Differences in Abdominal Body Composition According to Glycemic Status: An Inverse Probability Treatment Weighting Analysis

Background@#Several studies have reported that abdominal fat and muscle changes occur in diabetic patients. However, there are few studies about such changes among prediabetic patients. In this study, we evaluated the differences in abdominal fat and muscles based on abdominopelvic computed tomography in prediabetic and diabetic subjects compared to normal subjects. @*Methods@#We performed a cross-sectional study using health examination data from March 2014 to June 2019 at Ulsan University Hospital and classified subjects into normal, prediabetic, and diabetic groups. We analyzed the body mass index corrected area of intra-abdominal components among the three groups using inverse probability treatment weighting (IPTW) analysis. @*Results@#Overall, 8,030 subjects were enrolled; 5,137 (64.0%), 2,364 (29.4%), and 529 (6.6%) subjects were included in the normal, prediabetic, and diabetic groups, respectively. After IPTW adjustment of baseline characteristics, there were significant differences in log visceral adipose tissue index (VATI; 1.22±0.64 cm2/[kg/m2] vs. 1.30±0.63 cm2/[kg/m2] vs. 1.47±0.64 cm2/[kg/m2], P<0.001) and low-attenuation muscle index (LAMI; 1.02±0.36 cm2/[kg/m2] vs. 1.03±0.36 cm2/[kg/m2] vs. 1.09±0.36 cm2/[kg/m2], P<0.001) among the normal, prediabetic, and diabetic groups. Prediabetic subjects had higher log VATI (estimated coefficient= 0.082, P<0.001), and diabetic subjects had higher log VATI (estimated coefficient=0.248, P<0.001) and LAMI (estimated coefficient=0.078, P<0.001) compared to normal subjects. @*Conclusion@#Considering that VATI and LAMI represented visceral fat and lipid-rich skeletal muscle volumes, respectively, visceral obesity was identified in both prediabetic and diabetic subjects compared to normal subjects in this study. However, intra-muscular fat infiltration was observed in diabetic subjects only.

Differences in Abdominal Body Composition According to Glycemic Status: An Inverse Probability Treatment Weighting Analysis

Background@#Several studies have reported that abdominal fat and muscle changes occur in diabetic patients. However, there are few studies about such changes among prediabetic patients. In this study, we evaluated the differences in abdominal fat and muscles based on abdominopelvic computed tomography in prediabetic and diabetic subjects compared to normal subjects. @*Methods@#We performed a cross-sectional study using health examination data from March 2014 to June 2019 at Ulsan University Hospital and classified subjects into normal, prediabetic, and diabetic groups. We analyzed the body mass index corrected area of intra-abdominal components among the three groups using inverse probability treatment weighting (IPTW) analysis. @*Results@#Overall, 8,030 subjects were enrolled; 5,137 (64.0%), 2,364 (29.4%), and 529 (6.6%) subjects were included in the normal, prediabetic, and diabetic groups, respectively. After IPTW adjustment of baseline characteristics, there were significant differences in log visceral adipose tissue index (VATI; 1.22±0.64 cm2/[kg/m2] vs. 1.30±0.63 cm2/[kg/m2] vs. 1.47±0.64 cm2/[kg/m2], P<0.001) and low-attenuation muscle index (LAMI; 1.02±0.36 cm2/[kg/m2] vs. 1.03±0.36 cm2/[kg/m2] vs. 1.09±0.36 cm2/[kg/m2], P<0.001) among the normal, prediabetic, and diabetic groups. Prediabetic subjects had higher log VATI (estimated coefficient= 0.082, P<0.001), and diabetic subjects had higher log VATI (estimated coefficient=0.248, P<0.001) and LAMI (estimated coefficient=0.078, P<0.001) compared to normal subjects. @*Conclusion@#Considering that VATI and LAMI represented visceral fat and lipid-rich skeletal muscle volumes, respectively, visceral obesity was identified in both prediabetic and diabetic subjects compared to normal subjects in this study. However, intra-muscular fat infiltration was observed in diabetic subjects only.

Rocuronium Induced Masseter Muscle Rigidity during Intubation in Patients with Dental Surgery / 계명의대학술지

Masseter muscle rigidity (MMR), known as the ‘jaw of steel’, sometimes makes laryngoscope unusable due to the stiffness of the jaw. MMR during general anesthesia was previously considered as an early episode of malignant hyperthermia (MH). Generally, MMR occurs in the pediatric patients after induction with succinylcholine and volatile agents. However, MMR following the administration of non-depolarizing muscle relaxants is uncommon, although described in some reports. We report a case of 62-year-old male patient which developed MMR following intravenous administration of rocuronium during induction of anesthesia. Our patient was not found to be vulnerable to MH. Although fiberoptic nasotracheal intubation had been successfully performed in our case, an unanticipated difficult airway due to MMR can be experienced at any time. Therefore, we should be aware that, although rare, MMR can occur after using non-depolarizing muscle relaxant. Additionally, in case of any incident of MMR, anesthesiologists need to recognize the management of a difficult airway and to maintain adequate oxygenation in a variety of methods according to a difficult airway algorithm.

Acute normovolemic hemodilution for a patient with secondary polycythemia undergoing aortic valve replacement due to severe aortic stenosis - A case report -

Background@# A high hematocrit level in patients with erythrocytosis is linked with increased blood viscosity and increased risk of thromboembolism. Therefore, it is necessary to adequately lower the hematocrit level before performing a high-risk surgery. Case: A 67-year-old man was scheduled for aortic valve replacement due to severe aortic stenosis. The preoperative hematocrit level of this patient was very high due to secondary polycythemia by hypoxia. We decided to perform acute normovolemic hemodilution after anesthetic induction to reduce the risk of thromboembolism in the patient. The patient was discharged after a successful surgery and a post-operative period without any side effects. @*Conclusions@#We estimate that patients with secondary polycythemia may benefit from acute normovolemic hemodilution to reduce their hematocrit levels while undergoing cardiac surgery using cardiopulmonary bypass. However, it is necessary to control the hematocrit level, since a significant decrease can cause side effects.

Whole lung lavage using a rapid infusion system to treat a patient with pulmonary alveolar proteinosis / 영남의대학술지

Whole lung lavage (WLL) is a therapeutic procedure to remove accumulated material by infusing and draining the lungs with lavage fluid. This procedure has been regarded as the current standard of care to treat pulmonary alveolar proteinosis. However, the WLL protocol has not yet been standardized and the technique has been refined and modified a number of times. A rapid infusion system is a device used to infuse blood or other fluids at precise rates and normothermic conditions. This device is not typically used in WLL, which relies on the passive infusion of fluids using the gravitational force. However, in this study we performed WLL using a rapid infusion system, since we aimed to take advantage of its shorter operation time and greater degree of control over fluid volume and temperature. The patient’s symptoms improved without the occurrence of any complications.

Rocuronium Induced Masseter Muscle Rigidity during Intubation in Patients with Dental Surgery / 계명의대학술지

Masseter muscle rigidity (MMR), known as the ‘jaw of steel’, sometimes makes laryngoscope unusable due to the stiffness of the jaw. MMR during general anesthesia was previously considered as an early episode of malignant hyperthermia (MH). Generally, MMR occurs in the pediatric patients after induction with succinylcholine and volatile agents. However, MMR following the administration of non-depolarizing muscle relaxants is uncommon, although described in some reports. We report a case of 62-year-old male patient which developed MMR following intravenous administration of rocuronium during induction of anesthesia. Our patient was not found to be vulnerable to MH. Although fiberoptic nasotracheal intubation had been successfully performed in our case, an unanticipated difficult airway due to MMR can be experienced at any time. Therefore, we should be aware that, although rare, MMR can occur after using non-depolarizing muscle relaxant. Additionally, in case of any incident of MMR, anesthesiologists need to recognize the management of a difficult airway and to maintain adequate oxygenation in a variety of methods according to a difficult airway algorithm.

Comparison of Outcomes between Intubated and Non-intubated Video-assisted Thoracoscopic Wedge Resections Applied in the Same Patient / 계명의대학술지

In video-assisted thoracoscopic surgery (VATS), general anesthesia with endotracheal intubation was considered an optimal method of anesthesia for a long time. However, complications due to general anesthesia and one-lung ventilation have become a problem. In recent years, epidural anesthesia without endotracheal intubation has been attempted in various thoracic surgical procedures with various advantages and disadvantages reported. We compared postoperative pain and prognosis when different anesthesia methods were used in a patient who underwent the same operation twice in the interval of one year. When non-intubated video-assisted thoracoscopic surgery (NIVATS) underwent under epidural anesthesia, postoperative pain score was lower, adverse events were fewer, and the hospital stay was shorter than that of VATS. The patient also expressed high subjective satisfaction. Like previous studies, the results favored NIVATS under epidural anesthesia. However, greater attention and proficiency are required from the anesthesiologist for proper analgesia and sedation.

Comparison of Outcomes between Intubated and Non-intubated Video-assisted Thoracoscopic Wedge Resections Applied in the Same Patient / 계명의대학술지

In video-assisted thoracoscopic surgery (VATS), general anesthesia with endotracheal intubation was considered an optimal method of anesthesia for a long time. However, complications due to general anesthesia and one-lung ventilation have become a problem. In recent years, epidural anesthesia without endotracheal intubation has been attempted in various thoracic surgical procedures with various advantages and disadvantages reported. We compared postoperative pain and prognosis when different anesthesia methods were used in a patient who underwent the same operation twice in the interval of one year. When non-intubated video-assisted thoracoscopic surgery (NIVATS) underwent under epidural anesthesia, postoperative pain score was lower, adverse events were fewer, and the hospital stay was shorter than that of VATS. The patient also expressed high subjective satisfaction. Like previous studies, the results favored NIVATS under epidural anesthesia. However, greater attention and proficiency are required from the anesthesiologist for proper analgesia and sedation.

Comparison of Outcomes between Intubated and Non-intubated Video-assisted Thoracoscopic Wedge Resections Applied in the Same Patient / 계명의대학술지

In video-assisted thoracoscopic surgery (VATS), general anesthesia with endotracheal intubation was considered an optimal method of anesthesia for a long time. However, complications due to general anesthesia and one-lung ventilation have become a problem. In recent years, epidural anesthesia without endotracheal intubation has been attempted in various thoracic surgical procedures with various advantages and disadvantages reported. We compared postoperative pain and prognosis when different anesthesia methods were used in a patient who underwent the same operation twice in the interval of one year. When non-intubated video-assisted thoracoscopic surgery (NIVATS) underwent under epidural anesthesia, postoperative pain score was lower, adverse events were fewer, and the hospital stay was shorter than that of VATS. The patient also expressed high subjective satisfaction. Like previous studies, the results favored NIVATS under epidural anesthesia. However, greater attention and proficiency are required from the anesthesiologist for proper analgesia and sedation.

The relationship between the surgical Apgar score and postoperative complications in patients admitted to an intensive care unit after surgery

BACKGROUND: Surgical Apgar score (SAS) is a 10-point system that measures estimated blood loss, lowest heart rate and lowest mean blood pressure during surgery, and is known to be associated with postoperative complications. The purpose of this study was to evaluate the relationship between SAS and postoperative major complications in patient admitted to intensive care unit (ICU) after surgery. METHODS: We retrospectively reviewed 543 patients who were admitted to the ICU for 8 months. SAS, patient's demographics and postoperative outcomes were collected and analyzed based on anesthetic record and several medical records in an electronic chart system built in hospital. The patients were divided into three groups based on their SAS. The postoperative major complications, duration of ICU stay and duration of hospital stay were compared among the three groups. RESULTS: In the low score group, the rate emergency, trauma and hepatobiliary operation were high. In this group, the duration of ICU and hospital stay, use of mechanical ventilation and inotropic in ICU, and postoperative complication were also increased. SAS also had a weak negative correlation with ICU stay and hospital stay. Postoperative complication and mortality rate doubled when compared to reference group (SAS 7–10) according to univariate logistic regression. CONCLUSIONS: In patients admitted to ICU after surgery, SAS, which can be measured during surgery, is closely related to postoperative parameters including major complications, mortality, and ICU stay. In other words, it is thought that the postoperative outcomes can be improved through appropriate monitoring and intervention for patients with low SAS score.

Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report / 대한마취과학회지

Laryngospasm, an occlusion of the glottis, can occur at any time during anesthesia, and is associated with serious perioperative complications such as hypoxia, hypercabia, aspiration, bronchospasm, arrhythmia, prolonged recovery, cardiac collapse, and eventually catastrophic death. Importantly, postoperative negative pressure pulmonary edema (NPPE) is a rare, but well described life-threatening complication related to acute and chronic upper airway obstruction. Sugammadex well known for affirmatively reducing the postoperative pulmonary complications associated with residual neuromuscular blockade may have an indirect role in triggering the negative intrathoracic pressure by raising a rapid and efficacious respiratory muscle strength in acute upper airway obstruction. Herein, we report a case of postoperative NPPE following repetitive laryngospasm even after reversal of rocuronium-induced neuromuscular blockade using sugammadex.

Change of QT variability index during general anesthesia / 대한마취과학회지

BACKGROUND: The QT variability index (QTVI)-a non-invasive measure of beat-to-beat QT interval (QTI) fluctuations-is related to myocardial repolarization lability. The QTVI represents the relationship between QTI and the RR interval. Elevated QTVI is associated with an increased risk of malignant ventricular arrhythmias and sudden death. We investigated the influence of general anesthesia and tourniquets on the QTVI. METHODS: We studied fifty patients who received total knee replacement arthroplasty under sevoflurane anesthesia. We measured QTI, corrected QTI (QTc), T-wave peak-to-end interval (TPE), QTVI, and heart rate variability. All variables were calculated at baseline (B), 30 min after general anesthesia (A), 30 min (TQ1) and 60 min (TQ2) after tourniquet inflation, and at tourniquet deflation (TQR). RESULTS: Prolongation of QTI was detected at all times, and QTc was significantly prolonged TQR. TPE was unchanged during general anesthesia. The QTVI was significantly decreased and more negative during anesthesia and tourniquet inflation. After deflation of the tourniquet, the QTVI was restored to preanesthetic values. Low frequency (LF) was significantly decreased during general anesthesia, but high frequency (HF) was somewhat maintained, except at TQ2. The LF/HF ratio was significantly decreased at A and TQ2. CONCLUSIONS: Sevoflurane based general anesthesia induced repolarization stability and, more negativity of the QTVI, in patients undergoing total knee replacement arthroplasty.

Inhaled nitric oxide for the brain dead donor with neurogenic pulmonary edema during anesthesia for organ donation: a case report / 대한마취과학회지

Neurogenic pulmonary edema (NPE) in brain dead organ donors occurring after an acute central nervous system insult threatens organ preservation of potential organ donors and the outcome of organ donation. Hence the active and immediate management of NPE is critical. In this case, a 50-year-old male was admitted to the intensive care unit (ICU) for organ donation. He was hypoxic due to NPE induced by spontaneous intracerebral hemorrhage and intraventricular hemorrhage. Protective ventilatory management, intermittent recruitment maneuvers, and supportive treatment were maintained in the ICU and the operating room (OR). Despite this management, the hypoxemia worsened after the OR admission. So inhaled nitric oxide (NO) therapy was performed during the operation, and the hypoxic phenomena showed remarkable improvement. The organ retrieval was successfully completed. Therefore, NO inhalation can be helpful in the improvement of hypoxemia caused by NPE in brain dead organ donors during anesthesia for the organ donation.

Intraoperative very late stent thrombosis in patient undergoing arthroscopic shoulder surgery / 대한마취과학회지

No abstract available.

Transient left bundle branch block associated with hypoxia during monitored anesthesia care: A case report

Transient left bundle branch block (LBBB) is uncommon during anesthesia. It is mainly related to the changes in blood pressure or heart rate. Its occurrence can be confused with acute myocardial ischemia or ventricular tachycardia, therefore differential diagnosis is important. We report a case of transient LBBB which developed with hypoxia during monitored anesthesia care. LBBB is reversed to sinus rhythm after recovery from hypoxia.

Severe hypotension following urethral catheterization during general anesthesia in a patient with bladder cancer: A case report / 대한마취과학회지

The process of micturition is related to activation of the cardiovascular autonomic nervous system. Hypotension with bradycardia often occurs during or immediately after micturition. We experienced a case of sudden severe hypotension and bradycardia following urethral catheterization in a patient who underwent an urethral dilatation and transurethral resection of bladder tumor while under general anesthesia. The patient was treated with inotropics and intravenous fluids, and he recovered without any complications. The characteristics of this case are similar to the physiologic changes that occur in micturition syncope. Therefore, it is presumed that the autonomic reflex that was triggered by the urethral catheterization caused the hypotension and bradycardia.

Relation between preoperative autonomic function and blood pressure change after tourniquet deflation during total knee replacement arthroplasty / 대한마취과학회지

BACKGROUND: Tourniquets are used to provide a bloodless surgical field for extremities. Hypotension due to vasodilation and bleeding after tourniquet deflation is a common event. Hemodynamic stability is modulated by the autonomic nervous system (ANS). Heart rate variability (HRV) is a sensitive method for detecting individuals who may be at risk of hemodynamic instability during general anesthesia. The purpose of this study was to investigate ANS function to predict hypotension after tourniquet deflation. METHODS: Eighty-six patients who underwent total knee replacement arthroplasty (TKRA) were studied. HRV, systolic blood pressure variability (SBPV) and baroreflex sensitivity (BRS) were analyzed. We assigned two groups depending on the lowest systolic blood pressure (SBP) or mean BP (MBP) after tourniquet release (Group H; SBP 80 mmHg and MBP > 60 mmHg). RESULTS: Fifteen patients developed severe hypotension and ten patients were treated with ephedrine. Of the parameters of HRV, SBPV, and BRS, only BRSSEQ was significant being low in Group H. BRS and high-frequency SBPV were correlated with the degree of MBP change after tourniquet deflation. CONCLUSIONS: Preoperative low BRS is associated with hypotension after tourniquet deflation, suggesting the importance of baroreflex regulation for intraoperative hemodynamic stability.

Experience without using venoveno bypass in adult orthotopic liver transplantation / 대한마취과학회지

BACKGROUND: Venoveno bypass (VVB) has been used to achieve hemodynamic stability and decrease the incidence of renal dysfunction. However, VVB has many complications. The purpose of this study is to verify the safety of total clamping of the suprahepatic inferior vena cava (IVC) without VVB during orthotropic liver transplantation (OLT) in terms of anesthetic management. METHODS: Twenty-five patients without preoperative renal dysfunction who underwent primary OLT were enrolled in this study. Hemodynamic data and blood gas measurements were collected 1 hour after incision, 30 minutes after IVC total clamping and 30 minutes after reperfusion. Postoperative laboratory data, including blood urea nitrogen (BUN), creatinine (Cr) and glomerular filtration rate (GFR), were assessed at postoperative day (POD) 0-7, 30, 90, 180 and 1 year. RESULTS: Mean blood pressure was well maintained during IVC total clamping with infusion of inotropics. There was no case of severe acidosis (pH < 7.2) during the anhepatic period. The immediate postoperative Cr and GFR were not significantly different from those of the preoperative values. BUN increased from POD 1 and decreased after POD 6, while Cr increased at POD 90 only. CONCLUSIONS: In patients without preoperative renal dysfunction, when IVC was totally clamped, VVB does not need to be routinely performed to maintain hemodynamics during the anhepatic phase and renal function after OLT.

Hyperkalemia in a patient with rhabdomyolysis and compartment syndrome: A case report / 대한마취과학회지

Rhabdomyolysis is a life-threatening syndrome caused by skeletal muscle injury, which results in the leakage of myoglobin, other intracellular proteins and electrolytes into the circulatory system and urine. Acute kidney injury occurs in 13-50% of patients with rhabdomyolysis, which is the principal cause of their mortality. This is to report an emergency operation performed on a patient with traumatic rhabdomyolysis and compartment syndrome who developed life-threatening hyperkalemia caused by reperfusion injury after vascular anastomosis. The patient was treated with intravascular volume expansion, sodium bicarbonate, diuretics, insulin and Continuous Renal Replacement Therapy, but the patient expired 5 days after the operation.

Experience with inhaled nitric oxide therapy in patient with neurogenic pulmonary edema: A case report

Neurogenic pulmonary edema is known in patients after head injuries or other cerebral lesions. Typically, this form of pulmonary edema occurs minutes to hours after central nervous system injury and may manifest during the perioperative period. It is always a life-threatening symptom after increased intracranial pressure (ICP), where immediate therapeutic interventions are imperative. Rapid initiation of strategies aimed at ameliorating hypoxia including support of oxygenation and ICP reduction is paramount. We report a case that responded dramatically to inhaled nitric oxide (NO). This therapy, to our experience, seems to provide a way not to reduce pulmonary hypertension, but to improve ventilation-perfusion mismatch for the treatment of refractory hypoxemia in neurogenic pulmonary edema patient.