Neutrophilia is more predictive than increased white blood cell counts for short-term mortality after liver transplantation in patients with acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a life-threatening disease that requires urgent liver transplantation (LT). Accurate identification of high-risk patients is essential for predicting post-LT survival. The chronic liver failure consortium ACLF score is a widely accepted risk-stratification score that includes total white blood cell (WBC) counts as a component. This study aimed to evaluate the predictive value of total and differential WBC counts for short-term mortality following LT in patients with ACLF. Methods: A total of 685 patients with ACLF who underwent LT between January 2008 and February 2019 were analyzed. Total and differential WBC counts were examined as a function of the model for end-stage liver disease for sodium (MELD-Na) score. The association between total and differential WBC counts and 90-day post-LT mortality was assessed using multivariable Cox proportional hazards regression analysis. Results: The total WBC counts and neutrophil ratio were higher in patients with ACLF than in those without ACLF. The neutrophil ratio was significantly associated with 90-day post-LT mortality after adjustment (hazard ratio [HR], 1.04; P = 0.001), whereas total WBC counts were not significantly associated with 90-day post-LT mortality in either univariate or multivariate Cox analyses. The neutrophil ratio demonstrated a relatively linear trend with an increasing MELD-Na score and HR for 90-day post-LT mortality, whereas the total WBC counts exhibited a plateaued pattern. Conclusions: Neutrophilia, rather than total WBC counts, is a better prognostic indicator for short-term post-LT mortality in patients with ACLF.

Tachycardia-polyuria syndrome after swan-ganz catheterization in liver transplant patient - A case report -

Background@#Tachycardia-polyuria syndrome is characterized by polyuria occurring because of tachycardia with a heart rate of ≥ 120 beats/min lasting ≥ 30 min. We report such a case occurring after swan-ganz catheterization.Case: A 41-year-old male was scheduled for living-donor liver transplantation. After general anesthesia, atrial fibrillation occurred during swan-ganz catheterization, and polyuria developed 1 h later. During the anhepatic phase, the patient’s heart rate increased further, and cardioversion was performed. After a normal sinus rhythm was achieved, the patient’s urine output returned to normal. @*Conclusions@#The patient’s polyuria seemed related to the iatrogenic atrial fibrillation occurring during swan-ganz catheterization. Although we did not measure atrial natriuretic peptide, an increase in its concentration may have been the main mechanism of polyuria, as natriuresis was observed.

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Sudden cardiovascular collapse caused by severe anaphylaxis after cisatracurium use: a case report / 대한마취과학회지

Kounis syndrome is an acute coronary syndrome concurrently occurs with allergic or hypersensitivity reactions. In patient with this syndrome, inflammatory mediators released due to an allergic reaction implicate to induce coronary artery spasm and atheromatous plaque rupture. We describe a patient with coronary artery disease who developed acute perioperative myocardial infarction leading to cardiac arrest after the anaphylactic reaction to cisatracurium, which led to a suspicion of Kounis syndrome. Anesthesiologists should be aware that anaphylaxis or allergic reactions can progress to acute coronary syndrome, thereby significantly change the course of the disease.

An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report / 대한마취과학회지

A 54-year-old male patient was scheduled for an elective pylorus-preserving pancreaticoduodenectomy combined with video-assisted thoracic surgery at our hospital. This patient had a history of intubation failure in other institutions due to an epiglottic cyst. An airway assessment of the patient was normal. A preoperative laryngoscopy revealed a bulging epiglottic mass covering most of the epiglottis and occupying most of the pharyngeal space. The patient was administered intravenous midazolam 1 mg, fentanyl 50 microg, and glycopyrrolate 0.2 mg. A bilateral superior laryngeal nerve block was then performed with 2% lidocaine 2 ml on each side. A 10% lidocaine spray was applied on to the oropharynx. After preoxygenation with 100% oxygen over 10 minutes, a rigid fiberscope with an optical stylet loaded with a 37 Fr double lumen endotracheal tube was inserted orally and passed into the glottic aperture. The patient was fully awakened after surgical procedure and was transferred to the recovery room after extubation.

Anaphylactic reactions after cisatracurium administration in two patients: a report of two cases / 대한마취과학회지

Cisatracurium was initially characterized to have no evident histamine-releasing potential with excellent cardiovascular stability. However, severe anaphylactic reactions to cisatracurium that resulted in bronchospasms and cardiovascular collapse have been reported worldwide. Two cases of severe anaphylactic reactions after the administration of cisatracurium are presented. The anesthetics used in both cases were lidocaine, midazolam, propofol (microemulsion propofol in the second case), remifentanil and cisatracurium. After the administration of these drugs, bronchospasm and hypotension manifested, leading to the diagnosis of anaphylaxis and appropriate treatment. Skin intradermal testing confirmed that both cases were due to immune-mediated anaphylaxis to cisatracurium, despite the fact that neither of the patients had been exposed to the allergen previously. The anaphylaxis may be due to cross-reactivity between neuromuscular blocking agents and substances with quaternary ammonium ions. Anesthesiologists should be aware that cisatracurium has the potential to trigger severe anaphylactic reactions via an immune-mediated mechanism.

Misdiagnosis of pneumothorax by ultrasonography after central venous catheterization in a patient with pleural adhesion / 대한마취과학회지

No abstract available.

Rapid identification of spontaneously resolving capnothorax using bedside M-mode ultrasonography during laparoscopic surgery: the "lung point" sign: two cases report / 대한마취과학회지

Pneumothorax during general anesthesia is more difficult to diagnose compared with that of non-anesthetized patient. Furthermore, the early diagnosis of pneumothorax is to some extent difficult due to CO2-pneumoperitoneum during laparoscopic surgery. The use of ultrasonography to diagnose pneumothorax has increased in a variety of situations, demonstrating a better diagnostic rate than conventional chest radiography. Here, we report two cases of intraoperative capnothorax that were confirmed using the M-mode "lung point" sign. However, the insertion of a chest tube could have been avoided because the spontaneous resolution of capnothorax was quickly identified using bedside lung ultrasonography.

Total intravenous anesthesia in a 10-month-old patient with congenital myotonic dystrophy undergoing endoscopic third ventriculostomy: A case report / 대한마취과학회지

Myotonic dystrophy is a rare genetic disorder characterized by muscle atrophy and weakness. Surgical treatment of this condition poses various problems for the anesthesiologist. We describe the anesthetic management of a 10-month-old infant with congenital myotonic dystrophy, who was scheduled for endoscopic third ventriculostomy under general anesthesia. Anesthesia was induced with thiopental sodium, fentanyl, and vecuronium, and thereafter maintained via continuous infusion of propofol and remifentanil. The train-of-four ratio was monitored throughout the operation, and muscle relaxation was reversed with pyridostigmine and glycopyrrolate at the end of the procedure. We show that total intravenous anesthesia using propofol and remifentanil is a satisfactory anesthetic technique in very young patients with congenital myotonic dystrophy.

Transient adenosine-induced asystole in the surgical treatment of intracranial aneurysms: A report of two cases

Advances in anesthetic and surgical management, such as deep hypothermic circulatory arrest and temporary clipping, have improved outcomes for intracranial aneurysm patients. However, these techniques are associated with significant risks. We report on two cases in which adenosine administration was used to induce transient periods of cardiac asystole during intracranial aneurysm surgery. This asystole resulted in profound hypotension and collapse of the aneurysm, which facilitated its safe clipping.

Melatonin does not attenuate dynamic cardiovascular and cerebrovascular reflex responses to acute hypotension in healthy men / 대한마취과학회지

BACKGROUND: Melatonin has been shown to attenuate the reflex sympathetic increases that arise in response to orthostatic challenges. We tested the hypothesis that the attenuated sympathetic increase induced by melatonin premedication may weaken the arterial blood pressure (ABP) preserving the capability during acute hypotension, thereby altering dynamic cerebral autoregulation and causing a further decrease in cerebral blood flow (CBF). METHODS: Acute hypotension was induced in 12 healthy subjects by releasing bilateral thigh cuffs before and after an oral dose of melatonin (0.2 mg/kg). Heart rate (HR), arterial blood pressure (ABP), Modelflow estimate of cardiac output (CO), total peripheral resistance (TPR) and cerebral blood flow velocity (CBFV) by transcranial Doppler were measured. RESULTS: Steady state HR, the mean arterial pressure and CBFV were not altered 60 minutes after melatonin ingestion. Reduced systolic arterial pressure (DeltaSAP), changes in HR (DeltaHR), CO (DeltaCO), and TPR (DeltaTPR), DeltaHR/DeltaSAP and percentage restoration of SAP were not affected after a temporal decrease in ABP induced by thigh cuff release. In the cerebral circulation, melatonin did not affect changes in CBFV, cerebrovascular resistance index, the rate of regulation and percentage restoration of CBFV following a sudden decrease in ABP. CONCLUSIONS: Contrary to our hypothesis, melatonin did not affect the rapid vasodilatory and recovery responses of cardiovascular and dynamic cerebral autoregulation. These results suggest that melatonin premedication may not impair ABP and CBF preserving capability induced by sudden postural changes or hemorrhage.

Tumor Necrosis Factor-alpha and Apoptosis Following Spinal Nerve Ligation Injury in Rats

BACKGROUND: Spinal nerve ligation (SNL) injury in rats produces a pain syndrome that includes mechanical and thermal allodynia. Previous studies have indicated that proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) play an important role in peripheral mediation of neuropathic pain, and that altered dorsal root ganglion (DRG) function and degree of DRG neuronal apoptosis are associated with spinal nerve injury. The present study was conducted to evaluate the expression of TNF-alpha and the extent of apoptosis in the dorsal root ganglion after SNL in rats. METHODS: Sprague-Dawley rats were subjected to SNL of the left L5 and L6 spinal nerves distal to the DRG and proximal to the formation of the sciatic nerve. At postoperative day 8, TNF-alpha protein levels in the L5-6 DRG were compared between SNL and naive groups using ELISA. In addition, we compared the percentage of neurons injured in the DRG using immunostaining for apoptosis and localization of activated caspase-3. RESULTS: SNL injury produced significant mechanical and cold allodynia throughout the 7-day experimental period. TNF-alpha protein levels were increased in the DRG in rats that had undergone SNL (12.7 +/- 3.2 pg/100 microg, P < 0.001) when compared with naive rats (4.1 +/- 1.4 pg/100 microg). The percentage of neurons or satellite cells co-localized with activated caspase-3 were also significantly higher in rats with SNL than in naive rats (P < 0.001, P < 0.05, respectively). CONCLUSIONS: SNL injury produces mechanical and cold allodynia, as well as TNF-alpha elevation and apoptosis in the DRG.

Postanesthetic torsade de pointes in a patient with unrecognized long QT syndrome: A case report / 대한마취과학회지

Torsade de pointes (TdP) is a devastating form of polymorphic ventricular arrhythmia associated with corrected QT (QTc) interval prolongation. TdP usually terminates spontaneously but frequently recurs and may degenerate to ventricular fibrillation. The present report describes a case of TdP in a patient being transferred to the postanesthetic care unit following an emergency laparoscopic appendectomy. The patient had undergone open heart surgery 1 week before. Retrospective electrocardiogram analysis revealed the patient had QTc and Tpeak-Tend interval prolongation that had gone unrecognized. We believe TdP may have been induced by accentuation of sympathetic nervous system during emergence from general anesthesia.

Spectral analysis of respiratory-related hemodynamic variables in simulated hypovolemia: a study in healthy volunteers with spontaneous breathing using a paced breathing activity / 대한마취과학회지

BACKGROUND: A dynamic preload index such as stroke volume variation (SVV) is not as reliable in spontaneous breathing (SB) patients as in mechanically ventilated patients. This study examined the hypothesis that spectral analysis of hemodynamic variables during paced breathing (PB) activity may be a feasible index of volume changes and fluid responsiveness, despite insufficient respiratory changes in the preload index during SB activity. METHODS: Blood pressure and stroke volume (SV) were measured in 16 subjects undergoing PB (15 breaths/min), using a Finometer device and the Modelflow method. Respiratory systolic pressure variation (SPV) and SVV were measured and respiratory frequency (RF, 0.2-0.3 Hz) of power spectra of SPV (SPV(RF)) and SVV (SVV(RF)) were computed using fast Fourier transformation. Progressive hypovolemia was simulated with lower body negative pressure (LBNP). Volume challenges were produced by infusion of normal saline and subsequent release of LBNP to baseline. Fluid responsiveness, defined as a >20% increase in SV, was assessed by the area under the curve (AUC) of receiver operating characteristic curves. RESULTS: Graded hypovolemia caused a significant increase in SPV(RF) and a decrease in SVV(RF). During volume expansion, SPV(RF) decreased and SVV(RF) rose significantly. Fluid responsiveness was better predicted with SVV(RF) (AUC 0.75) than with SPV(RF), SPV, or SVV. SVV(RF) before volume challenge was significantly correlated with volume expansion-induced changes in SV (r = -0.64). CONCLUSIONS: These results suggest that RF spectral analysis of dynamic preload variables may enable the detection of volume change and fluid responsiveness in SB hypovolemic patients performing PB activity.

Accelerated idioventricular rhythm associated with desflurane anesthesia :A case report / 대한마취과학회지

Accelerated idioventricular rhythm is defined as a ventricular rhythm of 60-100 beats per minute or a ventricular tachycardia that does nor exceed 120 beats per minutes. Although, it rarely converts to a fatal arrhythmia like ventricular fibrillation, it needs to be differentiated from AIVR, which is from another origin. AIVR may occur due to ischemic heart disease (ST elevated myocardial infarction), cardiomyopathy, rheumatic fever and digitalis intoxication. We report here on a case of AIVR that was related to desflurane administration.

Anesthetic experience of a pediatric patient with Seckel syndrome associated with pneumonia : A case report / 대한마취과학회지

Seckel syndrome, also called bird-headed dwarfism, is an extremely rare, inherited, autosomal recessive disorder. The patients with Seckel syndrome are characterized by growth retardation, microcephaly with mental retardation, proportional dwarfism, bird like faces, and beak-like triangular nose. A literature review reveals that they have multiple anesthetic problems such as difficult airway management, difficult venous cannulation and concomitant medical diseases. We describe our experience in anesthetic management of a 21-month-old male patient with Seckel syndrome associated with pneumonia who underwent orchiopexy for bilateral cryptochidism.

Anesthetic management of a child with Apert syndrome : A case report

Apert syndrome involves abnormal growth of several bones such as craniofacial abnormalities, craniosynostosis and syndactyly of the feet and hands. Apert syndrome often demonstrates to the operating room for craniofacial and extremity operations. Previous reports reveal that children with Apert syndrome suffered difficulties in mask ventilation and difficult airway management during anesthetic management.We report our experience with anesthesia of a 26-month-old female patient with Apert syndrome who underwent syndactyly for separation.

Cement leakage into subcutaneous tissue after kyphoplasty: A case report

We describe a case of cement leakage from the pedicle of vertebrae to the subcutaneous tissue after kyphoplasty.We attempted to remove all cement leakage, but residual cement remained in the paraspinal tissue without any neurological complications.This case illustrates the importance of the right timing of cement injection and when to detach the bone-filler device from the cement.

Ultrasound-guided evaluation of the bifurcation of the femoral artery and vein in pediatric patients / 대한마취과학회지

BACKGROUND: The femoral arteries (FA) and femoral veins (FV) are useful access sites for diagnostic and interventional procedures. In adults, the usual puncture sites are 1-3 cm distal from the inguinal crease. In children, however, the optimal puncture site vessels are not known. The aim of our study was to assess the number of branches and bifurcation sites of the femoral vessels in children by using ultrasonography. METHODS: Color Doppler ultrasonography was used to determine bifurcation sites of the FA and FV, relative to the inguinal crease, in 48 children (median age, 4 yr; median weight, 18.7 kg) with American Society of Anesthesiologists (ASA) Physical Status (PS) score 1-2 and who were scheduled for general anesthesia. RESULTS: The numbers of FAs and FVs at the inguinal crease were 1.83 +/- 0.39 and 1.08 +/- 0.29, respectively, in infants, and 1.83 +/- 0.58 and 1.0 +/- 0.0, respectively, in 10-year-old children. The bifurcation site of the FA in infants and those aged 10 years was 0.78 +/- 0.30 cm and 1.47 +/- 0.27 cm proximal to the inguinal crease, respectively (P < 0.05), whereas the bifurcation site of the FV in these two age groups was -0.96 +/- 0.27 cm and -2.29 +/- 1.09 cm distal to the inguinal crease, respectively (P < 0.05). CONCLUSIONS: In children, the FA frequently bifurcates proximal to the inguinal crease, whereas the FV bifurcates distal to the inguinal crease. However, there are anatomical differences among age groups, so care should be taken to avoid complications during femoral vessel cannulation.