METHODS: Patients (age 55-75 and American Society of Anesthesiologists [ASA] 1-2) undergoing gastrectomy were enrolled in this study. Propofol and remifentanil were co-administered incrementally at 1 : 1 potent ratio (the P1R1 group), at 1 : 2 potent ratio (the P1R2 group), or at 2 : 1 potent ratio (the P2R1 group) using effect site target-controlled infusion and BIS was measured. 66% N2O was concomitantly administered to all groups. The dose-effect curves, the 90% effective dose (EC90) for adequate hypnosis (BIS 40), isobolograms and combination index were obtained by Calcusyn program (Biosoft) to reveal the interaction of propofol and remifentanil. RESULTS: The P2R1 group showed synergistic action on BIS. However, the other groups needed larger amount of each drug than the doses of additive action. The EC90 of the P2R1 group was propofol, 3.34 microg/ml and remifentanil, 2.41 ng/ml under 66% of N2O. CONCLUSIONS: Propofol dominant co-administration is needed for dose reduction in BIS guided hypnosis.

Transient bilateral vocal cord paralysis after endotracheal intubation with double-lumen tube: A case report / 대한마취과학회지

Vocal cord paralysis is one of the most serious anesthetic complications related to endotracheal intubation. The practitioner should take extreme care, as bilateral vocal cord paralysis can obstruct the airway and lead to disastrous respiratory problems. There have been many papers on bilateral vocal cord paralysis after neck surgery, but reports on such a condition after lung surgery are very rare. We report a case of bilateral vocal cord paralysis detected after removal of a double-lumen endotracheal tube in a 67-year-old patient who underwent wedge resection by video-assisted thoracoscopic surgery. We also note that he recovered spontaneously without complications within a day.

Comparison of the effectiveness of lidocaine and salbutamol on coughing provoked by intravenous remifentanil during anesthesia induction / 대한마취과학회지

BACKGROUND: Coughing is a side effect of opioids that is rarely studied. Here, we evaluated the incidence of remifentanil induced coughing during anesthesia induction in an attempt to identify its risk factors and to examine the preventive effects of lidocaine and salbutamol. METHODS: A total of 237 patients scheduled to undergo general anesthesia were allocated randomly into three groups. Group C received no medication, while Group L received 2% lidocaine at 0.5 mg/kg intravenously 1 minute prior to remifentanil infusion and Group S inhaled one metered aerosol puff of salbutamol 15 minutes prior to entering the operating room. Remifentanil was infused at 5 ng/ml by target controlled infusion and coughing was measured for five minutes and graded as none, mild, moderate, or severe based on the number of coughs. RESULTS: The incidences of coughing were 30.4%, 25.3%, and 35.4% in Groups C, L, and S, respectively. The incidences, onset times, and severity of coughing did not differ significantly among groups. In addition, multivariate analysis showed that non-smoking and a lower body weight were risk factors of remifentanil-induced coughing (odds ratio, 8.13; P = 0.024, 1.11, and 0.004, respectively). CONCLUSIONS: The incidence of remifentanil-induced coughing was 30%. A total of 0.5 mg/kg lidocaine and 1 metered aerosol puff of salbutamol did not prevent coughing. Non-smoking and low body weight were found to be risk factors of remifentanil-induced coughing.

The effect of multimodal approach with combination of antiemetics and total intravenous anesthesia on postoperative nausea and vomiting in very high-risk patients

BACKGROUND: Postoperative nausea and vomiting (PONV) is a long standing problem in both surgical patients and anesthesiologists, and the treatment of this problem is very important.The purpose of this study was to evaluate the effect of multimodal approach with combination of antiemetics and total intravenous anesthesia (TIVA) on PONV in very high risk patients identified by the Korean predictive model. METHODS: Between March 2008 and February 2009, we evaluated 96 patients who were considered to be at very high risk of PONV according to the Korean predictive model.Among the patients, those who received antiemetic combination of dexamethasone and ondansetron were allocated to treatment group (T) and, those who underwent operation without antiemetics were placed in control group (C).All patients were anesthetized using propofol and remifentanil.We evaluated the incidences of PONV in two groups during the first 24 hours after surgery. RESULTS: The overall incidence of PONV was 14 (29.17%) in C group and 4 (8.33%) in T group, respectively (P = 0.027). CONCLUSIONS: The overall incidence of PONV in T group was significantly lower than that of C group.This study shows that multimodal approach with combination of antiemetics and TIVA was effective in preventing PONV in patients with very high risk.

Protective Effects of Gabapentin on Allodynia and alpha2delta1-Subunit of Voltage-dependent Calcium Channel in Spinal Nerve-Ligated Rats

This study was designed to determine whether early gabapentin treatment has a protective analgesic effect on neuropathic pain and compared its effect to the late treatment in a rat neuropathic model, and as the potential mechanism of protective action, the alpha2delta1-subunit of the voltage-dependent calcium channel (alpha2delta1-subunit) was evaluated in both sides of the L5 dorsal root ganglia (DRG). Neuropathic pain was induced in male Sprague-Dawley rats by a surgical ligation of left L5 nerve. For the early treatment group, rats were injected with gabapentin (100 mg/kg) intraperitoneally 15 min prior to surgery and then every 24 hr during postoperative day (POD) 1-4. For the late treatment group, the same dose of gabapentin was injected every 24 hr during POD 8-12. For the control group, L5 nerve was ligated but no gabapentin was administered. In the early treatment group, the development of allodynia was delayed up to POD 10, whereas allodynia was developed on POD 2 in the control and the late treatment group (p<0.05). The alpha2delta1-subunit was up-regulated in all groups, however, there was no difference in the level of the alpha2delta1-subunit among the three groups. These results suggest that early treatment with gabapentin offers some protection against neuropathic pain but it is unlikely that this action is mediated through modulation of the alpha2delta1-subunit in DRG.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 microg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 microg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.

The effect of ambient pressure oxygen apply via T-piece in thoracoscopic surgery or thoracotomy

BACKGROUND: This prospective, randomized study was to investigate whether ambient pressure oxygen administration via T-piece can be used to reduce arterial desaturation during one-lung ventilation. It can be more beneficial for thoracoscopic surgery, where partial inflation of the non-ventilated lung by continuous positive airway pressure can make the operation itself difficult, delayed, or impossible. METHODS: Patients undergoing thoracotomy (Thoracotomy group, n = 50) or video-assisted thoracoscopic surgery (VATS) (VATS group, n = 50) were enrolled into this study. Each group was further divided into two groups: control group (n = 25), and ambient pressure group (n = 25), respectively. Fifteen minutes after two-lung ventilation (TLV1) PaO2, peak inspiratory pressure, plateau pressure, and tidal volume were measured. Then, in control group, one-lung ventilation was started as usual method while in ambient pressure group, the lumen of the non-ventilated lung was connected to a T-piece with 10 L/min flow rate of oxygen. Same measurements were repeated at 15 minutes and 1 hour after one-lung ventilation (OLV1, OLV2), and 15 minutes after resuming two-lung ventilation (TLV2). Fluid input, urine output, estimated blood loss, operation side/time, and one-lung ventilation time were recorded after operation. RESULTS: In thoracotomy group, there were no significant differences in PaO2 between control group and ambient pressure group. However, in VATS group, PaO2 at OLV1 and OLV2 were significantly higher in ambient pressure group than in control group. CONCLUSIONS: In patients undergoing VATS, application of ambient pressure oxygen to the non-ventilated lung during one-lung ventilation was effective in increasing PaO2.

Effects of Gender on White Blood Cell Populations and Neutrophil-Lymphocyte Ratio Following Gastrectomy in Patients with Stomach Cancer

Alterations of absolute number or percentage of circulating white blood cell (WBC) subsets are associated with psychological and physical stress. Gender effects on the changes of circulating WBC subsets following surgical treatment have not been determined. Therefore, the current study aimed to determine whether circulating neutrophils, lymphocytes and monocytes, and neutrophil-lymphocyte ratio (N/L) are different following major surgery according to the gender. We studied 409 male patients and 212 female patients who underwent total or subtotal gastrectomy due to stomach cancer, from 1 January to 31 December in 2005. The WBC count and percentage of its subsets were obtained from database and N/L was directly calculated from the full blood count preoperatively, immediate postoperatively, and postoperative day 1, 3, 5 in a retrospective manner. Compared to preoperative values, neutrophilia, lymphopenia, monocytopenia, and increased N/L were associated with gastrectomy in all patients. In the comparison study between genders, there were significantly increased proportion of neutrophils, decreased lymphocytes and monocytes, and higher N/L in female patients than in male patients after gastrectomy. These findings indicate that female patients showed more immune-compromised response to gastrectomy than male patients.

Bilateral Tension Pneumothorax and Bronchospasm in the Patients with Recent History of Croup: A case report / 대한마취과학회지

Tension pneumothorax is a rare but critical complication of mechanical ventilation. Many researchers regard elevated peak inspiratory pressure as a major etiology for pneumothorax during ventilatory care. Bronchospasm is another adverse events under general anesthesia and it has been reported that the risk of bronchospasm is increased in the children with recent upper respiratory infection. We have experienced a case of recurrent bronchospasm which finally ends up with bilateral tension pneumothorax and debilitating consequences. A 2 year-old boy with a history of croup one week before neuroblastoma excision operation developed several times of bronchospasm attacks during the operation. Episodes of bronchospasm continued in the ICU and complicated with sudden postoperative bilateral tension pneumothorax. Pneumothorax possibly associated with bronchospasm was rarely reported until now. Therefore, we present this case with the literature review.

Effects of Supplemented Remifentanil/Meperidine to Sevoflurane Anesthesia on the Recovery in the Pediatrics Undergoing Tonsillectomy

BACKGROUND: Recovery from anesthesia, postoperative pain, nausea and vomiting are very important after pediatric tonsillectomy surgery. We compared the effects of supplemented opioids (remifentanil, meperidine) combined with sevoflurane on the recovery and side effects. METHODS: Patients were randomized to receive meperidine (group M, n = 41) or remifentanil (group R, n = 43). Group R received a bolus dose of normal saline, and group M 1 mg/kg of meperidine. A continuous infusion of normal saline was followed in the group M, and remifentanil 0.25micro/kg/min in the group R. In all patients, signs of inadequate anesthesia were treated with an increase of sevoflurane concentration. Intraoperative hemodynamics, recovery profiles, and side effects were assessed. RESULTS: Supplemented remifentanil resulted in significantly lower systolic blood pressure and heart rate during operation (P < 0.05). The emergence from anesthesia was not different between groups. Although the patients in the group R had early recovery characteristics at recovery room, time to discharge at recovery room was longer in the group R than in the group M (P < 0.05). The incidence of retching and vomiting was not different between groups. Supplemented meperidine resulted in less analgesic requirements than the other group (P < 0.05). CONCLUSIONS: Supplemented remifentanil was associated with hemodynamic stability, however it provided later discharge time at recovery room. Postoperative analgesic requirements were reduced by the supplemented meperidine without increasing postoperative nausea, vomiting.